Over time, as experience develops, clinical reasoning themes emerge that speed our decision-making for commonly reoccurring scenarios. We begin, for example, to develop rules of thumb and analogies resulting in common pattern recognition that originate from past successes. The formal term for this is heuristics. In fact, clinicians rarely use formal computations to make patient care decisions in day-to-day practice. Rather, an intuitive understanding of probabilities combined with a concoction of rules of thumb, educated guesses, and mental shortcuts end up guiding practice.
However, if we are not careful, other factors can cloud our thinking. In particular, we must be mindful of biases, cultural background, and assumptions when making clinical judgments.
Biases are rooted in human nature and are hard to avoid. We can, however, mindfully consider them as we reflect to improve practice. Here are a few biases of importance to avoid when making clinical judgments.
is one of the most common errors. In this bias, clinicians make a quick diagnosis (often based on pattern recognition), fail to consider other possible diagnoses, and stop collecting data (jump to conclusions). In fact, even the suspected diagnosis is not always confirmed by appropriate testing. A premature closure issue common in correctional nursing might be “I know this patient-he is faking this condition to get attention”.
occurs when clinicians selectively accept clinical data that support a desired hypothesis and ignore data that do not. Clinicians who rely heavily on pattern recognition and become overconfident in diagnostic abilities can fall prey to premature closure and confirmation biases. For example, if a patient is acting erratically and an officer shares a high breathalyzer reading, a nurse may settle on the determination that the patient is intoxicated, even though there are signs of a head injury.
results in overweighing evidence that comes easily to mind. This could be recent evidence or what we perceive as meaningful events. For example, when a facility has an outbreak of the flu, and a patient comes to Sick Call with fever, chills, and general body ache, the natural thought would be that the patient has the flu. However, there are other diagnoses with these symptoms and this patient may, instead, have tuberculosis, Lyme disease, or acute sinusitis.
Assumptions about what is and isn’t present can also affect our thinking and judgment. A simple example can underscore how assumptions can get us tripped up. Consider this puzzle that you must solve. A donkey is tied to a 6 foot rope. A bale of hay is 8 feet away from the donkey. Without biting through the rope, how can the donkey get to the bale of hay? Answer: He just walks over to it. There is no mention that the rope is anchored to the ground. Most people hearing this story, though, assume that the donkey is tethered.
Sometimes we need to identify what isn’t there as well as what is there when evaluating a patient.
Our culture can lead to unconscious ‘habits of the mind’ that affect clinical judgment. Repeated personal experiences and cultural socialization are absorbed into our ways of thinking about the world around us. For example, over time, correctional clinicians may absorb a jaded view of inmate intentionality or the surrounding security culture of the facility. Attitudes about patient motivation can cloud our judgment and alter our interpretation of symptoms. We must be mindful of them, and work to disregard them in our daily practice.
This Clinical Judgment post is based upon The Correctional Nurse Educator class entitled Clinical Judgment for the Correctional Nurse.