CLINICAL

DECISION
MAKING

Nazar Deen
MSAPT,BSPT,DDPT,DHMS
Assistant Professor
IPTR JSMU
July 22th’ 2023 COURSE OBJECTIVES
Lecture 1
 Define clinical decision making and reasoning
process
 Discuss its importance for physical therapists
as health care professionals
 How does the client benefit from clinical
reasoning?
 Stress out the importance of evidence based
practice in clinical decision making versus
intuition and expertise
 Make the student work independently with the
patient/ client management model
LECTURE OBJECTIVE

 Define clinical decision making and

reasoning process
 PHYSICAL THERAPISTS:

 Provides services to individuals and populations to develop,

maintain and restore maximum movement and functional
ability throughout the lifespan. This includes providing
services in circumstances where movement and function are
threatened by ageing, injury, disease or environmental factors.

World confederation for Physical Therapy

 Physical therapy is concerned with identifying and maximizing
quality of life and movement potential within the spheres of
promotion, prevention, treatment/intervention, habilitation
and rehabilitation.

 This encompasses physical, psychological, emotional, and

social well being. Physical therapy involves the interaction
between physical therapist, patients/clients, other health
professionals, families, care givers, and communities in a
process where movement potential is assessed and goals are
agreed upon, using knowledge and skills unique to physical
therapists.

World Confederation for Physical Therapy

 CLINICAL DECISION MAKING
 Clinical decision making may be defined as choosing
between alternatives (Thompson & Dowding, 2002)

 We are all involved in decisions in life from the simple to

the complex, those that deal with patients and clients to
those that deal with our life outside work.

 Decision making can range from fast, intuitive, or heuristic

(mental shortcuts when we need a quick solution.)
decisions through to well reasoned, analytical, evidence-
based decisions that drive patient and client care
 CLINICAL DECISION MAKING
Cont…
 There is a spectrum of decision making - at one end of the
spectrum we use our intuition and experience to make
decisions, where there are typically a high volume of
simple decisions to be made.

 At the other end of the spectrum, there may be complex

decisions to be made, where the level of uncertainty is high
and an analytical and evidence-based approach is needed to
support the rules-based heuristics or experience we have
gained over time in 'similar' situations.
 CLINICAL DECISION MAKING
Cont…
 An Effective Practitioner is tasked with making clinical
decisions with patients and clients many times during their
health and care journey.

 Clinical decision making is a balance of experience,

awareness, knowledge and information gathering, using
appropriate assessment tools, your colleagues and
evidence-based practice to guide you.

 Good decisions = safe care.

 PATIENT AND CLIENT

 PATIENTS are individuals who are recipients of

physical therapy care and interventions

 CLIENTS are individuals who are not necessarily

sick or injured but who can benefit from a physical
therapist’s consultation, professional advice or
prevention services.

 Clients can also be businesses, schools or others to

whom physical therapists provide services.

 In Pakistan, the clients are usually individual

patients
REASONING/ DECISION
MAKING

 Thinking that is coherent and

logical. (Coherent= it is well
planned, so that it is clear and
sensible and all its parts go well with
each other)
 Cognitive process of looking for
reasons, beliefs, conclusions, actions
or feelings that occurs in daily life
 Cognition>>thinking
CLINICAL REASONING

 Sum of thinking and decision-making

processes associated with clinical practice

 Is the way of thinking and decision making

that guides the physical therapist in a
professional way, considering all factors
affecting the patient care such as the
patient’s concerns, the environmental and
social concerns as well as PT and ethical
concerns.
 DECISION MAKING

 The act of making up your mind about something,

or a position or opinion or judgment reached after
consideration.

 Decision Making is a management strategy and

process for selecting the most sensible solution
from a set of alternatives to achieve the best result
 CLINICAL DECISIONS

 Outcomes of clinical reasoning process

 Based on:

CLINICIAN’S CLIENT’S
Knowledge goals
Expertise Values
Goals Physical factors
Values and beliefs Cultural factors
Psychosocial skills Psychosocial factors
Procedural skills
 Resources
 finances
 Expertise
 Time
 environment
Clinical decision making

 Practice decision making

 Clinical reasoning
Reasoning  decision making
 CLINICAL DECISION
MAKING REQUIRES

 Cognitive and collaborative skills

 Clinical reasoning should take into account:
Cognitive
Metacognitive
Emotional
Reflexive
Social capabilities
THE CORE SKILSS OF CLINICAL
DECISION MAKING

 Good, effective clinical decision making requires a combination

of experience and skills. These skills include:
 1. Knowledge
 2.Pattern recognition

 3. Critical Thinking

 4. Meta cognition
 5. Communication skills
 6. Evidence Based Approaches
 7 . Team work
 8 . Sharing
 9 . Reflections
THE CORE SKILSS OF CLINICAL
DECISION MAKING
1. KNOWLEDGE
THE CORE SKILSS OF CLINICAL
DECISION MAKING
1. KNOWLEDGE

 Clinical reasoning requires a rich

organization of a wide range of knowledge
including scientific and professional
theory , procedural know-how and personal
philosophy of practice , values and ethics
THE CORE SKILSS OF CLINICAL
DECISION MAKING

 2. Pattern recognition: learning from

experience.
 Pattern recognition occurs when the nurse
compares the signs and presenting
symptoms of a patient problem with
patterns recognised from memory in order
to match the presenting trend (Gordon,
1987).
THE CORE SKILSS OF CLINICAL
DECISION MAKING
2.PATTEN RECOGNITION

 Pattern recognition required hypothesis

which are later defined.
 The clinical pattern recognition requires a
sound knowledge of theory
 Pattern recognition alone is a faster process
used frequently by experts, chunks of stored
memory
 Alternative Choices of
 Assessment, interpretation,
Management actions and decisions
THE CORE SKILSS OF CLINICAL
DECISION MAKING
2.PATTEN RECOGNITION

 Analysis affected by ?
 Faulty knowledge
 Personal bias
THE CORE SKILSS OF CLINICAL
DECISION MAKING
3. CRITICAL THINKING

 Thinking skills
 Critical Thinking: removing emotion from our
reasoning, being 'sceptical', with the ability to clarify
goals, examine assumptions, be open-minded,
recognize personal attitudes and bias, able to
evaluate evidence.

 Analyze , synthesize, inquire and evaluate the data

in addition to what has been provided by the
referring physicians and/ or patient's goal(s) with
current problem
THE CORE SKILSS OF CLINICAL
DECISION MAKING
4. METACOGNTION

 Cognition about cognition

 Thinking about thinking
 Reflexive Self awareness/self monitoring

 Recognition about lack of knowledge and / or skills

causing prompting to remediate the lacking

 Identify the quality of information obtained ,

inconsistencies and enables monitoring of reasoning
and performance
THE CORE SKILSS OF CLINICAL
DECISION MAKING
5. COMMUNICATION SKILLS

 Communication Skills: active listening - the ability to

listen to the patient, what they say - what they don't
say, their story, their experiences and their wishes thus
enabling a patient-centred approach that embraces self-
management; information provision - the ability to
provide information in a comprehensible way to allow
patients/clients, their carers and family to be involved
in the decision making process.

 It is a two-way process. In other words, it involves

both the sending and receiving of information. It is,
therefore an active process. There is nothing passive
about communication, in either direction
THE CORE SKILSS OF CLINICAL
DECISION MAKING
6. Evidence-based approaches

 Evidence-based approaches: using available

evidence and best practice guidelines as part of the
decision making process.

 Evidence Based Decision-Making is a process for

making decisions about a program, practice, or policy
that is grounded in the best available research evidence
and informed by experiential evidence from the field
and relevant contextual evidence.
THE CORE SKILSS OF CLINICAL
DECISION MAKING
6. Evidence-based approaches
THE CORE SKILSS OF CLINICAL
DECISION MAKING
6. Evidence-based approaches
THE CORE SKILSS OF CLINICAL
DECISION MAKING
7. Team work

 Team work: using the gathered evidence to enlist

help, support and advice from colleagues and the wider
multi-disciplinary team. It's important to liaise with
colleagues, listen and be respectful, whilst also being
persistent when you need support so that you can plan
as a team when necessary.

 Effective team working has been shown to reduce

medical errors, increase patient safety and improve
patient mortality rates. It also leads to better staff
outcomes including reduced stress and improved job
satisfaction.
THE CORE SKILSS OF CLINICAL
DECISION MAKING
8. sharing

 Sharing: your learning and getting feedback from

colleagues on your decision making
THE CORE SKILSS OF CLINICAL
DECISION MAKING
9. Reflection

 Reflection: using feedback from others, and the

outcomes of the decisions to reflect on the
decisions that were taken in order to enhance
practice delivery in the future. It's also important to
reflect on your whole decision making strategies to
ensure that you hone your decision making skills
and learn from experience.
 Reflective decision-making is a process of
structured thinking to help you analyse your
decision. It means being open-minded, honest, and
using self-awareness to reflect on
your decision-making process, not the decision
itself
 Case example discussion
and reading assignment

Article to be discussed in class next week:

Clinical decision making in Physical therapy: a

practitioner’s perspective