Reasoning like a doctor or like a nurse? A systematic integrative review.

When physicians and nurses are looking at the same patient, they may not see the same picture. If assuming that the clinical reasoning of both professions is alike and ignoring possible differences, aspects essential for care can be overlooked. Understanding the multifaceted concept of clinical reasoning of both professions may provide insight into the nature and purpose of their practices and benefit patient care, education and research. We aimed to identify, compare and contrast the documented features of clinical reasoning of physicians and nurses through the lens of layered analysis and to conduct a simultaneous concept analysis. The protocol of this systematic integrative review was published doi: 10.1136/bmjopen-2021-049862. A comprehensive search was performed in four databases (PubMed, CINAHL, Psychinfo, and Web of Science) from 30th March 2020 to 27th May 2020. A total of 69 Empirical and theoretical journal articles about clinical reasoning of practitioners were included: 27 nursing, 37 medical, and five combining both perspectives. Two reviewers screened the identified papers for eligibility and assessed the quality of the methodologically diverse articles. We used an onion model, based on three layers: Philosophy, Principles, and Techniques to extract and organize the data. Commonalities and differences were identified on professional paradigms, theories, intentions, content, antecedents, attributes, outcomes, and contextual factors. The detected philosophical differences were located on a care-cure and subjective-objective continuum. We observed four principle contrasts: a broad or narrow focus, consideration of the patient as such or of the patient and his relatives, hypotheses to explain or to understand, and argumentation based on causality or association. In the technical layer a difference in the professional concepts of diagnosis and the degree of patient involvement in the reasoning process were perceived. Clinical reasoning can be analysed by breaking it down into layers, and the onion model resulted in detailed features. Subsequently insight was obtained in the differences between nursing and medical reasoning. The origin of these differences is in the philosophical layer (professional paradigms, intentions). This review can be used as a first step toward gaining a better understanding and collaboration in patient care, education and research across the nursing and medical professions.

Illness scripts in nursing: Directed content analysis.

AIMS: To explore the possible extension of the illness script theory used in medicine to the nursing context. DESIGN: A qualitative interview study. METHODS: The study was conducted between September 2019 and March 2020. Expert nurses were asked to think aloud about 20 patient problems in nursing. A directed content analysis approach including quantitative data processing was used to analyse the transcribed data. RESULTS: Through the analysis of 3912 statements, scripts were identified and a nursing script model is proposed; the medical illness script, including enabling conditions, fault and consequences, is extended with management, boundary, impact, occurrence and explicative statements. Nurses often used explicative statements when pathophysiological causes are absent or unknown. To explore the applicability of Illness script theory we analysed scripts' richness and maturity with descriptive statistics. Expert nurses, like medical experts, had rich knowledge of consequences, explicative statements and management of familiar patient problems. CONCLUSION: The knowledge of expert nurses about patient problems can be described in scripts; the components of medical illness scripts are also relevant in nursing. We propose to extend the original illness script concept with management, explicative statements, boundary, impact and occurrence, to enlarge the applicability of illness scripts in the nursing domain. IMPACT: Illness scripts guide clinical reasoning in patient care. Insights into illness scripts of nursing experts is a necessary first step to develop goals or guidelines for student nurses' development of clinical reasoning. It might lay the groundwork for future educational strategies.

Reasoning like a doctor or like a nurse? An integrative review protocol.

INTRODUCTION: Clinical reasoning, a major competency for all health professionals, has been defined and studied 'within' each profession. We do not know if content, process and outcomes are comparable 'between' physician and nursing clinical reasoning. This paper aims to set up a protocol for an integrative review to analyse and synthesise the scientific nursing and medical clinical reasoning literature. It builds on the history of nursing and medical clinical reasoning research and aims to create a higher level of conceptual clarity of clinical reasoning, to increase mutual understanding in collaboration in patient care, education and research. METHODS AND ANALYSIS: This integrative review follows stepwise the methods described by Whittmore and Knafl: problem identification, literature search, data evaluation, data analysis and presentation.The initial systematic and comprehensive search strategy is developed in collaboration with the clinical librarian and is performed in electronic databases, PubMed, CINAHL, PsycInfo and Web of Science from 30 March 2020 to 27 May 2020. Empirical and theoretical studies are included. This search will be accompanied by ancestry searching and purposeful sampling. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart will summarise the selection process. The quality of eligible studies will be evaluated with a checklist, suitable for diverse study methods.The data analysis is inspired by concept analysis of Walker and Avant and layered analysis of an intervention of Cianciolo and Regehr. We will extract the data of the included studies conforming these layers and features, to capture the multifaceted nature of clinical reasoning in both professions. The data will be presented in a validity matrix to facilitate comparing and contrasting. ETHICS AND DISSEMINATION: Ethics approval is not required. The outcomes will be disseminated through conference presentations and publications.

Testing for coeliac disease rarely leads to a diagnosis: a population-based study.

BACKGROUND: Coeliac disease (CD) has an estimated prevalence of ∼1% in Europe with a significant gap between undiagnosed and diagnosed CD. Active case finding may help to bridge this gap yet the diagnostic yield of such active case finding in general practice by serological testing is unknown. OBJECTIVE: The aim of this study was to determine (1) the frequency of diagnosed CD in the general population, and (2) to investigate the yield of active case finding by general practitioners. METHODS: Electronic medical records of 207.200 patients registered in 49 general practices in The Netherlands in 2016 were analysed. An extensive search strategy, based on International Classification of Primary Care codes, free text and diagnostic test codes was performed to search CD- or gluten-related contacts. RESULTS: The incidence of CD diagnosis in general practice in 2016 was 0.01%. The prevalence of diagnosed CD reported in the general practice in the Netherlands was 0.19%, and considerably higher than previously reported in the general population. During the one year course of the study 0.95% of the population had a gluten-related contact with their GP; most of them (72%) were prompted by gastrointestinal complaints. Serological testing was performed in 66% (n = 1296) of these patients and positive in only 1.6% (n = 21). CONCLUSION: The number of diagnosed CD patients in the Netherlands is substantially higher than previously reported. This suggests that the gap between diagnosed and undiagnosed patients is lower than generally assumed. This may explain that despite a high frequency of gluten-related consultations in general practice the diagnostic yield of case finding by serological testing is low.Key pointsThe diagnostic approach of GPs regarding CD and the diagnostic yield is largely unknownCase finding in a primary health care practice has a low yield of 1.6%CD testing was mostly prompted by consultation for gastrointestinal symptomsThere is a heterogeneity in types of serological test performed in primary care.

Multimorbidity in General Practice: Unmet Care Needs From a Patient Perspective.

Introduction: In the Netherlands, as in many other countries, current clinical guidelines are directed at single diseases. Patients with multiple chronic conditions may benefit from a more patient-tailored approach. Therefore, our objective is to explore the general practice care needs of patients with multimorbidity from a patient perspective. We also assessed their care experiences and the impact of chronic conditions on their daily functioning. Methods: We conducted a qualitative study, using semi-structured interviews complemented with self-report questionnaire assessments for triangulation, with consenting community-dwelling patients with three or more chronic conditions. Participants were identified through purposeful sampling in three general practices. Two researchers independently coded and thematically analyzed the audiotaped and anonymously transcribed interviews using the constant comparative method. The self-report questionnaire assessments were used to describe the patient characteristics and for triangulation of the data retrieved from the semi-structured interviews. Results: After 12 interviews, saturation was achieved. Overall, most participants were positive about their relationship with the general practitioner (GP) and practice nurse (PN) as well as the care they received in general practice. However, several unmet care need themes were observed: firstly, lack of a holistic approach (by the GP and PN), in particular, insufficient attention to the patient's state of functioning, their limitations in daily life, and their well-being; secondly, they mentioned that personal continuity of care was important to them and sometimes lacking; thirdly, lack of patient-tailored explanations about diseases and treatments. Conclusion: From a community-dwelling multimorbid patient perspective, general practice care could benefit from improving personal continuity of care, attention to personal circumstances and daily functioning, and patient-tailored communication.

From protocolized to person-centered chronic care in general practice: study protocol of an action-based research project (COPILOT).

AIM: To develop a proactive person-centered care approach for persons with (multiple) chronic diseases in general practice, and to explore the impact on 'Quadruple aims': experiences of patients and professionals, patient outcomes and costs of resources use. BACKGROUND: The management of people with multiple chronic diseases challenges health care systems designed around single disease. Patients with multimorbidity often receive highly fragmented care that may lead to inefficient, ineffective and potentially harmful treatments and neglect of essential health needs. A more comprehensive, person-centered approach is advocated for persons with multiple morbidities. However, examples on how to provide more person-centered care and evidence of its impact are scarce. A group of Dutch general practitioners (GPs) took the initiative to develop such a care approach. METHODS/DESIGN: Mixed methods with a development and pilot-testing phase. The proactive person-centered approach will be developed using an action-based research design consisting of multiple plan-act-observe-reflect-adjust cycles. In each cycle, experiences of patients and primary care professionals from 13 practices will be collected via interviews, observations and focus groups. Starting point for the first cycle is a 'person-centered consultation' of up to 1 h in which the GP discusses the health status and health care needs of the patient. Furthermore, shared decisions between GP and patient are made on treatment goals and follow-up. In the pilot-test phase, a nested case cohort study allows to explore the impact of the new approach on 'Quadruple aim' outcomes comparing persons with and without exposure to the new care approach. DISCUSSION: This study will provide a proactive person-centered approach for persons with multimorbidity in primary care and estimate its potential impact on quadruple outcomes.

The effect of patient feedback on physicians' consultation skills: a systematic review.

PURPOSE: The effect of patient feedback interventions as a method of improving physicians' consultation (i.e., communication, interpersonal) skills is equivocal; research is scarce, and methods and rigor vary. The authors conducted this systematic review to analyze the educational effect of feedback from real patients on physicians' consultation skills at the four Kirkpatrick levels. METHOD: The authors searched five databases (PubMed, EMBASE, Cochrane, PsycInfo, ERIC; April 2010). They included empirical studies of all designs (randomized controlled, quasi-experimental, cross-sectional, and qualitative) if the studies concerned physicians in general health care who received formal feedback regarding their consultation skills from real patients. The authors have briefly described aspects of the included studies, analyzed their quality, and examined their results by Kirkpatrick educational effect level. RESULTS: The authors identified 15 studies (10 studies in primary care; 5 in other specialties) in which physicians received feedback in various ways (e.g., aggregated patient reports or educator-mediated coaching sessions), conducted in the United States, the Netherlands, the United Kingdom, Australia, and Canada. All studies that assessed level 1 (valuation), level 2 (learning), and level 3 (intended behavior) demonstrated positive results; however, only four of the seven studies that assessed level 4 (change in actual performance or results) found a beneficial effect. CONCLUSIONS: Some evidence for the effectiveness of using feedback from real patients to improve knowledge and behavior exists; however, before implementing patient feedback into training programs, educators and policy makers should realize that the evidence for effecting actual improvement in physicians' consulting skills is rather limited.

Reliability of consultation skills assessments using standardised versus real patients.

OBJECTIVES: Training in and assessment of consultation skills are high on the agenda of vocational training institutes for postgraduate training. There is a need to establish valid and reliable instruments to assess consultation skills in authentic settings. We investigated the number of assessors and observations needed to achieve reliable assessments of the consultation skills of general practice trainees (GPTs) using a communication instrument (MAAS-Global) and either standardised patient (SP) encounters or videotaped real patient (RP) encounters. METHODS: Eight teachers at the Vrije Universiteit (VU) University Medical Centre in Amsterdam attended a training course on the use of the MAAS-Global instrument, which they subsequently used to assess the consultation skills of 53 GPTs in 176 videotaped consultations (102 with SPs, 74 with RPs). All consultations were randomly allocated and assessed by two teachers independently. The reliability of the ratings was estimated using generalisability theory. RESULTS: It was easier to obtain acceptable reliability using RP consultations than SP consultations. Two assessors and five consultations were required to achieve minimal reliability (generalisability coefficient 0.7) with RPs, whereas three assessors and 30 consultations were needed to achieve minimal reliability with SPs. CONCLUSIONS: Inter-observer and context variability in the assessment of the consultation skills of GPTs remains high. To achieve acceptable levels of reliability, large samples of observations are required in both formats, but, interestingly, RP encounters require a smaller sample than SP encounters.

Does patient feedback improve the consultation skills of general practice trainees? A controlled trial.

CONTEXT: This study aimed to assess if an additional patient feedback training programme leads to better consultation skills in general practice trainees (GPTs) than regular communication skills training, and whether process measurements (intensity of participation in the programme) predict the effect of the intervention. METHODS: We carried out a controlled trial in which two sub-cohorts of GPTs were allocated to an intervention group (n = 23) or a control group (n = 30), respectively. In 2006, allocated first-year GPTs in the VU University Medical Centre attended a patient feedback training programme in addition to the regular communication skills training. The control group attended only regular communication skills training. Trainees were assessed by simulated patients who visited the practices and videotaped the consultations at baseline and after 3 months. The videotapes were randomly assigned to eight trained staff members. The MAAS-Global Instrument (range 0-6) was used to assess (a change in) trainee consultation skills. RESULTS: were analysed using a multi-level, linear mixed-model analysis. Results Data on 50 GPTs were available for the follow-up analysis. Both intervention group and control group GPTs improved their consultation skills: mean MAAS-Global scores for all participants were 3.29 (standard deviation [SD] 0.75) at baseline and 3.54 (SD 0.66) at follow-up (P = 0.047). The improvement in MAAS-Global scores in the intervention group did not differ significantly from the improvement in the control group. The analysis showed a trend for intensity of participation in the patient feedback programme to predict greater improvement in MAAS-Global scores. DISCUSSION: Although the baseline scores were already in the high range, consultation skills in both groups improved significantly. This is reassuring for current teaching methods. The patient feedback programme did not improve consultation skills more than regular communication skills training. However, a subgroup of GPTs who participated intensively in the programme did improve their consultation skills further in comparison with the less motivated subgroup.

Validity aspects of the patient feedback questionnaire on consultation skills (PFC), a promising learning instrument in medical education.

OBJECTIVE: A focus on the communicator competency is considered to be an important requirement to help physicians to acquire consultation skills. A feedback questionnaire, in which patients assess consultation skills might be a useful learning tool. An existing questionnaire on patient perception of patient-centeredness (PPPC) was adapted to cover the 'communicator' items in the competency profile. We assessed the face and content validity, the construct validity and the internal consistency of this new patient feedback on consultation skills (PFC) questionnaire. METHODS: We assessed the face validity of the PFC by interviewing patients and general practice trainees (GPTs) during the developmental process. The content validity was determined by experts (n=10). First-year GPTs (23) collected 222 PFCs, from which the data were used to assess the construct validity (factor analysis), internal consistency, response rates and ceiling effects. RESULTS: The PFC adequately covers the corresponding 'communicator' competency (face and content validity). Factor analysis showed a one-dimensional construct. The internal consistency was high (Cronbach's alpha 0.89). For the single items, the response rate varied from 89.2% to 100%; the maximum score (ceiling effect) varied from 45.5% to 89.2%. CONCLUSION: The PFC appears to be a valid, internally consistent instrument. PRACTICAL IMPLICATIONS: The PFC may be a valuable learning tool with which GPTs, other physicians and medical students can acquire feedback from patients regarding their consultation skills.

Development and feasibility of a patient feedback programme to improve consultation skills in general practice training.

OBJECTIVE: To develop an attractive and effective patient feedback training programme for general practice trainees (GPTs). METHODS: First, an exploratory study was conducted in which patients and GPTs were interviewed after they had worked with patient feedback. This contributed to the development of the patient feedback training programme. Subsequently, in a feasibility study, first-year GPTs asked patients to give feedback on their consultation skills by completing a questionnaire. The outcomes of group discussions with the GPTs and the results of the evaluation forms filled in by the GPTs were analysed. RESULTS: Forty-eight GPTs collected 878 questionnaires. GPTs and patients alike expected patient feedback to be a major tool for acquiring consultation skills. The GPTs encountered several obstacles in the organisation of this programme in their practice. They reported that the learning effects were more limited than they had expected because patients gave positively biased answers and because not all consultations provided an appropriate source of patient feedback. CONCLUSION: The new patient feedback programme on consultation skills is feasible for patients and GPTs. PRACTICE IMPLICATIONS: To optimise the educational potential and benefits of patient feedback, GPTs should ask for feedback from patients after challenging consultations, and should stimulate patients to be critical in their answers.

Avascular necrosis of the head in paediatric hip fractures, an inevitable complication.

Hip fracture in patients with open physis is known for its low occurrence rate. However, despite its rare presentation, this type of fracture is known for its serious complications. Avascular necrosis (AVN), coxa vara, premature closure of the physis and secondary displacement are major complications that will determine prognosis. AVN with associated growth disturbances is the most serious complication and also an influential factor in predicting the outcome. This paper reports a retrospective study of 20 children who sustained a hip fracture according to Delbet type I-IV followed for at least 2 years. AVN was observed in four patients (21%), two of whom developed a complete AVN Ratliff type I within 6 months, requiring reconstructive surgery. Non-AVN-associated coxa vara (n=5) and re-displacement (n=3) are complications with less serious effects on outcome. Our clinical results regarding AVN and its risk factors - such as age group and type of fracture - are comparable to the results of other documented reports. An overview of both avoidable and inevitable AVN risk factors, including possible preventative measures, is presented in this report.