Recent Trends In Diagnostic Decision Making In Clinical Practice

Clinicians’ practice is prone to complex diagnostic decision making, often in unsecure circumstances, uncertainty, time pressure and incomplete information. Processes of gathering information, drawing meaning, evaluation and coming to a diagnostic decision are influenced by multiple factors. Models of clinical decision making are based on cognitive models of human though and decision making. Knowledge about cognitive models of decision making and understanding possible flaws and biases is important for efficacy of experts’ proficiency in clinical environment. When making diagnostic decisions, one cannot entirely depend on intuitive decisions, as clinical environment is complex and dynamic. Past experience with similar cases is not always a reliable basis, as each case is unique. The importance of research in this direction is exceptionally big in terms of decisions made in clinical environment, where mistakes can cause great negative impact on patients’ health and well-being. We present general theoretical tendencies in the area of decision making – their strengths and weaknesses, also under which circumstances is one or the other method of decision making the better option to use. We also propose an instrument to evaluate psychopathological symptoms, which is intended to help clinicians’ practice in registering and structuring observed symptoms of patient and to direct and assist the decision-making process in clinical practice. Provided are basic psychometric characteristics, evaluating accuracy and eventual practical uses

The past and future of the AHP in health care decision making

Objective. Health care decision making is a complex process involving many stakeholders and allowing for multiple decision criteria. The Analytic Hierarchy process (AHP) can support these complex decisions that relate to the application and coverage of health care technologies. The objective of this study is to review the past applications of the AHP in supporting health care decision making, and to make recommendations for its future use.\ud Method. We conducted a systematic review of AHP applications in health care, as described in the relevant medical, health-economical, psycho-sociological, managerial, and applied mathematical literature.\ud Results. We found 62 distinctive AHP applications in health care. Of the retrieved applications, 13 % focus on shared decision-making between patient and clinician, 27 % on the development of clinical practice guidelines, 5 % on the development of medical devices and pharmaceuticals, 40 % on management decisions in health care organizations, and 15 % on the development of national health care policy.\ud Conclusions. From the review it is concluded that the AHP is suitable to apply in case of complex health care decision problems, a need to improve decision making in stead of explain decision outcomes, a need to share information among experts or between clinicians and patients, and in case of a limited availability of informed respondents. We foresee the increased use of the AHP in health economical assessment of technology

Clinical Decision Diagnosis Support System for Complementary and Alternative Medicine Practitioners in Lifestyle-related Diseases Management

Chronic diseases accounted for 60% of all deaths – corresponding to a projected 36.65 million deaths worldwide in 2007. 2.8% of the world population suffers from diabetes mellitus and it may cross 5.4% by the year 2025. Hypertension is a major burden on health care. Prevalence of lifestyle-related diseases increases. Low accessibility to and non-affordability of orthodox medicine by rural dwellers and their need to keep healthy to be economically productive have led to their dependence on medicinal plants to remedy afflictions. Complementary and Alternative Medicine (CAM) attracts patronage due to patients’ dissatisfaction with conventional health care, a desire for treatment and care that work, good relationship with practitioner, provision of information, a desire for greater control over one’s health, and a desire for cultural and philosophical congruence with personal beliefs about health and illness. Medicinal plants’ threatened sustainability makes adulteration and species’ substitutions reduce their efficacy, quality and safety. It was found that CAM practitioners who participated in this study relied heavily upon knowledge that had 'stood the test of time' (traditional theory and practice) and 'that which worked' (experientially based knowledge) as the basis for clinical decision-making. The safe, effective and efficient delivery of client care is informed primarily by sound clinical decision making. Body mass index (BMI) plays a significant role in the process. Strategies that guide practitioners through the process of decision making may not only foster professional excellence in CAM practice, but also help to improve the quality of client care. Clinical decision-making is a complex process that is reliant on accurate and timely information. Clinicians are dependent (or should be dependent) on massive amounts of information and knowledge to make decisions that are in the best interest of the patient. CAM practitioners of modern time need currency and timeliness on computations of patients’ body mass index, waist circumference and body shape combination; product/therapy data on therapeutic efficacy; product quality and safety; adverse reactions and herb-drug interactions. This paper presents a clinical decision diagnosis system supporting CAM practitioners to effectively treat emerging lifestyle-related diseases with medicinal plants. Keywords: body mass index, complementary and alternative medicine, lifestyle-related diseases, medicinal plants, clinical decision support syste

Applying a midwifery-specific decision-making tool to midwives' clinical reasoning and midwifery practice when managing a woman's perineum in labor: An exploratory study

INTRODUCTION: Many of the risk factors for perineal trauma are modifiable, and midwives are in an ideal position to mitigate such risks. To date, no investigation using a midwifery-specific decision-making tool has sought to determine how midwives make decisions within a midwifery philosophy/context or identify the factors that may contribute to that decision making about perineal management. We sought to apply such a tool to midwives' narratives and explore their clinical reasoning and midwifery practice when managing a woman's perineum in labor. METHODS: A qualitative interview-based study with practicing midwives in one regional Australian maternity unit was conducted. The decision-making matrix specified by a psychometrically robust and validated measure of clinical decision making and midwifery practice-guided analysis. RESULTS: Effective clinical decision making in response to perineal trauma is contingent on a heuristic and individualized "working hypothesis" that combines distinct elements of an optimal clinical decision- making process. Midwives' narratives highlighted their ability to engage in some form of clinical reasoning. Some elements of midwifery practice was lacking within several midwives' narratives, thus resulting in them abdicating their professional role. CONCLUSION: The manner and processes by which midwives engage effectively with perineal management are complex. However, a significant influence on this process appears to be recollections from original training in perineal management, which appears to be largely rote and taught by example. We recommend balance between practical experience and synthesis with current evidence within a midwifery philosophy to optimize perineal care and risk modification

Intuition in Nursing Practice : Knowledge, Experience, and Clinical Decision Making

Intuition is a commonly used aspect in nursing practice. As the evidence based practice is the prominent practice today, the intuition based practice is hidden and somewhat devalued. Although it is difficult to define due to its nature, intuition is an essential part of effective clinical decision making. This research is an inductive qualitative content analysis that focuses on novice nurse and expert nurse, and their use of intuition based on knowledge and experience. Benner’s From Novice to Expert theory as well as Carper’s Fundamental Patterns of Knowing in Nursing theory form the theoretical framework of this research. Benner’s theory talks about five stages of nurses’ professional development, whereas Carper’s theory focuses on the different ways of knowing in nursing profession. The aim is to define intuition, knowing, and clinical decision making. In addition, this research describes the impact of knowledge and experience on intuition and clinical decision making related to novice nurse and expert nurse. The research material consists of 20 scholarly articles, for instance from Sage and Research gate. Although intuition has been used by nurses in practice every day, the attention given to this kind of nursing practice is too little. Therefore, this subject area has not been researched enough. The research shows that intuition is a complex term to define. It can be seen as unconscious awareness of reasoning, a sixth sense, or a gut-feeling. It is used during nursing practice in clinical decision making. Intuition is mainly used by expert nurses, but unlike in Benner’s model, also novice nurses can use it, especially if they have some previously gained life experience. Knowledge and experience are the most influencing factors on intuition. Therefore, gaining nursing intuition requires a good knowledge base and clinical experience. Other factors affecting successful clinical decision making are the different aspects of knowing that include, for instance, knowing the self, the profession, and the patient

Paramedic clinical decision making during high acuity emergency calls: design and methodology of a Delphi study

<p>Abstract</p> <p>Background</p> <p>The scope of practice of paramedics in Canada has steadily evolved to include increasingly complex interventions in the prehospital setting, which likely have repercussions on clinical outcome and patient safety. Clinical decision making has been evaluated in several health professions, but there is a paucity of work in this area on paramedics. This study will utilize the Delphi technique to establish consensus on the most important instances of paramedic clinical decision making during high acuity emergency calls, as they relate to clinical outcome and patient safety.</p> <p>Methods and design</p> <p>Participants in this multi-round survey study will be paramedic leaders and emergency medical services medical directors/physicians from across Canada. In the first round, participants will identify instances of clinical decision making they feel are important for patient outcome and safety. On the second round, the panel will rank each instance of clinical decision making in terms of its importance. On the third and potentially fourth round, participants will have the opportunity to revise the ranking they assigned to each instance of clinical decision making. Consensus will be considered achieved for the most important instances if 80% of the panel ranks it as important or extremely important. The most important instances of clinical decision making will be plotted on a process analysis map.</p> <p>Discussion</p> <p>The process analysis map that results from this Delphi study will enable the gaps in research, knowledge and practice to be identified.</p

A phenomenological study of clinical decision making by flight nurse specialists in emergency situations

Clinical decision making is an integral, multifaceted phenomenon fundamental to nursing practice. The domain of flight nursing practice is unique in terms of knowledge, structure, clinical presentations and environment. The uniqueness and diversity of patient scenarios and the advanced practice level of the flight nurse role blend to provide a potential rollercoaster flight mission. At the time this research was conducted nursing standards to guide clinical decision making were being developed. Medically orientated clinical guidelines were in place, but they were designed to highlight a specific, well defined clinical scenario or skill. It has been argued that guidelines for nursing practice do not always parallel the complex clinical situations in which advanced practitioners may find themselves (Malone, 1992b). Flight Nurse Specialists (FNSs) with greater than two years flight nursing experience employed by the Royal Flying Doctor Service (RFDS) - Western Operations were interviewed regarding their experiences of clinical decision making in emergency situations. Using a phenomenological methodology, indepth interviews were audiotaped and transcribed. The interviews were analysed using the method described by Colaizzi (1978). Data was described and interpreted, common themes were extrapolated and analysed. A Gestalt of Knowing was identified by the interconnection and interrelationships of the extrapolated themes. The three themes are: Ways of Knowing the Patient, Context of Knowing and Reflective Practice. Ways of Knowing the Patient is constructed with the sub-themes intuitive knowing, experiential knowing and objective knowing. The second theme, Context of Knowing, is made up of the sub-themes aviation environment, non or minimised involvement in triage, knowing co11eagues, solo practitioner, experiential level and practice guidelines. Self-critique and change in practice formed the theme Reflective Practice. Findings provide a significant contribution to the knowledge of clinical decision making in nursing and to the practice of flight nursing in the Western Australian context. Several recommendations arose from the findings in relation to further research, policy making, standards development and practice developments. Further research is needed into the themes and sub-themes. FNSs need to be allowed to undertake the role of triage for those flights that they will undertake as the solo health professional. The development of standards for flight nursing would benefit from the consideration of the findings of this study and other qualitative studies of clinical decision making. Reflective practice should be considered as a mechanism for not only evaluating practice but as a mechanism for identifying stressful events

Developing clinical decision tools to implement chronic disease prevention and screening in primary care: the BETTER 2 program (building on existing tools to improve chronic disease prevention and screening in primary care).

BackgroundThe Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice (BETTER) trial demonstrated the effectiveness of an approach to chronic disease prevention and screening (CDPS) through a new skilled role of a 'prevention practitioner'(PP). The PP has appointments with patients 40-65 years of age that focus on primary prevention activities and screening of cancer (breast, colorectal, cervical), diabetes and cardiovascular disease and associated lifestyle factors. There are numerous and occasionally conflicting evidence-based guidelines for CDPS, and the majority of these guidelines are focused on specific diseases or conditions; however, primary care providers often attend to patients with multiple conditions. To ensure that high-level evidence guidelines were used, existing clinical practice guidelines and tools were reviewed and integrated into blended BETTER tool kits. Building on the results of the BETTER trial, the BETTER tools were updated for implementation of the BETTER 2 program into participating urban, rural and remote communities across Canada.MethodsA clinical working group consisting of PPs, clinicians and researchers with support from the Centre for Effective Practice reviewed the literature to update, revise and adapt the integrated evidence algorithms and tool kits used in the BETTER trial. These resources are nuanced, based on individual patient risk, values and preferences and are designed to facilitate decision-making between providers across the target diseases and lifestyle factors included in the BETTER 2 program. Using the updated BETTER 2 toolkit, clinicians 1) determine which CDPS actions patients are eligible to receive and 2) develop individualized 'prevention prescriptions' with patients through shared decision-making and motivational interviewing.ResultsThe tools identify the patients' risks and eligible primary CDPS activities: the patient survey captures the patient's health history; the prevention visit form and integrated CDPS care map identify eligible CDPS activities and facilitate decisions when certain conditions are met; and the 'bubble diagram' and 'prevention prescription' promote shared decision-making.ConclusionThe integrated clinical decision-making tools of BETTER 2 provide resources for clinicians and policymakers that address patients' complex care needs beyond single disease approaches and can be adapted to facilitate CDPS in the urban, rural and remote clinical setting.Trial registrationThe registration number of the original RCT BETTER trial was ISRCTN07170460

How to improve ethical decision-making in clinical practice? Practical models and guidelines

Background: Clinical practice in palliative care is characterized by the need of making ethico-clinical decisions, particularly at the end-of-life. End-of-life situations are situations in which a severe deterioration in health, due to the evolution of a disease or another cause, threatens the life of a person irreversibly in the near future, posing the need to make ethico-clinical decisions. Often, these decisions are difficult and challenging; the so-called “ethical challenges” emerge. Despite its ubiquity, there is no consensualized definition of this expression. Various terms are used interchangeably, e.g., “ethical challenges”, “ethical problems”, “ethical issues”, “ethical dilemmas”. Moreover, even though there is a wide range of ethical decisions that need to be made in palliative and end-of-life care, there is no unique model or guideline to help professionals and teams in making difficult and complex decisions. Aim: To explore practical models and guidelines that can be used in clinical contexts to improve ethical decision-making in palliative and end-of-life situations. Methods: This presentation is based on the work developed within project DELiCare: Decisions, Decision-making, and End-of-Life Care: Ethical Framework and Reasoning. The overall project, its objectives, methods, results, and implications will be presented in an integrated fashion, including the application of ethical decision-making models and guidelines to specific clinical cases. Results: End-of-life decisions are rooted in clinical, sociocultural, political, legal, economic, and ethical concerns. Several models and guidelines for ethical decision-making at the end-of-life coexist but are rarely used in clinical practice. These models and guidelines can be a relevant aid for healthcare professionals and teams. They can stimulate the debate around disputed and controversial issues, helping professionals to follow a well-informed and shared decision-making model in order to meet patients’ values, wishes and preferences. Conclusions: Decision-making processes underlying end-of-life decisions are influenced by and foster clinical, ethical, sociocultural, religious, political, legal, and economic concerns and debates. Healthcare professionals working in palliative and end-of-life care often perceive these decision-making processes as complex and challenging. The use of practical models and guidelines can enhance professionals and teams’ competencies and effectiveness in making ethico-clinical decisions at the end-of-life.info:eu-repo/semantics/acceptedVersio