Durning, S. The International Council of Nurses (ICN) noted that, globally, advanced practice nurses, including clinical nurse specialists, nurse practitioners, nurse midwives and nurse anaesthetists are one of the fastest growing health professions, responsible for innovating health care systems, improving access to care, achieving better health outcomes, and reducing health care costs (ICN,2021). Despite a comprehensive search of the US literature addressing clinical reasoning in NP education, few papers directly addressed the topic of DR. , The origins of the history and physical examination. , Zottmann, J. M. , & The actionable outcomes of critical thinking, clinical reasoning, and situational awareness. , & (2019); Downes et al. Schoenbaum, S. Graber, M. L. See Table3 for descriptions of the educational interventions and measures used to assess DRrelated competencies. , Purposeful search for history and exam data to confirm or refute the differential, based on script activation and elaborated illness scripts. 2. , Juve, C. , When a patient presents with symptoms of pain to the spine, knee, hip or shoulder, clinicians often initiate a cascade of history questions, physical examination tests, clinical measures and imaging tests in order to diagnose the sources of the symptoms.24 Musculoskeletal care is plagued by overuse of diagnostic tests. Repetitive operation of Type 2 leads to Type 1 (. , , & Use of the clock model (T). Traditionally, assimilation of clinical and DR processes in NP education has relied primarily on implicit learning through the preceptorled clinical practice component of the NP curriculum, with little incorporation into the didactic curriculum. (2014). , (2019). Lambe, K. A. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews, Using specialized standardized patients to improve differential diagnoses. 1 Whilst apparent that components of DR are valued in NP education, simply mapping those components does not fully reflect whether DR is sufficiently addressed in NP education. Here we argue that identifying and classifying patients based on this model can lead to overcomplicated or asymptomatic diagnostic labeling that may not translate into better patient outcomes. Diagnostic reasoning can be defined as the process of evaluating the results of some operations (questions or practical actions), to establish which specific conditions hold on an individual or, generically, on a sample. de Faria, R. M. D. Conclusions A diagnostic suggestion in a GPs referral letter did not influence subsequent diagnostic accuracy, confidence, or time to diagnose for medical interns. , Schmidt, H. G. , & For example, the Thessaly test for meniscal tears was initially developed in a study with a low-quality design and the results were not replicated afterward.6, 16, 17 Clinicians should look closely at study designs, reference standards and how the tests were described as these have most commonly influenced biases in diagnostic accuracy studies.18 Further, the severity of the population group may influence outcomes. Based on longitudinal cohorts, the field of knee osteoarthritis (OA) as greatly expanded this knowledge in the last decade. Pauli, E. Jones, M. Consideration of cost, risks and benefits, and sensitivity and specificity of testing, Articulates correct diagnosis with rationale. Cognitive processes are used to analyse empirical knowledge, based on evidence and science. [PMC free article] [PubMed] [CrossRef] [Google Scholar]. Methods We developed a model for improving diagnostic performance through feedback using a six-step qualitative research process, including a review of existing models from within and outside of medicine, a survey, semistructured interviews with individuals working in and outside of medicine, the development of the new model, an interdisciplinar. Is a process by which clinicians collect, process, and interpret patient information to develop an action plan; Creates a story from the patient's history, physical exam, test results and serial observation; Serves to enhance acquisition and storage of knowledge through repeated exposure to real case examples; Helps the learner develop memory schemes for representing and relating clinical problems. Evidencedbased therapeutic interventions; Includes patient's/caregiver's preferences related to therapeutic interventions, Development of advanced integrative thinking skills. , Succinct presentation of findings. Diagnostic reasoning strategies and diagnostic success - PubMed , Connelly, S. Clinical reasoning (CR) can be defined as "a process that operates toward the purpose of arriving at a diagnosis, treatment, and/or management plan." 1 It is a complex process that involves a series of steps and cognitive functions. , , , , & Table 1 provides the most commonly used test metrics in diagnostic assessment. Best practice would base such guidelines in DR science, focused specifically on the teaching of DR. Preceptor development in DR may be an additional necessary component to support student learning. , Ongoing, iterative process that occurs dynamically as relationships evolve. Rencic, J. , Ability to determine correct differential diagnoses. Meyer, A. N. D. Kiesewetter, J. Finnegan, L. Li, T. Presentation is thorough, concise and organized. , Identify individual areas for improvement. Harris, I. , the contents by NLM or the National Institutes of Health. , This lack of a robust body of literature poses challenges for educators wishing to adopt best practices and improve student learning outcomes relative to DR. 1 Bethesda, MD 20894, Web Policies Two facets of diagnostic reasoning related to scientific thinking are recognizing the difference between confounded and unconfounded evidence and selecting appropriate interventions that could provide learners the evidence necessary to make an appropriate causal conclusion (i.e., the control-of-variables strategy). Synthesize and assimilate elements of the biopsychosocial assessment into conclusions that are diagnostically accurate. , , & (2012); Schumaker and Bergeron(2016); Surjadi et al. Giuliano, M. (2019); Tiffen et al. Korenstein D., Chimonas S., Barrow B., Keyhani S., Troy A., Lipitz-Snyderman A. Selecting image modalities that are costeffective whilst detecting enough information to formulate the correct diagnosis. (2019); Sweeney et al/ (2017), Organization of the encounter; strong empathy, connection and interaction with patient; openended questions; minimal medical jargon; clear communication; effective therapeutic communication; respect for patient dignity and worth; therapeutic communication and relationship building; communicates effectively with team members; demonstrates cultural awareness and sensitivity; reviews chart prior to patient encounter; completes the encounter in a timely manner; maintains professional standards; Sets the context for further interaction; determine the meaning of the illness to the patient and assess this in realms that address the whole person; effective interviewing strategies to calm, focus and reassure the anxious patient; communication techniques that foster patient confidence and trust; professional and respectful interactions with patients and members of the interprofessional team; responsible and follows through on tasks; recognizing and overcoming barriers to practicing patientcentred care in the current demanding health care delivery system. The component of NP knowledge arising from nursing is oriented to caring for person, health and environment, whilst the component adopted from medicine is oriented toward the diagnosis and treatment of disease. In this study, we investigated broad content-independent behavioral indicators of diagnostic accuracy and checked whether and how quickly diagnostic accuracy could be predicted from these behavioral indicators when they were displayed in a collaborative . The pathophysiologic reliability of the diagnosis is a check on the reasonableness of causal linkages between clinical events, ascertained from use of biomedical knowledge. The likely, but unconfirmed, diagnosis, without ruling out other diseases. The EPA assessment tool focused on 6 major competencies: information gathering, physical examination, clinical judgement/ assessment, management plan, professionalism and overall clinical competence. (2016); Benbenek et al. A detailed characterisation study of 127 patients to help develop targeted intervention (TIPPs), https://www.ncbi.nlm.nih.gov/books/NBK458/, http://www.who.int/classifications/icd/factsheet/en/. Chen, C. Comparison of critical thinking, clinical reasoning, diagnostic reasoning, and clinical judgement. National Library of Medicine Barker, C. , & , & Flipping the objective structured clinical examination: A teaching innovation in graduate nursing education, Using problembased learning in teaching advanced health assessment: An innovative approach. In a cohort of 127 patients with patellofemoral pain, one group identified three subgroups classified as strong, weak and tighter and weak and pronated foot based on six common clinical measures such as flexibility, strength, patellar mobility and posture of the foot.46 The authors proposed that these subgroups could be used to develop targeted rehabilitation approaches that can further improve patients outcomes. Rikers, R. M. , Results Sixty-seven full-text articles were first identified. , (2016); Conelius et al. , Frontiers | Exploring the Process of Preservice Teachers' Diagnostic Information may be obtained primarily through reading, visual imagery, and listening. Journal of the American Medical Informatics Association, http://creativecommons.org/licenses/by-nc-nd/4.0/, https://www.icn.ch/news/internationalnursingconferenceshinesspotlightadvancedpracticenursing. Thus, the unaccomplished aims become part of the future implications of our review. Develop hypotheses to explain a patients clinical problem and apply collected information to test the hypotheses in order to try and confirm or exclude a hypothesis. (2016); Conelius et al. , The clock model: A tool for clinical reasoning in the emergency department, Standardized patients: A creative teaching strategy for psychiatricmental health nurse practitioner students. It notes that the clinical encounter has parallels in hypothetico-deductive reasoning, sharing key elements but not the sequential structure. Gordon, R. , University of Iowa Indigenous Land Acknowledgement, Faculty/Fellows as Clinician Educators (FACE), Clinical Problem Solving/Diagnostic Reasoning Session, Tips for Facilitating Diagnostic Reasoning Sessions, Tips on Finding a Master Clinician Advisor, University of Iowa Indigenous Land Acknowledgement. Interpretive summary statement of the patient's presentation that captures key aspects most relevant to diagnosing the patient's condition (clinical context, risk factors, temporal pattern) using qualified medical terminology and clearly communicating the clinical inferences. Our screening and selection process was done in duplicate by two independent reviewers, whilst our data extraction process was completed by two reviewers who extracted data from a subset of eligible studies to ensure good agreement between the extractors. Better understanding of the scope of their role as advanced practice nurses. Bennett, S. L. (2018); LaManna et al. (2016; Calohan et al. Develop individualized treatment plans that are evidenced based and encompass patient safety. SIDM, for example, has developed an interprofessional consensus curriculum (Olson et al.,2019) with individual, teambased and systemlevel competencies. The review underscores the compelling need to develop and disseminate a more systematic approach to teaching and evaluating DR. Whilst challenging, NP scholarship about teaching DR is in need of increased scientific rigour with stronger conceptual ties to the science and principles of DR, and to pedagogical best practices. var bugzillaReferrer = window.location.href; Boston. Decker, S. I. All Rights Reserved (2019); Weber and Snow(2006), Capstone OSCEs (E). Critical thinking versus clinical reasoning versus clinical judgment, An introductory clinical core course in psychiatric management: An innovative lifespan course blending all nurse practitioner majors, Reaching common ground: The role of shared mental models in patient safety, Journal of Patient Safety and Risk Management. Ho, A. M. H. We take the opposite perspective: namely, that effective and welldeveloped clinical thinking skills must be taught in order to develop safe and effective NP practice at the independent provider level. Key history components and supporting diagnostics were entered into the Isabel IDEAS system. Uses evidencebased clinical reasoning in formulating a diagnosis. (2017). Take home message: These examples demonstrate that phenotyping based on patients characteristics, reported outcome measures and clinical examination can help us better understand different profiles of patients and different trajectories of presentation for a given diagnostic label. Experienced NP students demonstrated greater use of clinical and biological inferential reasoning in their diagnostic reasoning as compared with novice NP students. We could determine for which patient we can simply prescribe watchful waiting compared to those that requires intensive rehabilitation, which could redirect cost to improve coverage of rehabilitation. Prevalence of femoroacetabular impingement imaging findings in asymptomatic volunteers: a systematic review. Garrett, L. Boshuizen, H. P. A. Our review suggests that NP faculty development around teaching and conducting scholarship in DR may be necessary. Servicelearning clinic (T, E). Department of Internal Medicine Therefore, clinical reasoning is of paramount importance to link the test results to an appropriate management plan in a complete care pathway. Higher order thinking is posited on the concept that some forms of learning require greater cognitive processing and indirectly require different forms of learning beyond memorization, facts and, concepts. The clinical thinking skills of DR and the advanced clinical knowledge base to which they are applied are inseparable. (2014); Pearson et al. The template assists the student to move from a chief complaint to potential diagnoses to intentional history gathering to priority exam components to diagnostic testing, resulting in a narrowed differential and final diagnosis, Describe the use of the clock model for teaching clinical reasoning to NP students in the emergency department, Clinical reasoning involves both the use of the scientific method to analyse information and pattern recognition to deliberately reach a clinical decision; diagnostic reasoning is the complex process used to gather and analyse patient information, evaluate its significance, and weigh alternative actions, Embeds the concept of time in clinical reasoning by presenting clinical reasoning as a logical progression of 12 steps for information analysis and pattern recognition to reach a deliberate and timely clinical decision, Describe the use of a series of simulated SP clinical scenarios with PMHNP students to build diagnostic reasoning skills, Build diagnostic reasoning skills to conceptualize case formulations and examine differential diagnoses related to mental disorders, Students received didactic content on a specific mental health disorder including assessment, diagnostic and screening tools. Effectiveness of the McKenzie method of mechanical diagnosis and therapy for treating low back pain: literature review with meta-analysis. Since then, DR has become a principal component of teaching clinical reasoning in medical education globally (Cooper et al.,2021; Englander et al.,2013; Gilkes et al.,2022; Olson et al.,2019). Combs, T. Specific areas for NP faculty teaching and scholarship development include a stronger focus on clinical reasoning science and theory in general and diagnostic reasoning in particular; the development of a common language for teaching, discussing and conducting research in DR; increased specificity in the development of competencybased pedagogies for DR; and approaches for conducting more robust educational research. Heuristics are shortcuts used to simplify decision making in otherwise complex situations, frequently occurring as part of system 1 thinking. Marshall, C. Whilst beyond the scope of this paper to describe the cognitive science of DR in detail, several summaries of DR are available (Bowen,2006; Croskerry,2009; Thammasitboon et al.,2018) and generally include the following: clinical knowledge development and organization (Charlin et al.,2007); patient interaction and encounter management skills (Hasnain et al.,2001); hypothesisdirected history and exam skills (Thampy et al.,2019); script activation (Custers,2015); problem representation (Bowen,2006; Chang et al.,1998; Connor & Dhaliwal,2015); analytic and nonanalytic thinking (Lambe et al.,2016); generating an appropriate and relevant differential diagnosis (Xu et al.,2021); appropriate and relevant diagnostic testing (Steiger et al.,2011); determining the working diagnosis (Charlin et al.,2007); developing an evidencebased and patientcentred management plan (Cooper et al.,2021); reflecting on one's DR competencies (Mamede et al.,2012; Olson et al.,2019). , , Some scholars (see Monteiro et al.,2020, for example) have argued that clinical thinking skills cannot be reliably taught; rather, the development of these skills is the result of many years of clinical experience and expertise. The curriculum was found to increase students' skills in cardiovascular assessment and diagnostic reasoning, Case Report (Teaching) with repeat measures comparative design, Describe the diagnostic accuracy and selfreported confidence levels of NP students using a diagnostic decision support system (DDSS) over their educational program and evaluate differences between PNP and FNP students, Use of diagnostic decision support to improve diagnostic accuracy, The Isabel IDEAS DDSS was implemented together with online cases into PNP and FNP curricula. 8600 Rockville Pike Moher, D. At its core, the ICD diagnostic system improves communication among providers of healthcare and should be considered a minimum competency for healthcare diagnosticians. Sood, L. McKenzie, J. E. Warner, C. Sinacore, J. M. , No patient or public contribution was included in this review, as the public is generally not familiar with DR or its teaching approaches. Assessment of an emergency physician (EP)'s diagnostic reasoning skills is essential for effective training and patient safety. Enhancing clinical decision making: Development of a contiguous definition and conceptual framework. Finnegan, L. Information processing theory stipulates that diagnostic competency requires the ability to quickly and reliably access a welldeveloped, accurate, and wellorganized clinical knowledge base, arrive at a situationally appropriate interpretation of the data and generate an appropriate and relevant differential diagnosis. (2014). , University of Regina, Define diagnostic reasoning - is a type of critical thinking - includes a systematic way of thinking that evaluates each new piece of data to support some hypothesis and reduce others. Developmental OSCEs (T, E). (2010). , & Broadening the reach of standardized patients in nurse practitioner education to include the distance learner, Objective structured clinical evaluation effectiveness in clinical evaluation for family nurse practitioner students. , Data was collected using RedCap. All team members participated in extracting data from the articles. The essentials Core competencies for professional nursing education, Scoping studies: Towards a methodological framework, International Journal of Social Research Methodology.