Giovanna P
Decision Making-DBX-DL01
Dual Process Theory and Reasoning Process in Advanced Practice Nursing
Bellini-Leite (2022) displayed that the Dual Process Theory posits that there are two systems of thinking system 1 and 2. System 1 (Type 1) is fast, intuitive, and automatic. It operates with little or no effort and is often influenced by emotions and heuristics. While system 2 (Type 2) is slower, more deliberate, and analytical. It requires conscious effort and is used for complex problem-solving and decision-making.
In advanced practice nursing (APN), recognizing when to engage each system is crucial. For instance, in Case 1, the NP may initially rely on System 1 to quickly diagnose gallbladder disease based on symptoms and findings. However, as the patient’s condition worsens and he presents with shortness of breath, the NP must engage System 2 to reassess and consider pulmonary embolism, integrating more complex data and differential diagnoses. Additionally, in Case 2, the initial assessment may lead the NP to a rapid conclusion of influenza using System 1. However, continued lethargy and inability to manage fever would necessitate a System 2 approach, prompting the NP to reassess for more serious conditions like viral meningitis (Norman et al., 2024).
Cognitive Dispositions to Respond
Vinaykumar et al. (2023) explained that cognitive dispositions to respond are inherent tendencies or biases that influence how individuals interpret information and make decisions. In the APN setting, these can manifest as anchoring which consist of relying too heavily on the first piece of information encountered such as initial symptoms of RUQ pain leading to a gallbladder diagnosis. For example, in Case 1, Menakuru et al. (2023) displayed that the use of testosterone and other androgens has been found to cause polycythemia due to the stimulation of erythropoiesis which leads to increased blood viscosity, which can have negative outcomes such as increased thromboembolic risk and major adverse cardiac events. If APN would investigate more about past medical history of the patient, rather than rely on what was written in the computer, APN might treat the high risk of PE as prophylaxis.
Confirmation bias is another type of cognitive disposition which consists of favoring information that confirms pre-existing beliefs such as assuming a viral illness without considering alternative diagnoses (Vinaykumar et al., 2023). Therefore, APNs must be conscious of these biases and actively seek out contradictory evidence or alternative explanations to improve diagnostic accuracy. According to Featherston et al. (2020), biases have the potential to seriously impact the quality, consistency and accuracy of decision making in allied health practice.
Cognitive Debiasing
According to Griffith et al. (2020), cognitive debiasing refers to strategies aimed at reducing the impact of cognitive biases on decision-making. In the APN context, this can involve encouraging reflective practice to question initial judgments, utilizing checklists or guidelines to ensure comprehensive assessment, and engaging in peer discussions or consultations to gain different perspectives. Therefore, these strategies can help mitigate bias and foster more accurate and holistic patient evaluations.
Case 2 stated “The patient did not want to look at the clinician in a brightly lit room”. Burger et al. (2020) emphasized that photophobia and fever are common symptoms of meningitis. As per Case 2, this misdiagnosis resulted on the patient spending several days in the hospital but did completely recover. According to Watari and Schiff (2023), a thorough understanding of symptoms allows for more accurate differential diagnoses, because each symptom can point to multiple conditions, and recognizing subtle differences can help differentiate between potentially serious illnesses and benign conditions. Deep symptom knowledge enhances clinical reasoning skills, because it equips nurse practitioners to utilize both Type 1 (intuitive) and Type 2 (analytical) thinking effectively; therefore, this balance allows for efficient initial assessments while also engaging in thorough evaluations when symptoms are complex or evolving.
Application of Type 1 and Type 2 Processes & Improving APRN Practice
In both cases, applying Type 1 and Type 2 processes can enhance decision-making. For example, in Case 1, type 1 was a quick assessment of RUQ pain leading to a diagnosis of gallbladder disease. However, type 2 was re-evaluated after worsening symptoms, utilizing detailed history and diagnostic testing such as CT angiography to identify the pulmonary embolism (Bellini-Leite, 2022). Moreover, in Case 2, type 1 was the initial assumption of influenza based on common symptoms during flu season. While, type 2 was further investigated when symptoms worsen, leading to the diagnosis of viral meningitis, utilizing comprehensive assessments and lab tests (Norman et al., 2024).
Considerations for improving practice in both cases will include the implementation of protocols and guidelines based on EBP, obtaining an accurate past medical history, training on cognitive biases, and seeking another professional opinion while assessing a patient. Firstly, a solid foundation in symptomatology supports the integration of evidence-based practices and it allows nurse practitioners to apply current research findings to clinical scenarios, ensuring that patient care is informed by the latest medical knowledge by implementing standardized protocols (Griffith et al., 2020). For conditions such as RUQ pain, having a protocol for potential differential diagnoses can prevent oversight of serious conditions like pulmonary embolism. According to Beauchemin et al. (2019), implementation of evidence-based guidelines directly affects clinicians in their work environment; therefore, providers should be actively involved in the process of adaptation of guidelines to integrate them into the local workflow.
Secondly, Flugelman (2021) displayed that an accurate past medical history assessment is crucial because it provides the foundation for diagnosis, guides further investigations, and allows for tailored treatment plans by revealing key information about a patient’s previous illnesses, surgeries, medications, and allergies, ultimately enabling healthcare providers to make informed decisions and deliver the best possible care.
Thirdly, training on cognitive biases with regular workshops or training on recognizing and mitigating cognitive biases can enhance critical thinking skills among NPs (Griffith et al. (2020). Royce et al. (2019) explained that reflective practice and cognitive bias awareness may help learners move toward adaptive expertise and help clinicians improve diagnostic accuracy. Finally, encouraging a culture of second opinions by promoting an environment where seeking professional opinions is normalized can help catch potential diagnostic errors (Vinaykumar et al., 2023). For example, Burger et al. (2020) displayed that second opinions in internal medicine are valuable in terms of the establishment of diagnoses, initiation of treatment and improvement of symptoms, in a considerable number of patients.
In conclusion, a deep knowledge of symptoms is vital for nurse practitioners to ensure accurate diagnoses, enhance clinical reasoning, and provide holistic, patient-centered care. This expertise ultimately leads to better patient outcomes and fosters a higher standard of nursing practice. Additionally, cognitive debiasing is essential for nurse practitioners to enhance diagnostic accuracy and improve patient outcomes by recognizing and addressing cognitive biases through structured reasoning, reflective practices, and adherence to evidence-based guidelines, NPs can make more informed and accurate clinical decisions. This commitment to cognitive debiasing not only improves individual practice but also contributes to a culture of safety and quality in healthcare.
References
Beauchemin, M., Cohn, E., & Shelton, R.C. (2019). Implementation of Clinical Practice Guidelines in the Health Care Setting: A Concept Analysis. Advances in Nursing Science, 42(4), 307-324. https://doi.org/10.1097/ANS.0000000000000263.
Bellini-Leite, S.C. (2022). Dual Process Theory: Embodied and Predictive; Symbolic and Classical. Frontiers in Psychology, 13, 805386. https://doi.org/10.3389/fpsyg.2022.805386.
Burger, P.M., Westerink, J., & Vrijsen, B.E.L. (2020). Outcomes of second opinions in general internal medicine. PLoS One, 15(7), e0236048. https://doi.org/10.1371/journal.pone.0236048.
Burstein, R., Noseda, R., & Fulton, A.B. (2019). Neurobiology of Photophobia. Journal of Neuro-Ophthalmology, 39(1), 94-102. https://doi.org/10.1097/WNO.0000000000000766.
Featherston, R., Downie, L.E., Vogel, A.P., & Galvin, K.L. (2020). Decision making biases in the allied health professions: A systematic scoping review. PLoS One, 15(10), e0240716. https://doi.org/10.1371/journal.pone.0240716.
Flugelman, M.Y. (2021). History-taking revisited: Simple techniques to foster patient collaboration, improve data attainment, and establish trust with the patient. GMS Journal for Medical Education, 38(6), Doc109. https://doi.org/10.3205/zma001505.
Griffith, P.B., Doherty, C., Smeltzer, S.C., & Mariani, B. (2020). Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: A scoping review. Journal of the American Association of Nurse Practitioners, 33(11), 862-871. https://doi.org/10.1097/JXX.0000000000000479.
Menakuru, S.R., Atta, M., Dhillon, V.S., & Salih, A. (2023). Testosterone Usage Leading to Pulmonary Embolisms and Deep Vein Thrombosis: A Case Report and Review of Literature. Hematology Reports, 15(2), 290-297. https://doi.org/10.3390/hematolrep15020029.
Norman, G., Pelaccia, T., Wyer, P., & Sherbino, J. (2024). Dual process models of clinical reasoning: The central role of knowledge in diagnostic expertise. Journal of Evaluation in Clinical Practice, 30(5), 788-796. https://doi.org/10.1111/jep.13998.
Royce, C.S., Hayes, M.M., & Schwartzstein, R.M. (2019). Teaching Critical Thinking: A Case for Instruction in Cognitive Biases to Reduce Diagnostic Errors and Improve Patient Safety. Academic Medicine, 94(2), 187-194. https://doi.org/10.1097/ACM.0000000000002518.
Vinaykumar, N., Gugapriya, T.S., & Kalaiselvi, S. (2023). Exploring Knowledge of Cognitive Disposition to Respond in Clinical Decision-Making among Early Clinical Learners. Maedica (Bucur), 18(2), 317-322. https://doi.org/10.26574/maedica.2023.18.2.317
Watari, T., & Schiff, G.D. (2023). Diagnostic excellence in primary care. Journal of General and Family Medicine, 24(3), 143-145. https://doi.org/10.1002/jgf2.617.