Decisions relating to the timely and effective delivery of prehospital care depend on “clinical reasoning”, a skill that integrates extensive clinical experience and domain specific knowledge to support the collection and evaluation of clinical data, and the synthesis of information to guide patient management decisions. In contrast to health care centred within an institution where decisions can be supported by expert opinion, access to medical records, and advanced diagnostic tests, patient care in the prehospital domain usually requires independent, time critical decision making in an environment where similar support is unavailable or incomplete. Hence sound and reliable thinking and decision-making skills are fundamental to prehospital practice.
Cognitive skills such as clinical reasoning have generated substantial interest in nursing and allied health fields. This is evidenced by this text edited by Higgs and Jones, which explores the issue of clinical reasoning from several perspectives.
An investigation of the current status of knowledge regarding clinical reasoning introduces the reader to key concepts in the first section of this text. Although theoretical constructs are compared and analysed, practical applications remain paramount.
The application of these skills within the health disciplines of medicine, nursing, physiotherapy and occupational therapy is the focus of the second section. This is followed by a very practical discussion of techniques used to teach clinical reasoning, which examines educational design strategies that are employed in several health disciplines.
Unfortunately, clinical reasoning in the prehospital setting does not rate a mention. Given the relatively recent genesis of prehospital care as a health discipline, this omission is not surprising. There is a paucity of published work on critical thinking and clinical reasoning in this setting, which could suggest that the value of these skills are not yet fully appreciated in the field of prehospital care.
Paramedic practice is sometimes dominated by rule-driven behaviour, which can be a function of organisational preference where individuals are not responsible for autonomous practice of the type normally associated with the role of a health professional. As such, cognitive skills such as clinical reasoning are not often explicitly recognised, but are instead subsumed by more tangible aspects of prehospital practice. Technical skills are commonly cited as important elements of the discipline, as these are most amenable to observation and measurement. However these technical skills are of little value if the decisions to implement or withhold these interventions are incorrect or logically flawed.
Higgs and Jones illustrate the importance of positioning clinical reasoning as a keystone of professional practice:
In the absence of sound clinical reasoning, clinical practice becomes a technical operation requiring direction from a decision maker. It is the role of professional health care practitioners to practise in a manner which demonstrates professional autonomy, competence and accountability, to engage in lifelong learning and to contribute to the development of the knowledge base of their discipline. In order to achieve these outcomes health professionals need to be able to reason effectively, to make sound and defensible clinical decisions and to learn through their clinical experience and other avenues in order to continually develop their knowledge as the basis for making effective clinical decisions and useful contributions to the knowledge of the field.
Education programs that aspire to produce health professionals must ensure that graduates have developed sound clinical reasoning skills. As Higgs and Jones suggest, “not only can clinical reasoning be learned, but that teachers, mentors and experienced clinicians can help others, both novices and peers to develop their clinical reasoning expertise.”
This text is an excellent resource that can assist novices to develop these skills, and can be recommended as a prescribed text to support their studies. The text also enables experts to refine their clinical reasoning skills and to assist others in making the transition from technician to clinician.
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