APNA 30th Annual Conference Session 4035: October 22, 2016 - PDF document

APNA 30th Annual Conference Session 4035: October 22, 2016 SELF-REFLECTIVE PRACTICE: A CRITICAL-REFLECTION WORKSHOP FOR BUILDING REFLECTIVE SKILL IN CLINICAL DECISION MAKING Rosalind De Lisser, MS, FNP, PMHNP Aaron Miller, MS, PMHNP UCSF School of Nursing NO FINANCIAL RELATIONSHIPS TO DISCLOSE OBJECTIVES • Define clinical decision making and identify cognitive processes related to challenges in the decision making process. • Discuss dual processing and how it relates to clinical decision making and cognitive failure. • Discuss verbal and written critical reflection and its' use in improving clinical decision making. DeLisser 1

APNA 30th Annual Conference Session 4035: October 22, 2016 WHY CRITICAL REFLECTION?? • A cognitive exercise which is designed to improve and increase self awareness • Provides the expert a structured process for exploring clinical challenges and lifelong learning • Provides the learner with a process with which to explore and understand clinical decision making, professional development, and role attainment THE WORK WE DO…. • Is challenging • Subjectivity and perceptions get in the way • Diagnoses can be unclear • Errors happen • Treatment and lack thereof….can be lethal • Creates the opportunity for vicarious traumatization CLINICAL DECISION MAKING DeLisser 2

APNA 30th Annual Conference Session 4035: October 22, 2016 WHAT DO WE KNOW ABOUT CLINICAL DECISION MAKING? • 10-15% of clinical diagnoses are wrong! • The decision making process is complex • Errors in clinical decision making are usually not due to a lack of knowledge • Errors in clinical decision making are related to the clinician’s thinking also known as cognitive failure Croskerry, M.D. (2013). From mindless to mindful practice – cognitive bias in clinical decision making. NEJM, 368(26), 2445-2448. COGNITIVE FAILURES?? • The human mind is vulnerable • We are impacted by BIASES! • Logical fallacies – flaws in reasoning • False assumptions • Failures in reasoning DUAL PROCESSING • 2 simultaneous cognitive processes • Was once a theory – but it has now been confirmed by FMRI that these dual processes involve differing cortical mechanisms and that we move from one to the other while learning • Type One: Intuitive • Type Two: Analytical DeLisser 3

APNA 30th Annual Conference Session 4035: October 22, 2016 DECISION MAKING AND DUAL PROCESSING Type ONE: Intuitive Type TWO: Analytical • Experiential • Hypothetico-deductive • Heuristic • Normative reasoning • Gestalt effect or pattern • Robust decision making • Recognition primed • Acquired, critical, logical thought • Unconscious thinking • Deliberate, purposeful thinking Croskerry, P. (2009). A universal model of diagnostic reasoning. Academic Medicine, 84(8), 1022-1028. TYPE ONE – INTUITIVE • Draws on experience of the clinician • Action on pattern recognition • Heuristics- mental short cuts that aid in rapid decision making • First impressions • Unconscious bias TYPE TWO- ANALYTICAL • Hypothetico-deductive • Normative reasoning • Robust decision making • Acquired, critical, logical thought • Deliberate, purposeful thinking DeLisser 4

APNA 30th Annual Conference Session 4035: October 22, 2016 CLINICAL DECISION MAKING: HYPOTHETICO-DEDUCTIVE METHOD Reflection Hypothesis Testing Hypothesis Generation Information Gathering COGNITIVE WHAT TO DO WHEN FAILURE GETS IN THE WAY? REFLECTION VS. CRITICAL REFLECTION Reflection Critical Reflection • Looking back • Questioning • Considering • Analyzing • Remembering • Reframing • Connecting • Relating past experience to future practice DeLisser 5

APNA 30th Annual Conference Session 4035: October 22, 2016 CRITICAL REFLECTION • Metacognitive process • Founded in Transformative Learning • The reflective practitioner • A process of analyzing, questioning, and reframing a personal experience to enhance learning and inform future behavior • Promotes self regulation and lifelong learning • No evidence to suggest that it improves patient care 2 KINDS • Verbal • On the fly, embedded in opening or closing of meetings or seminars • May be focused or very broad • Written • Process follows well known SOAP format • Documented account of past experience and its’ impact on future behavior THINK : PAIR : SHARE • Think about a recent patient encounter that surprised or challenged you. • Choose an experience that surprised or challenged you • You did not have the knowledge • You did not have the skill • It went well .. But you don’t know why? • Personal challenges • Confused, anxious, triggered DeLisser 6

APNA 30th Annual Conference Session 4035: October 22, 2016 THINK : PAIR : SHARE • Share with your neighbor: 2 minutes • What happened and how did it impact you? • What did you do? • What do you need to know to do it differently in the future? • Group debrief GROUP DEBRIEF: PROVEN TO BE ONE OF MOST EFFECTIVE WAYS TO BUILD AND STRENGTHEN TEAMS THE LEAP NOTE • LEaP: Learning from your Experiences as a Professional • A guideline to assist in process of critical reflection • Not a cookbook but a guide • Based on a chosen experience • Important to understand and follow LEaP guide • Feedback and reflection DeLisser 7

APNA 30th Annual Conference Session 4035: October 22, 2016 STEP ONE: CC • Choose an experience that surprised or challenged you • You did not have the knowledge • You did not have the skill • It went well .. But you don’t know why? • Personal challenges • Confused, anxious, triggered STEP TWO-THREE • Step Two: Subjective • Describe what happened • Step Three: Objective • Other’s peoples perspective • New data from the literature or other sources STEP FOUR – FIVE • Step Four: Assessment • Synthesize relate past experience / knowledge to present experience and new knowledge • Lessons learned • Step Five: Plan • SMART goals DeLisser 8

APNA 30th Annual Conference Session 4035: October 22, 2016 PRACTICE : PAIR : SHARE : DEBRIEF • Choose a 2 nd CC • Take 5 minutes to write your subjective account: step 2 • Follow the LEaP guide • Pair and share how you would approach steps 3-5 • Group debrief THANK YOU! QUESTIONS? Aronson, L. (2011). Twelve Tips for teaching reflection at all levels of medical education. Medical Teacher, 33 , 200-205. Aronson, L, Kruidering M, Niehaus B, O’Sullivan P. (2012) UCSF LEaP: Learning from your Experiences as a Professional: Guides for Critical Reflection. Chinn, P.L. (2004). Peace and Power Creative Leadership for Building Community . Sudbury, Ma: Jones and Bartlett. Croskerry, P. (2009). A universal model of diagnostic reasoning. Academic Medicine, 84(8), 1022-1028 Croskerry, M.D. (2013). From mindless to mindful practice – cognitive bias in clinical decision making. NEJM, 368(26), 2445-2448. Dhaliwal, G. (2006). Clinical decision-making: Understanding how clinicians make a diagnosis. New England Journal of Medicine. Elstein, A.S., Shulman, L.S., & Sprafka, S.A. (1978). Medical problem solving: an analysis of clinical reasoning. Cambridge, Mass. Harvard University Press. Mezirow, J. (1991). Transformative dimensions of adult learning. San Francisco, CA: Jossey-Bass. Sandars, J. (2009). The use of ciritical reflection in medical education: AMEE guide no. 44. AMEE Guide, 31, 685-695. Schon, DA. (1983) The reflective practitioner: How professionals think in action. New York, NY: Basic Books. Sloman, S.A. (1996). The empirical case for two systems of reasoning. Psychological Bulletin, 119(1), 3-22. Trimble, M. & Hamilton, P. (2016). The thinking doctor: clinical decision making in contemporary medicine. Clinical Medicine, 16(4), 343-346. DeLisser 9