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INTRODUCTIONIn this chapter, we begin to explore what it means to ‘think like a nurse’.We define and discuss the importance of clinical reasoning, outline theclinical reasoning process and illustrate how clinical errors are linkedto poor reasoning skills. This chapter creates a foundation for the onesthat follow and a backdrop to a series of authentic and clinically relevantclinical scenarios.Learning to ‘think like a nurse’ is challenging and requires commitment,practice and multiple opportunities for application of learning. However,the benefits are significant for you, as a curious, competent and intelligentnurse, and also for the people who will be the recipients of your care.Simply stated, effective clinical reasoning skills improve the quality ofpatient care, prevent adverse patient outcomes and enhance nurses’work satisfaction.4 CLINICAL REASONING: LEARNING TO THINK LIKE A NURSEWHAT DOES IT MEAN TO ‘THINK LIKE A NURSE’?While there are a number of similarities in the way nurses and other health professionals think, thereare also significant differences. Unlike many health professionals who ‘treat’ and ‘retreat’, therapeuticrelationships between nurses and their patients can extend over hours, days or even longer. During thistime, nurses maintain constant vigilance and engage in multiple episodes of clinical reasoning for eachperson in their care, responding to the complex nature of the illness experience in ways that are authentic,holistic and person-centred.‘Thinking like a nurse’ is a form of engaged moral reasoning. Educational practices must helpstudents engage with patients with a deep concern for their well being. Clinical reasoning mustarise from this engaged, concerned stance, always in relation to a particular patient and situationand informed by generalised knowledge and rational processes, but never as an objective,detached exercise. (Tanner, 2006, p. 209)WHY IS CLINICAL REASONING IMPORTANT?Nurses are required to care for and make decisions about complex patients with diverse health needs. Asthey are responsible for a significant proportion of the clinical judgments in healthcare, their ability torespond to challenging and dynamic situations requires not only psychomotor skills and knowledge, butalso sophisticated thinking abilities.A body of evidence has identified that clinical reasoning skills have a positive impact on patientoutcomes while, conversely, nurses with poor clinical reasoning skills often fail to detect patientdeterioration, resulting in a failure to rescue (Cooper et al., 2011). Clinical reasoning errors have beenimplicated as a key factor in the majority of adverse patient outcomes (Institute of Medicine, 201 0). Thereasons for this are multidimensional and include the tendency to make errors in time-sensitive situationswhere there is a large amount of complex data to process, and difficulties in distinguishing between aclinical problem that needs immediate attention and one that is less acute (Hoffman, 2007).WHAT IS CLINICAL REASONING?Clinical reasoning is a systematic and cyclical process that guides clinical decision making, particularlyin unpredictable, emergent and non-routine situations, and leads to accurate and informed clinicaljudgments. Clinical reasoning is defined as ‘the process by which nurses (and other clinicians) collectcues, process the information, come to an understanding of a patient problem or situation, plan andimplement interventions, evaluate outcomes, and reflect on and learn from the process’ (Levett-Joneset al., 2010, p. 516). The clinical reasoning cycle (Figure 1.1) is informed by a body of researchundertaken by Hoffman (2007) and Levett-Jones et al. (2010).THE CLINICAL REASONING PROCESSA diagram showing the clinical reasoning cycle and describing the nursing actions that occur duringeach stage is provided in Figure 1.2. The cycle begins at 1200 hours and moves in a clockwise directionthrough eight stages: look, collect, process, diagnose, plan, act, evaluate and reflect. Although eachstage is presented as a separate and distinct element in this diagram, in reality clinical reasoning is adynamic process and nurses often combine one or more stages or move back and forth between thembefore reaching a diagnosis, taking action and evaluating outcomes. Table 1.1 provides an example of anurse’s clinical reasoning while caring for a man following surgery for an abdominal aortic aneurysm.Stages of the clinical reasoning cycle
Consider the patient situationDuring the first stage of the clinical reasoning cycle, the nurse begins to gain an initial impression of thepatient and identifies salient features of the situation. This first impression, which Tanner (2006) refers to as‘noticing’, is critical but can be negatively influenced by the nurse’s preconceptions, assumptions and biases.CHAPTER 1: CLINICAL REASONING: WHAT IT IS AND WHY IT MATTERSReflect onprocess andnew learningEvaluateoutcomesFigure 1.1Considerthe patientsituationCLiniCaLreasoningCYCLE!Establishgoal{s)The clinical reasoning cycleCollect cues/InformationIdentifyproblems/issuesSource: T. Levett-Jones, K. Hoffman, Y. Dempsey, S . Jeong , D. Noble, C. Norton , J . Roche &N. Hickey (201 0) . The ‘five rights’ of clinical reasoning: An educational model to enhance nursingstudents’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today, 30(6),515-20.
Collect cues/informationThe importance of the cue collection stage of the clinical reasoning cycle cannot be underestimated,as early subtle cues when missed can lead to adverse patient outcomes (Levett-Jones et al., 2010).During the second stage, the nurse begins to collect relevant information about the patient. He/shereviews the information that is currently available, including the handover report, the patient’ smedical and social history, clinical documentation, electronic medical records and other availableinformation.The nurse then identifies additional information that is required , such as vital signs and/or a focusedhealth assessment. Importantly, the nurse focuses on collecting specific cues relevant to the person ‘scondition at this point in time. When appropriate, the nurse also seeks to elicit the patient’s understandingof the situation and the family’s or carer’s concerns.Lastly, the nurse recalls knowledge related to the patient ‘s particular situation. A breath and depth ofknowledge is therefore imperative for accurate clinical reasoning. Unless a nurse has a deep understandingof the applied sciences, especially pathophysiology, the ability to make sense of and correctly interpretcues will be impacted.
Process informationIn the third stage of the clinical reasoning cycle, the nurse interprets the cues that have been collectedand identifies significant aberrations from normal. Cues are grouped into meaningful clusters;clinical patterns are identified , inferences are made and hypothe ses are generated. During thi s s tage ,experienced nurses call upon their wide repertoire of previous clinical experiences matching thefeatures of patient’s presentation with other similar situations. They are also able to ‘think ahead’anticipating potential outcomes and complications depending on the particular course of action (orinaction).56 C LI NICAL RE ASONING: LEARN ING TO THINK LIK E A NURS EContemplate what youhave learnt from thisprocess and what youcould have donedifferently.Evaluate theeffectiveness ofoutcomes and actions.Ask: ‘Has the situationimproved nowr’Select a course of actionbetween the differentalternatives available.Figure 1.2Describe or list facts,context. objects orpeople.Reflect onpr” o c ess andn e w learningC onsi d erOLiniOaLreasoningOYOL9The clinical reasoning process with descriptorsReview current information (e.g. handover reports, patienthistory. patient charts, results of investigations andnursing/medical assessments previously undertaken) .Gather new information (e.g. undertake patient assessment).Recall knowledge (e.g. physiology, pathophysiology,pharmacology, epidemiology, therapeutics, culture, contextof care, ethics, law).ProcessSyndlesise facts andinferences to make adefinitive diagnosis ofthe patient’s problem.Interpret analyse data to come to anunderstanding of signs or symptoms;compare normal vs abnormal.Discriminate: distinguish relevant fromirrelevant information; recogniseinconsistencies, narrow down theinformation to what is most importantand recognise gaps in cues collected.Relate: discover new relationships orpatterns; clus t er cues together toidentify relationships between them.Infer: make deductions or form opinionsthat foll ow logically by interpretingsubjective and objective cues; consideralternatives and consequences.Match current situation to pastsituations or current patient to pastpatients (usually an expert thoughtprocess).Predia an outcome (usually an expertthought process).Source: Adapted from T. Levett-Jones , K. Hoffman , Y. Dempsey, S. Jeong, D. Noble, C. Norton , J. Roche & N. Hickey (2010). The ‘fi ve rights’ ofclinical reasoning : An educational model to enhance nursing students ‘ ability to identify and manage clinically ‘at risk ‘ patients. Nurse EducationToday , 30(6) , 515-20.Table 1 .1 Phases of the clinical reasoning cycle with examplesProcessConsiderthe patientsituationCollect cues/informationDescriptionDescribe person and context .Review current information(e.g . handover reports, patienthistory, patient charts, results ofinvestigations and nursing/medicalassessments previously undertaken)Gather new information (e .g .undertake patient assessment).Recall knowledge (e.g . physiology,pathophysiology, pharmacology,epidemiology, therapeutics, culture,context of care, ethics, law) .Example of a nurse’s thinkingMr Smith is a 60-year-old man admitted to ICUyesterday following surgery for an abdominal aorticaneurysm (AAA) .Mr Smith has a history of hypertension and he takesbeta-blockers. His BP was 140/80 mmHg an hourago .Mr Smith’s vital signs are: T 37 .6 °C, PR 116, RR 20,BP 110/60 mmHg .His urine output is averaging 20 mUhr. He has anepidural running@ 10 mUhr.BP and PR are influenced by fluid status .Epidurals can lower the BP because they can causevasodilation .CHAPTER 1: CLINICAL REASONING: WHAT IT IS AND WHY IT MATTERS 7Table 1.1 Phases of the clinical reasoning cycle with examples (continued)ProcessinformationIdentify theproblem/issueEstablish goalsTake actionEvaluateReflect onprocess andnew learningInterpret: analyse cues to come to anunderstanding of signs or symptoms.Compare normal vs abnormal.Discriminate: distinguish relevantfrom irrelevant information;recognise inconsistencies; narrowdown information to what is mostimportant; recognise gaps in cuescollected.Relate: discover new relationshipsor patterns; cluster cues together toidentify relationships between them.Infer: make deductions or formopinions that follow logicallyby interpreting subjectiveand objective cues; consideralternatives and consequences.Match current situation to pastsituations or current patient topast patients (usually an expertthought process).Predict an outcome (usually anexpert thought process).Synthesise facts and inferencesto make a definitive nursingdiagnosis.Describe what you want tohappen, a desired outcome and atime frame.Select a course of action betweenthe different alternatives available.Evaluate the effectiveness ofoutcomes and actions. Ask: ‘Hasthe situation improved now?’Contemplate what you have learntfrom this process and what youcould have done differently.Mr Smith’s BP is low, especially for a person witha history of hypertension. He is tachycardic andoliguric.Although Mr Smith is slightly febrile, I’m moreconcerned about his hypotension, tachycardia andoliguria.Although Mr Smith’s hypotension, tachycardiaand oliguria could be signs of impending shock,his BP decreased soon after we increased hisepidural rate.Mr Smith’s BP is probably low because of his epiduraland blood loss during surgery.AAAs are often hypotensive post-op.If we don’t give Mr Smith a fluid challenge, he coulddevelop acute kidney injury or go into shock.Mr Smith has reduced cardiac output related todecreased intravascular volume and vasodilationevidenced by hypotension, tachycardia and oliguria.To improve Mr Smith’s cardiac output,haemodynamic status and urine output over the next1-2 hours.I will phone the medical officer (using ISBAR) torequest an order for a fluid challenge, increased IVrate and aramine if needed.Mr Smith’s BP has improved and his urine output isnow averaging > 30 ml/hr. I’ll continue to monitorhim as he may need another fluid challenge oraramine later.I now understand …I should have .. .Next time I will .. .Source: K. Hoffman (2007). A comparison of decision-making by ‘expert’ and ‘novice’ nurses in the clinical setting, monitoring patient haemodynamic statuspost abdominal aortic aneurysm surgery. Unpublished PhD thesis, University of Technology, Sydney; and T. Levett-Jones, K. Hoffman, Y. Dempsey, S. Jeong,D. Noble, C. Norton, J. Roche & N. Hickey (201 0). The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identifyand manage clinically ‘at risk’ patients. Nurse Education Today, 30(6), 515-20.8~——– —————————CLINICAL REASONING: LEARNING TO THINK LIKE A NURSE
Identify problems/issuesImproving the diagnostic process is not only possible, but it also represents a moral, professional,and public health imperative. (Institute of Medicine, 2010)The fourth stage of the cycle is where the nurse synthesises all of the information that has been collectedand processed in order to identify the most appropriate nursing diagnoses. A three-part ‘actual’ diagnosisor a two-part ‘risk’ diagnosis may be formulated. The accuracy of this step is critical as the nursingdiagnosis is used to determine appropriate goals of care and subsequent nursing actions. The followingexamples are adapted from Berman et al. (2017).Nursing diagnosis
A nursing diagnosis is a problem that becomes apparent following a thorough and systematicinterpretation of subjective and objective data. An actual nursing diagnosis consists of the person’sproblem, the related aetiology (causal relationship between a problem and its related or risk factors),and supporting evidence/cues.For example: Dehydration related to post-operative nausea and vomiting evidenced by dry mucousmembranes, oliguria, poor skin turgor, hypotension and tachycardia.
A risk nursing diagnosis is a clinical judgment about a potential problem where the presence ofrisk factors indicates that a problem may develop unless nurses intervene appropriately. A riskdiagnosis is written in two parts and does not include signs and symptoms.For example: Risk of infection related to skin tear and type 2 diabetes.
Establish goalsThe fifth stage of the cycle is where the nurse clarifies and prioritises the goals of care depending onurgency. Goals must be SMART (Specific, Measureable, Achievable, Realistic and Timely) anddesigned to address the nursing diagnoses previously identified. Without SMART goals, the nursecannot determine the efficacy of their actions.
Take actionIn this stage the nurse selects the most appropriate course of action to achieve the goals of care andaddress the nursing diagnoses. The nurse also decides who is best placed to undertake the interventions,and who should be notified and when.
Evaluate outcomesThis stage requires the nurse to re-examine objective and subjective data (patient cues) in order toevaluate how effective the nursing interventions have been, and whether the patient’s problem hasimproved. If the evaluation identifies that the patient’s condition has not improved, the nurse reconsidersthe patient’s situation and seeks to identify a more appropriate course of action. There may be a need toengage in a new cycle of clinical reasoning at this stage.
Reflect on process and new learningEffective clinical reasoning requires both cognitive and metacognitive (thinking about one’s thinking) skillsin order to develop the ability to ‘think like a nurse’ (Mezirow, 1990). Thus, the final step of the clinicalreasoning cycle involves reflection. This requires nurses to critically review their practice with a view torefinement, improvement or change. Reflection is intrinsic to learning. It is a deliberate, orderly andstructured intellectual activity that allows nurses to process their experience, and explore their understandingof what they did, why they did it, and the impact it had on themselves and others (Boud, 20 15).Nurses reflect in and on practice by asking themselves questions such as:What happened and why?What was done well and what should be improved?What should be done differently if presented with the same or similar situation?• What has been learnt that can be used when caring for other patients?What is needed to improve future practice, for example more knowledge about a specific conditionor more practice in particular skills?CHAPTER 1: CLINICAL REASONING: WHAT IT IS AND WHY IT MATTERSCLINICAL REASONING AND CRITICAL THINKINGAs a client’s status changes, the nurse must recognise, interpret, and integrate new informationand make decisions about the course of action to follow. For satisfactory client outcomes clinicalreasoning goes hand in hand with critical thinking. (Martin, 2002, p. 245)Clinical reasoning is dependent on a critical thinking ‘disposition’ (Scheffer & Rubenfeld, 2000).Critical thinking is a complex collection of cognitive skills and affective habits of the mind and has beendescribed as the process of analysing and assessing thinking with a view to improving it (Paul & Elder,2007). To think like a nurse requires you to learn the knowledge, ideas, skills, concepts and theories ofnursing, and develop your intellectual capacities to become a disciplined, self-directed, critical thinkercapable of clinical reasoning (Paul & Elder, 2007).Nurses who are critical thinkers strive to be clear, accurate, precise, logical and fair when they listen,speak, read and write (Paul & Elder, 2007). Critical thinkers think deeply and broadly, eliminatingirrelevant, inconsistent and illogical thoughts as they reason about patient care. The quality of theirthinking improves over time and through reflection (Norris & Ennis, 1989). Below is a list of attributesnurses need to develop their critical thinking and clinical reasoning skills (Scheffer & Rubenfeld, 2000,p. 358; Rubenfeld & Scheffer, 2006, pp. 16-24):• A holistic and contextual perspective-consideration of the whole person, taking into account theentire situation, including relationships, background and environmentCreativity-the ability and desire to generate, discover or restructure ideas; and the ability toimagine alternativesInquisitiveness-a thoughtful, questioning and curious approach; and an eagerness to explorepossibilities and alternativesPerseverance-a dedication to the pursuit of knowledge despite any obstacles that are encounteredIntuition-insightful patterns of knowing brought about by previous experiences and pattern recognition• Flexibility-the capacity to adapt, modify or change thoughts, ideas and behaviours• Academic integrity-seeking the truth through sincere, honest processes, even if the results arecontrary to one’s assumptions or beliefsReflexivity-contemplation of assumptions, thinking and behaviours for the purpose of deeperunderstanding and self-evaluationConfidence-a firm belief in one’s reasoning abilitiesOpen-mindedness-receptiveness to different views and sensitivity to one’s biases, prejudices,preconceptions and assumptions.QUESTIONING ASSUMPTIONS ANDUNDERSTANDING ERRORSNurses are human and we make the same kinds of thinking errors in our practice as we do in our dayto-day lives. Sometimes we overlook or misinterpret the significance of an important cue, or we jump toconclusions or fail to take into account alternative possibilities or options. Additionally, preconceptions,assumptions, biases, stereotypes and stigmatism can negatively influence our clinical reasoning and insome cases even prevent clinical reasoning from occurring. We may be unaware of the assumptions andprejudices that we hold as they are often long-standing and deeply embedded. For this reason nursesmust develop insight and self-awareness by deliberately reflecting on their biases and preconceptions.Failure to do so can undermine the accuracy of clinical reasoning and consequently patient safety.Nurses can help avoid clinical reasoning errors by being mindful and reflective, and by using themultitude of decision support resources available to help them make a decision. They can also maintaina healthy skepticism and make it a habit to ask: ‘What is influencing my thinking about this patient?’,‘Could my interpretation be flawed?’ and ‘What other nursing diagnosis is possible in this situation?’.Table 1.2 provides a list of clinical reasoning errors, many of which arise because of flawedassumptions and beliefs. Some of these errors are then illustrated in the narratives that follow.9–~— – –~–~~~———–10 CLINICAL REASONING: LEARNING TO THINK LIKE A NURSETable 1.2 Clinical reasoning errorsErrorAnchoringAscertainment biasConfirmation biasDiagnosticmomentumFundamentalattribution errorOverconfidence biasPremature closurePsych-out errorUnpacking principleDefinitionThe tendency to lock onto salient features in the patient’s presentation too early in theclinical reasoning process, and failing to adjust this initial impression in the light of laterinformation. This error is compounded by confirmation bias.When a nurse’s thinking is shaped by prior assumptions and preconceptions, forexample ageism, stigmatism and stereotyping.The tendency to look for confirming evidence to support a nursing diagnosis ratherthan look for disconfirming evidence to refute it, despite the latter often being morepersuasive and definitive.Once labels are attached to patients, they tend to become stickier and stickier. Whatstarted as a possibility gathers increasing momentum until it becomes definite andother possibilities are excluded.The tendency to be judgmental and to blame patients for their illnesses (dispositionalcauses) rather than examine the circumstances (situational factors) that may have beenresponsible. Patients with a mental illness and from minority or marginalised groups areat particular risk of this error.A tendency to believe we know more than we do. Overconfidence bias reflects a tendencyto act on incomplete information, intuition or hunches. Too much faith is placed on opinioninstead of carefully collected cues. This error may be augmented by anchoring.The tendency to accept a nursing diagnosis without sufficient evidence and beforeit has been fully verified. This error accounts for a high proportion of inaccurate orincomplete nursing diagnoses.People with a mental illness are particularly vulnerable to clinical reasoning errors, andco-morbid conditions may be overlooked or minimalised. A variant of this error occurswhen medical conditions (such as hypoxia, delirium, electrolyte imbalance and headinjuries) are misdiagnosed as psychiatric conditions.Failure to collect and unpack all of the relevant cues, and consider differential diagnosesmay result in significant possibilities being missed.Source: Adapted from P. Croskerry (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78(8), 1-6.Examples of clinical reasoning errorsSome of the clinical reasoning errors listed in Table 1.2 are illustrated here with authentic clinicalexperiences. As you read these narratives, it will become evident that even experienced, committed andwell-intentioned health professionals can make errors if they allow their thinking process to be cloudedby assumptions, preconceptions and stereotypes. Environmental and situational factors such as noise,fatigue, stress, multitasking and interruptions can also impede thinking processes. As you read theseexamples, it is important to reflect on your own biases and prejudices, and any personal or contextualfactors that negatively influence your thinking, as this will enhance your self-awareness, emotionalintelligence and clinical reasoning ability.CHAPTER 1: CLINICAL REASONING WHAT IT IS AND WHY IT MATTERSFundamental attribution errorThis incident occurred when I was a newly registered nurse working on a medical ward.The patient was an elderly man (70+ years) who was admitted for a stroke. During hisadmission the man had some degree of hemiparesis from his stroke; however, thissubsided to a large degree. The man appeared to be extremely resistive to our effortsto make him as independent as possible. He wanted a great deal of assistance with hisactivities of daily living and more than required for his level of disability. He requiredconstant encouragement to participate in any sort of physical activity, no matter howminimal. The man was eventually transferred to a rehabilitation unit. Some weeks laterhe returned to our ward as he would ‘not participate’ in his rehabilitation program. Thehandover reported that he had ‘failed rehab’. I judged him on his previous behaviourand I assumed he was just lazy (based on the information from the rehab staff). On hisreturn to my ward he continued to constantly want assistance and seemed to bedetermined to become dependent. I insisted (often strenuously and on reflectionharshly) that he walk and participate in his own care. Around this time he also startedto mention pain which hadn’t really featured till then. He was investigated and wasfound to have widespread bony metastasis from an unknown primary cancer. He diedthree weeks later. I was astounded and felt very guilty as I had judged this man, makingassumptions that were proven to be erroneous. I did, however, ensure that this manreceived the very best care for the last three weeks of his life.Doctor Jennifer DempseyUniversity of NewcastleAscertainment biasWhile employed as a mental health nurse in a GP practice I assessed a 65-year-oldwoman, Alice, 1 who was referred by her GP as he was concerned about her mentalstate. Upon assessment I found Alice had been diagnosed three years prior with thedegenerative neurological condition, amyotrophic lateral sclerosis (ALS). She wasdivorced, lived alone in a council flat in a small seaside village and had limited contactwith her daughter and grandchildren who lived six hours drive away. She had a priorhistory that included childhood sexual abuse, a previous suicide attempt (in the contextof domestic violence) and two episodes of major depression which had responded wellto psychotropic medication and supportive psychotherapy.Although Alice had significant physical symptoms that affected her mobility attimes, she described having managed well until four months ago when her relationshipwith her daughter had deteriorated severely. The abandonment had increased hersense of isolation and this estrangement appeared to have been a trigger for a relapseinto major depression, with severe depressive symptoms, including increased loss ofmotivation, tearfulness, disordered sleep, loss of appetite and a heightened sense ofhopelessness and suicidal ideation. Further discussion revealed that her GP hadinitiated a neurological review, which revealed minimal deterioration in physicalfunctioning, and an aged care assessment (ACAT), with a view to increasing the level ofsupport services available to Alice.After consultation with Alice’s GP, it was agreed that a psychiatrist review waswarranted and I prepared a comprehensive referral to the mental health services. Atthe time I was working part-time with the Community Mental Health Team and thuswas present at the intake meeting where all referrals were reviewed as part of aI Pseudonym1112 CLINICAL REASONING: LEARNING TO THINK LIKE A NURSEmulti-disciplinary team process. The nurse from the Acute Care Service responsiblefor presenting the referrals to the team commenced reading the referral. Before hehad finished, he commented, ‘This is a waste of time; of course the woman’sdepressed, who wouldn’t be with a degenerative illness; besides, she’s old.’ Anotherteam member responded, ‘Tell the GP to refer her to palliative care.’Sadly for Alice, the mental health service declined a psychiatrist review; the MentalHealth Service for Older Persons likewise declined a review and recommended insteadthat the application process for placement in an aged care facility be started. Alice’s‘real’ issues were not addressed because of the ageism and preconceptions of themental health team.Associate Professor Rachel RossiterCharles Sturt UniversityAnchoringWorking as a nurse educator, I had been paged to come to recovery. Two RNs wereseeking advice about the management of a patient (Mrs L) who had had a left hipreplacement and was in severe pain, very distressed and calling out loudly andincoherently. The anaesthetist had been notified but was in theatre with another patient.Mrs L had been given morphine by the anaesthetist before being transferred to recovery.As ordered, she was given three further bolus doses of morphine at 3-minute intervalsbut with minimal effect. The nurses were encouraging her to use her PCA button but shewas not coherent enough to comply. I tried to do a thorough pain assessment but washampered in my attempts as the patient was unable to reply to my questions. I did anassessment of the wound … the dressing was dry and intact and the bellovac draininga small amount. There was a small amount of urine in the catheter bag. I examined thearea surrounding the wound convinced that there must be a surgical problem. Itappeared normal and I could see no obvious reason for the pain.Time was passing without any improvement and we were all becoming anxious andconcerned about Mrs L’s distress and pain. I was about to phone the anaesthetist againbut decided to check her wound one more time. In the process I briefly noticed thatMrs L’s catheter had not been taped to her leg and was actually lying under her thigh.Lifting it over her leg I saw that it had also been kinked. As I untwisted it, urine beganto quickly flow. Within minutes there was close to 1600 mL in the catheter bag and MrsL had drifted off into a morphine-induced state. Her resps were now 6 and oxygen sats85 per cent. We increased the oxygen to 10 L per minute with little effect and phonedthe anaesthetist for an order of naloxone as she had become narcotised. Had I notanchored onto the belief that Mrs L’s pain must be coming from the surgical site Iwould have done a more comprehensive assessment, identified the cause of her pain,not administered as much morphine, and prevented respiratory depression fromoccurring. Checking that catheters are draining properly and not kinked or blockedbecame part of my routine post-operative patient assessment following this experience.Professor Tracy Levett-JanesUniversity of Technology, SydneyCHAPTER 1: CLiNICAL REASONING: WHAT IT IS AND WHY IT MATTERSREFERENCESBerman, A., Synder, S., Levett-Jones, T., Dwyer, T., Hales, M., Harvey, N., … Stanley, D. (2017).Kozier and Erb’s Fundamentals of Nursing (4th edn). Sydney: Pearson.Boud, D. (2015). Feedback: Ensuring that it leads to enhanced learning. The Clinical Teacher, 12(1),3-7.Cooper, S., Buykx, P., McConnell-Henry, T., Kinsman, L. & McDermott, S. (2011). Simulation: Can iteliminate failure to rescue? Nursing Times, 107(3).Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them.Academic Medicine, 78(8), 1-6.Duffield, C., Roche, M., O’Brien-Pallas, L., Diers, D., Alsbett, C., King, M., … Hall, J. (2007). Gluing ItTogether: Nurses, Their Work Environment and Patient Safety. University of Sydney, NSW.Hoffman, K. (2007). A comparison of decision-making by ‘expert’ and ‘novice’ nurses in the clinicalsetting, monitoring patient haemodynamic status post abdominal aortic aneurysm surgery.Unpublished PhD thesis, University of Technology, Sydney.Institute of Medicine. (2010). The Future of Nursing: Focus on Education. Accessed March 2017 at.Levett-Jones, T., Hoffman, K., Dempsey, Y., Jeong, S., Noble, D., Norton, C., … Hickey, N. (2010).The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ abilityto identify and manage clinically ‘at risk’ patients. Nurse Education Today, 30(6), 515-20.Martin, C. (2002). The theory of critical thinking. Nursing Education Perspectives, 23(5), 241-47.Mezirow, J. (1990). Fostering Critical Reflection in Adulthood: A Guide to Transformative andEmancipatory Learning. San Francisco: Jossey Bass.Norris, S. P. & Ennis, R. H. (1989). Evaluating Critical Thinking. Pacific Grove, CA: MidwestPublications, Critical Thinking Press.Paul, R. & Elder, L. (2007). The Thinker’s Guide for Students on How to Study and Learn a Discipline.Dillon Beach, USA: Foundation for Critical Thinking Press.Rubenfeld, M. & Scheffer, B. (2006). Critical Thinking Tactics for Nurses. Boston: Jones and Bartlett.Scheffer, B. & Rubenfeld, M. (2000). A consensus statement on critical thinking in nursing. Journal ofNursing Education, 39, 352-59.Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgement in nursing.Journal of Nursing Education, 45(6), 204-11.13

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