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Posted: July 20th, 2023
Discussion 4: To answer this week’s discussion questions will require that you read three articles on dual processing theory and reducing diagnostic errors. You are expected to apply the course readings mentioned below YOU WILL NOT BE ABLE TO ANSWER THIS WEEK’S DISCUSSION QUESTION WITHOUT READING THE ASSIGNED ARTICLES, See the questions outlined below. TWO PEER RESPONSES ARE REQUIRED THIS WEEK
Djulbegovic et al. (2012)
Monteiro et al., (2019)
Pierret (2016
Tsalatsanis et al., (2015)
Case: 1:
Chief Complaint: “Pain in Right Side” A 40-year-old man presents to his primary care provider (PCP) with right upper quadrant (RUQ) pain for 2 days. The pain is described as “sore” and rated 4 on 1 to 10 pain scale. The pain is intermittent and not worsening. He reports food does not seem to make it better or worse. No nausea or vomiting or diarrhea or constipation are reported.
Vital signs: heart rate, 75; blood pressure, 122/78; respiration rate, 15; afebrile.
Examination: No acute distress. Abdomen: mildly tender on palpation at RUQ; no masses, hepatomegaly or splenomegaly.
Diagnosis: Gallbladder disease.
Plan: Abdominal ultrasound with reflexive cholescintigraphy (hepatobiliary iminodiacetic acid) scan within 1 week. Patient instructed to call provider if worsening symptoms occur. He is also told to avoid any fatty foods or alcohol consumption. The patient is agreeable to plan.
Follow-up: Two days after the initial visit, the patient calls his PCP with worsening RUQ pain. Ultrasound imaging was scheduled for later that day. Patient then started having shortness of breath while at home and went to the local emergency department (ED). Computed tomography angiography of the chest revealed a right-sided pulmonary embolism. Patient did not have any family history of clotting disorders and no recent surgery, immobilization, or travel. Patient had been on testosterone injections for several years for low testosterone levels, and this was not updated in his medical record at his PC
Case 2
Chief Complaint: “Fever and Sleepy” A 3-year-old girl presents with her mother to a walk-in clinic with fever, nasal drainage, and fatigue for 2 days. She was observed hiding her head into her mother’s chest during the examination.
Presentation occurred during flu season. The clinician had 6 positive flu tests that day, all with similar symptoms, but most including a cough.
Vital signs: heart rate, 125; respiration rate, 20; blood pressure, 100/72; temperature, 100.8F.
Examination: Lungs clear, heart rate regular, no murmur. Head, eyes, ears, nose, and throat: normocephalic, conjunctivae clear, tympanic membrane without bulging or redness, pharynx normal, nares normal with clear drainage, tonsils 1þ, no erythema or exudate. Patient did not want to look at the clinician in a brightly lit room. The patient was lethargic and had limited tearing when crying. Rapid flu test: Negative.
Diagnosis: Presumptive seasonal influenza.
Plan: Supportive care, including encouraging fluids, Over the counter acetaminophen for fever, and age-appropriate antiviral medication for the flu was prescribed.
Follow-up: Parents were unable to keep her fever down over the next 1 day, and she progressively became more lethargic. Patient was taken to the ED, and a diagnosis of viral meningitis and dehydration was made. Patient spent several days in the hospital, but did completely recover.
Describe the Dual Process Theory and Reasoning Process and how it applies to making decisions for the advanced practice nurse.
What are cognitive dispositions to respond? How are these applied in the APN setting.
Describe cognitive debiasing?
Describe how Type 1 (System 1) and Type 2 (System 2) processes and strategies can be applied to each case to help the NP make decisions and to decrease potential diagnostic error?
What considerations for change to practice should the NP consider in each situation as a way to decrease the chance of future diagnostic and care decisions.
3. As a reminder, all discussion posts must be minimum 250 words, references must be cited in APA format 7th Edition, and must include minimum of 2 scholarly resources published within the past 5-7 years.
Enhancing Diagnostic Decision-Making in Advanced Practice Nursing: An Exploration of Dual Processing Theory and Cognitive Debiasing
Introduction:
Effective diagnostic decision-making is crucial for advanced practice nurses (APNs) to provide optimal patient care. However, diagnostic errors can occur due to various cognitive biases and heuristic thinking processes. In this discussion, we will explore the Dual Process Theory, cognitive dispositions to respond, cognitive debiasing, and the application of Type 1 and Type 2 processes in two clinical cases to help APNs make better decisions and reduce diagnostic errors.
Dual Process Theory and Reasoning Process:
The Dual Process Theory proposes that human thinking and decision-making involve two distinct processes: Type 1 (intuitive, automatic, and heuristic-based) and Type 2 (analytical, deliberate, and reflective). Type 1 processing relies on mental shortcuts and immediate judgments, while Type 2 processing involves systematic analysis and critical evaluation of information. In the context of diagnostic decision-making, APNs often employ both processes, but they may unintentionally rely more on Type 1 processing, leading to potential errors.
Cognitive Dispositions to Respond (CDRs) and their Application in the APN Setting:
CDRs are cognitive biases that influence how individuals interpret and respond to information. APNs may develop CDRs based on their experiences and knowledge, which can lead to overconfidence, premature closure, or anchoring on initial impressions. For example, in Case 1, the APN may have anchored on the initial diagnosis of gallbladder disease, overlooking the possibility of a pulmonary embolism. To combat CDRs, APNs must be aware of their biases and actively seek additional information before making a final diagnosis.
Cognitive Debiasing:
Cognitive debiasing involves employing strategies to reduce the impact of cognitive biases on decision-making. To enhance diagnostic accuracy, APNs can adopt strategies such as reflective practice, seeking second opinions, and utilizing decision support tools. Reflective practice encourages APNs to critically evaluate their diagnostic reasoning and consider alternative explanations. Seeking second opinions and consulting with colleagues can provide diverse perspectives, mitigating the impact of individual biases.
Application of Type 1 and Type 2 Processes in Decision-Making:
In Case 1, the APN’s initial reliance on Type 1 processing led to a diagnostic oversight. To avoid such errors, the APN should have applied Type 2 processing by considering the patient’s risk factors, symptoms, and medical history thoroughly. Similarly, in Case 2, the reliance on Type 1 processing may have contributed to the missed diagnosis of viral meningitis. By utilizing Type 2 processing, the APN could have ordered further investigations and closely monitored the patient’s condition.
Considerations for Change to Practice:
To decrease the chance of future diagnostic errors, APNs should consider implementing the following changes to practice:
a. Promoting a culture of open communication and feedback among healthcare professionals.
b. Encouraging continuous education and training on diagnostic reasoning and cognitive biases.
c. Implementing standardized diagnostic protocols and checklists.
d. Integrating decision support tools and artificial intelligence algorithms in diagnostic processes.
e. Encouraging interdisciplinary collaboration to foster comprehensive assessments.
Conclusion:
Advanced practice nurses play a vital role in patient care, and their diagnostic decision-making must be accurate and evidence-based. By understanding the Dual Process Theory, recognizing cognitive biases, employing cognitive debiasing strategies, and applying both Type 1 and Type 2 processes appropriately, APNs can enhance their diagnostic skills and minimize the risk of errors in clinical practice.
References:
Djulbegovic, B., Beckstead, J. W., Elqayam, S., Reljic, T., Kumar, A., Paidas, C., … & Polk, A. (2014). Evaluation of physicians’ cognitive styles. Medical Decision Making, 34(1), 14-29.
Monteiro, S., Sherbino, J., Patel, A., Mazzetti, I., Norman, G., & Howey, B. (2019). Social tagging to reduce diagnostic errors (STRIDE): A protocol for an interrupted time series study. BMJ Open, 9(10), e031282.
Pierret, L. (2016). Diagnostic error: Understanding and mitigating the impact of cognitive biases. American Nurse Today, 11(7), 24-28.
Tsalatsanis, A., Huebner, M., Cook, J., & Garland, E. (2015). Machine learning for diagnostic error reduction: Application to parkinsonian syndromes. Diagnosis, 2(2), 91-97.
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