Introduction
Clinical reasoning has been defined as a “broad term denoting the thinking, judgements and decision making involved in clinical practice (Ajjawi et al, 2012 p207). In Jenny’s case, the team employed the 8 phases of clinical reasoning which allows health professionals to make wise clinical judgments. ‘Professional decision making’ or clinical decisions were taken by the team using patient data, data from professional experience and theoretical knowledge.
The 8 phases of clinical reasoning helped the team understand and analyse the contextual factors contributing to Jenny’s health and identify roles of health professionals involved in the case management. The team members actively analysed and discussed the available options to achieve the best possible outcome, to help Jenny walk again.
Overview of Jenny’s story
Jenny is a 19 year old obese, homeless, Aboriginal female with Type 1 Diabetes Mellitus. She has been separated from her parents for 4 years. She has been living on the streets and in boarding houses. Currently, she lives with 6 non-indigenous residents in the boarding house who have social issues like substance abuse. Jenny lacks any knowledge of diabetes and does not know how to monitor or manage her disease. Jenny also does not have a designated GP due to her constantly changing places. Jenny has been admitted to the hospital twice for the same reason, insulin shock. Jenny does not have family or friends and lacks support for independent living.
Contextual factors
About 4.4% of Australians are affected by diabetes (AIHW, 2011). According to research, the health of Indigenous Australians is worse than any other group in Australia (Donald et al., 2012). Indigenous Australians are at a high risk of health due to chronic diseases, diabetes being one of them (Donald et al., 2012). The burden of disease among aboriginal Australians is greater that other Australian community (Burke et al., 2007). Jenny was admitted to the hospital due to a head injury she had suffered due to an insulin shock. An insulin shock results from hypoglycaemia, a condition occurring due to less food or excess insulin, which causes the blood sugar to drop suddenly.
Within the contextual framework, Jenny, who is a homeless diabetic female, separated from her parents and living on the streets, is a victim of the socioeconomic inequalities such as poverty and overcrowding (Daniel et al., 1999). Socioeconomic status is linked to the risk factors including diet, exercise and lifestyle choices as indicated by several studies which confirm that the Aboriginals are among the lowest status groups of Australia (Australian Bureau of Statistics, 2006; Daniel et al., 1999). Jenny is obese and researchers have confirmed the relationship between high caloric intake and lack of physical activity among Aboriginals and the development of obesity (Australian Bureau of Statistics, 2006).
Health professionals
The health professionals working closely with Jenny are the physiotherapist, dietician, rehabilitation medical consultant and the nursing staff including the nurse unit manager. The health professionals worked together as an “interdisciplinary team” by integrating their “separate discipline approaches into a single consultation” (Jessup, 2007).
Physiotherapists are “trained in anatomy, pathology, physiology and rehabilitation techniques” and treatment of musculoskeletal problems (The Role of Physiotherapy in the Provision of Primary Health Care, n.d.). Since Jenny had difficulty with walking the physiotherapist’s role was to help her in walking independently.
The dietician’s role was to offer dietary and nutritional advice to Jenny since she is a diabetic and lacks knowledge about maintenance of her disease.
The role of the rehabilitation medical consultant is to help Jenny with rehabilitation and employment assistance, since she lacks support from family and friends, and is a homeless female.
The Nurse Unit Manager has a variety of roles and in Jenny’s case was responsible for leading discussion with the involved doctors, and staff including the physiotherapist and dietician regarding the clinical concerns of the patient (Review of the Nurse Unit Manager Role, 2008).
However, some health professionals such as the OT, Neurologist, diabetes educator, indigenous worker, social worker, community worker and Jenny’s family members were missing.
Clinical reasoning definition, application and critique
Higgs and Jones (2008) define clinical reasoning as “a critical skill in the health professions, central to the practice of professional autonomy, and it enables practitioners to take ‘wise’ action, meaning taking the best judged action in a specific context” (p.4).
The team of professionals considered Jenny’s situation by taking into account the available facts and data. In phase 2, the team members gathered evidence which included “professional craft knowledge”; “theoretical knowledge”; and “data gained from interaction with the client” (Ajjawi et al., 2012, p.212-213). Jenny is a homeless Indigenous female; studies about indigenous Australians and the impact of disease on them due to their low socioeconomic status (Australian Bureau of Statistics, 2006; Daniel et al., 1999).
The collective information was processed and analysed in phase 3 of clinical reasoning. During phase 4, the team members identified the problems associated with Jenny’s inability to walk and made a definitive diagnosis of her insulin shock and inability to walk. Accordingly, Jenny was placed in the rehabilitation unit with a physiotherapist. The desired outcome, a goal was established to help Jenny walk again. A timeframe for this outcome was not set. When the nurse unit manager saw Jenny walking confidently, the team members collectively agreed that the desired outcome was achieved and Jenny was discharged.
There is immense scope for improvement of clinical reasoning in this case. According to Higgs and Jones (2008), the core dimension of clinical reasoning is “mutual decision making” (p.5) which means involvement of the client, which Jenny’s team failed to do. Jenny was never an active participant in the decision making process. Considering her cultural and social background, the team should have adopted a more “patient centered approach” which necessitates “a strong emphasis on patient education, with expert therapists being willing to serve as patient advocate or moral agent in helping them be successful” (Higgs & Jones, 2008, p.9). This goal could have been accomplished with the participation of an indigenous social worker and a diabetes educator who would educate Jenny about the nature and management of her disease.
Community support
Community services relevant to Jenny’s case are as follows:
The Aboriginal and Torres Strait Islander Health Programs (2013) are government run services for improving access of healthcare to Australians. Since Jenny is a homeless with no support, this service will help her with primary health care and management of her chronic disease, diabetes.
Jenny could be referred to ‘The Aboriginal and Torres Strait Islander Chronic Disease Fund’ (2012) which aims to improve the management of chronic disease in Aboriginal people and improve their life expectancy.
The National Diabetes Services Scheme (NDSS) (2013) is a community service related to jenny’s case. The Australian Government works together with Diabetes Australia to help diabetics understand and effectively manage their life with the disease. The NDSS offers affordable and reliable access to services and supplies necessary for the safe and effective management of diabetes.
Conclusion
Clinical reasoning allows healthcare professionals to make wise and informed decisions in the best interest of the patient. Applying the phases of clinical reasoning improves the outcomes in healthcare and clinical settings. In this case, the clinical reasoning process indicates that Jenny lacks social inclusion. She needs community support. She needs a healthcare team which will actively engage her in the treatment process and educate her about the nature of her disease using the empowerment approach so that she is able to make informed decisions related to her diet, health and disease management. She needs to be referred to an appropriate community based program to address her multiple needs.
References
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Higgs, J., & Jones, M. A. (2008). Clinical decision making and multiple problem spaces. In J. Higgs, M. A. Jones, S. Loftus & N. Christensen (Eds.) Clinical reasoning in the health professions (3rd ed. pp. 3-18). New York: Elsevier.
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The Role of Physiotherapy in the Provision of Primary Health Care (n.d.). Web.