[PDF] - APNA 30th Annual Conference Session 4035: October 22, 2016 PDF Document

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APNA 30th Annual Conference Session 4035: October 22, 2016 DeLisser 1

Rosalind De Lisser, MS, FNP, PMHNP Aaron Miller, MS, PMHNP UCSF School of Nursing

SELF-REFLECTIVE PRACTICE:

A CRITICAL-REFLECTION WORKSHOP FOR BUILDING REFLECTIVE SKILL IN CLINICAL DECISION MAKING

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.

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APNA 30th Annual Conference Session 4035: October 22, 2016 DeLisser 2

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

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APNA 30th Annual Conference Session 4035: October 22, 2016 DeLisser 3

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

ther while learning
Type One: Intuitive
Type Two: Analytical

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APNA 30th Annual Conference Session 4035: October 22, 2016 DeLisser 4

Hypothetico-deductive
Normative reasoning
Robust decision making
Acquired, critical, logical

thought

Deliberate, purposeful

thinking

Experiential
Heuristic
Gestalt effect or pattern
Recognition primed
Unconscious thinking

DECISION MAKING AND DUAL PROCESSING

Type ONE: Intuitive Type TWO: Analytical

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

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APNA 30th Annual Conference Session 4035: October 22, 2016 DeLisser 5

CLINICAL DECISION MAKING: HYPOTHETICO-DEDUCTIVE METHOD

Information Gathering Hypothesis Generation Hypothesis Testing Reflection

COGNITIVE WHAT TO DO WHEN FAILURE GETS IN THE WAY?

Questioning
Analyzing
Reframing
Relating past experience to

future practice

Looking back
Considering
Remembering
Connecting

REFLECTION VS. CRITICAL REFLECTION

Reflection Critical Reflection

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APNA 30th Annual Conference Session 4035: October 22, 2016 DeLisser 6

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
r seminars
May be focused or very broad
Written
Process follows well known SOAP format
Documented account of past experience and its’ impact
n 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

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APNA 30th Annual Conference Session 4035: October 22, 2016 DeLisser 7

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

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APNA 30th Annual Conference Session 4035: October 22, 2016 DeLisser 8

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

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APNA 30th Annual Conference Session 4035: October 22, 2016 DeLisser 9

PRACTICE : PAIR : SHARE : DEBRIEF

Choose a 2nd 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.