Selasa, 16 Juni 2009

TEACHING CLINICAL DECISION-MAKING

Clinical decision-making is the systematic process by which skilled providers make judgments regarding a patient’s condition, diagnosis and treatment. Despite the importance of sound clinical decision-making to the provision of high quality services, it is not well taught in either preservice education or inservice training. There is so much basic knowledge to be acquired that it leaves little time for complex skills such as clinical decision-making. And even when there is enough time, decision-making is a difficult skill to teach and learn.

Until recently, very little was known about how decisions are made. For experienced providers, decision-making is an intuitive process based on knowledge and experience. Many of the steps necessary to arrive at a decision can be completed rapidly and unconsciously. Such providers are unable to explain how they make decisions, which in turn makes it difficult to teach this skill to others. Nor is it easy for learners to identify how a decision is made when simply observing other providers in action. Consequently, they have nothing to model for developing their own skill.

It is now known, however, that there is a process to clinical decision-making that can be broken down into a series of steps that help the provider to gather the information needed to form accurate judgments, begin appropriate care and evaluate the effectiveness of that care. There are a number of different ways to name these steps, but they describe the same process. Two such approaches are illustrated below.

• Assessment , or Gathering information
• Diagnosis , or Interpreting the information
• Planning, or Developing the care plan
• Intervention , or Implementing the care plan
• Evaluation , or Evaluating the care plan

An important strategy in teaching clinical decision-making is to be sure that learners are aware of this step-by-step process and what occurs in each step. They also must understand that, although there is a sequence of steps for clinical decision-making, movement through the steps is rarely linear or sequential. Rather, it is an ongoing, circular process, in which the provider moves back and forth between the steps as the clinical situation changes and different needs or problems emerge.

Learners should be introduced to the steps in clinical decision-making early in their education. After that, these steps should receive continual emphasis and be used in a variety of situations. Throughout the curriculum, learners should be given opportunities and appropriate situations in which to apply these steps and practice their decision-making skills. Whether they are actively practicing their own skills or observing more experienced providers, learners should focus on understanding the reasoning and judgment that are the basis for each step in the process. How a decision is made is as important as what decision is made. Explaining how a decision is made usually requires the active involvement of the teacher because the process of decision-making is not easy to observe or identify.

Another key strategy in teaching clinical decision-making is to provide as much experience and practice in decision-making as possible. This experience, together with clinical knowledge, is a key component of successful decision-making. Teachers should:

• Expose learners to as many and as wide a variety of patients as possible.
• Put learners in the clinical setting as early as possible and provide careful guidance as they gain their experience.
• Give learners as much structured independence as possible; they must be given the opportunity and time to draw their own conclusions and consider their own decisions.
• Provide learners with a forum, for example, case reviews or clinical conferences, for comparing their decisions with the decisions made by more experienced providers.

It is important that the teacher discuss the decision-making process with each learner, and that learners share their experiences with one another. By sharing experiences, learners get that many more cases or approaches to the same case to “file away” for future use, even though they may not have been directly involved in the cases themselves.

Finally, the teacher should give learners feedback on how the clinical decision-making process was applied in a given situation. This will strengthen future performance more effectively than focusing on whether or not the “correct answer” was identified. In fact, a wrong answer for the right reason should receive more positive feedback than a right answer for the wrong reason.

Often, it is not possible to give learners experience with all the types of situations they will encounter as independent practitioners. Their “memory files” of experience can nevertheless be built up in other ways. Extensive use of case studies, role plays and simulations, in which specific clinical situations are acted out, can contribute significantly to learners’ experience. For example, true shoulder dystocia during childbirth is uncommon, but repeated drilling or practice on models of the corrective maneuvers for shoulder dystocia will help learners respond to the emergency when it happens.

Tools for teaching clinical decision-making are presented throughout this learning resource package. The case studies and clinical simulations have been designed to facilitate the teaching of decision-making by reinforcing the steps involved in the process. The partograph exercises are also effective tools for decision-making. Their purpose is not simply to help learners plot data on the partograph, but rather to use those data for identifying and responding to problems as soon as, or even before, they occur. The tools alone, however, will not effectively teach clinical decision-making. The teacher must take an active role in discussing, questioning, explaining and challenging the learners about how decisions are being made each time one of these tools is used. And this interaction must continue as the learners move into the clinical area and work with patients.

Clinical decision-making is still a difficult skill to teach. But by beginning early in the curriculum and continually providing practice opportunities and guidance—whether by using the tools included in this learning resource package or through experience with patients—teachers will help learners more fully understand the decision-making process and develop their decision-making skills. As a result, the quality of care received by patients will be improved.

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