An Innovative Approach To Investigating Clinical DecisionMaking Within Speech And Language Therapy

1
 An Innovative Approach To
Investigating Clinical Decision-Making Within
Speech And Language Therapy

• Sylvia Taylor-Goh,
• Dr Ruth Mayagoitia-Hill,
• Professor Sheila Kitchen
• Royal College of Speech Language Therapists
  Conference, London
• 18/3/2009

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What is clinical decision-making

• Multiple terms have been used in the literature
  to describe closely related processes and many
  authors use the terms
• clinical reasoning,
• critical thinking,
• clinical judgement,
• and clinical decision-making interchangeably.

3
Clinical Reasoning

• Carr, (2004)
• the process of applying knowledge and expertise
  to a clinical situation to develop a solution
• Banning, (2007)
• Reasoning is a process that pertains to the
  thought processes, organisation of ideas and
  exploration of experiences to reach conclusions.
  Reasoning may be viewed as a form of thinking
  that is often apparent during the presentation of
  ideas or discourse in which the logistics of an
  argument are collated in a logical manner in
  order to reach a rational conclusion.

4
Critical Thinking

• Facione et al., (1994)
• a process of purposeful, self-regulatory
  judgement an interactive, reflective, reasoning
  process
• Lipman Deatrick, (1997)
• the careful, deliberate, goal directed thinking
  based on principles of science and the scientific
  method

5
Clinical Judgement

• Benner et al., (1996)
• the ways in which nurses come to understand the
  problems, issues or concerns of clients/
  patients, to attend to salient information and to
  respond in concerned and involved ways
• Redelmeier et al., (2001)
• the exercise of reasoning under uncertainty
  when caring for patients . . . combining
  scientific theory, personal experience, patient
  perspectives and other insights . . . a process
  including missing data, conflicting information,
  limited time and long-term trade-offs.

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Decision Making

• Matteson Hawkins, (1990)
• process of making a mental choice between two
  or more options that follows a consideration of
  all the variations of the options.
• Muir, (2004)
• if there is no uncertainty and the
  relationship between the problem and outcome were
  certain, then no decisions would be required,
  rather the best solution to the problem could be
  calculated. Therefore a distinguishing
  characteristic of decision-making is that it only
  occurs where there is uncertainty about the
  choices to be made.
• Dowie, (1993)
• defines judgements as the assessment of
  alternatives and decisions as choosing between
  alternatives.

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Clinical decision-making frameworks

• Normative - based within a positivist paradigm,
  this approach seeks to elucidate how decisions
  should be made in an ideal world where decisions
  are based on logical and known conclusions
  supported by clear or probable evidence.
•  
• Descriptive - this approach investigates how
  decisions are made within a real world context
  and no limitations are placed upon the exclusive
  use of rationality or logic.
•  
• Prescriptive - this approach is concerned with
  how decision-making can be improved.
•  

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Normative theory

• The majority of the early research into clinical
  decision-making was based on normative theory and
  studies in medicine used statistics and
  mathematical probability to determine the most
  effective outcome for a specific question (Iansek
  et al., 1983)
• Many studies within this approach utilise Bayes
  Theorem, a statistical method which combines
  prior beliefs (probabilities) and preferences
  (utilities) to make a decision.
• This approach is often adopted where linear
  judgements need to be made and where an optimal
  decision, based on the evidence can be deduced.
• It is commonly seen in diagnostic (Thomson et
  al., 2006), surgical (Doubilet and McNeil, 1982)
  and pharmacological research (Lalonde et al.,
  2004)

9
Descriptive theories

• Descriptive theories examine how individuals make
  judgements and decisions in the real world.
• No preconditions are set with regard to logic or
  rationality.
• The best known descriptive theory is the
  Information Processing Theory (IPT) which
  (Newell and Simon, 1972) also referred to as
  hypothetico-deductive approach.
• This theory postulates that human judgement and
  the reality of reasoning are bounded and
  limited to the capacity of the human memory. IPT
  suggests that when individuals are making
  decisions they go through a number of stages that
  are guided predominately by the acquisition of
  cues from the environment.

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Prescriptive framework

• The prescriptive framework originated with the
  work of Bell et al., (1988) who were concerned
  that there appeared to be a dichotomy between
  the normative and descriptive approaches and
  they proposed a need for theories to improve the
  quality of decision-making in practice.
• The outcome of this approach lead to the
  development of decision trees, clinical
  guidelines and computerized decision packages
  which are designed to aid decision- making (Kim,
  2005).

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Clinical decision-making research

• Case Scenarios (Offredy, 2003)
• Focus Groups (Kuipers et al., 2006)
• Interview (Jette et al., 2003)
• Observation (Bucknell, 2000)
• Observation footage Interview (Coleman et al,
  1999)
• Questionnaire (Nazareth et al., 1993)
• Questionnaire using case vignettes (Weaver et al,
  1990)

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Clinical Decision-Making research in Speech
Language Therapy

• Focus appears to be on the outcome and not the
  process of clinical thinking.
• Many textbooks guide the reader from diagnosis to
  management by use of decision frameworks and
  decision trees (Dodd, 1995 Yoder Kent, 1998
  Manning, 2000 White, 2000) resulting in the
  acceptance of a linear, logical model of clinical
  decision-making.

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Clinical Decision-Making research in Speech
Language Therapy

• Duffy, (1998) suggests that the processes of
  clinical decision-making have become unclear as a
  consequence of student training which views
  diagnosis as a linear, test-orientated and
  mechanistic process.
• Campbell, (1998) in an editorial review, outlined
  four decision-making approaches which he suggests
  can be used within Speech and Language Therapy
• pattern recognition,
• decision-making trees,
• diagnosis by exhaustion
• hypothetical-deductive reasoning.

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Research Question Aims

• Are there differences and similarities in the
  process and content of clinical decision-making
  by Biomedical Engineers, Occupational Therapists
  and Speech Language Therapists when assessing
  for electronic assistive technology?
• To examine whether there are differences in
  clinical decision making
• between disciplines
• between specialist assistive technology centres
  and non- specialist centres
• between experts and novices
• To explore the perceptions of each profession in
  relation to their specific role and expertise.

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Design Method

• A process tracing approach, Protocol Analysis
  (Ericsson Simon, 1984) using concurrent
  thinking-aloud verbal protocols
• Two video and audio enhanced written case
  scenarios of adults who require electronic
  assistive technology post acquired brain injury
  (validated externally)
• Participants asked to think-aloud as they read
  / view/ listen to case scenarios
• Questions re their perception of their expertise
  and role during assessment for EAT after
  think-aloud session.

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Protocol Analysis think-aloud

• The central assumption of protocol analysis is
  that it possible to ask individuals to verbalize
  their thoughts in a manner that doesnt alter the
  sequence of thoughts mediating the completion of
  a task, and can therefore be accepted as valid
  data on thinking.
• Ericsson Simon (1993) argue that the closest
  connection between thinking and verbal reports is
  found when individuals verbalize thoughts
  generated during task completion (concurrent
  thinking aloud ) rather than after (retrospective
  thinking aloud).

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Using the think aloud approach

• Thinking aloud / explanation / commentary /
  dialogue
• Need to ensure that the request to think aloud
  actually results in the thinking aloud of ones
  thoughts as opposed to providing an explanation
  or a commentary.
• Practice tasks are required to ensure that the
  participant is able to think aloud.
• Physical interaction
• limiting eye contact and physical proximity is
  essential in enabling the participant to think
  aloud without distraction.

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Using the think aloud approach

• Use of vocabulary
• the vocabulary used has a significant impact upon
  the validity and reliability of the verbal data
  produced.
• It can change the focus of the session from
  thinking aloud to dialogue / explanation simply
  by saying what are you thinking rather than
  keep thinking aloud. The impact of this from a
  theoretical perspective is explanation involves a
  different metacognitive process and therefore the
  underlying unconscious thinking process has been
  interrupted and changed.

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Using the think aloud approach

• Method of providing additional information
• the main methodological challenge in this
  context is how to deliver any additional
  information without the participant losing the
  think-aloud aspect of the procedure.
• Self conscious /self exposure
• Some participants find the process of thinking
  aloud difficult as they are concerned about
  exposing any self perceived areas of
  incompetence.

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Using the think aloud approach

• Messy, unstructured verbal detail
• the resultant verbal data arising from a think
  aloud session is likely to be unstructured, full
  of false starts, jumping from topic to topic and
  messy. This, apparently, is how we think!
• Some people find it stressful thinking aloud
  because their thoughts are unstructured.

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Enhanced Case Scenarios - Written

• All professions appear at ease with thinking
  aloud from the written case scenarios.
• There appears to be at least 2 categories of
  reactions
• For most, thinking aloud while reading the case
  information seems to be intuitive and they relate
  to the written info as to a real patient.
• For a few others, it is more task orientated and
  perfunctory.
• Some participants appear to be able to visualise
  the individual easily and can begin to make
  decisions without the use of the video and speech
  sample.

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Enhanced Case Scenarios - Written

• Participants are convinced by the reality of the
  individual , often make empathic remarks, refer
  to them by name and mention similarities with
  someone they have worked with.
• While reading the physical status section many
  participants physically mimic the movements in
  order to make them meaningful.

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Enhanced Case Scenarios- Footage

• Many participants seem to find the reality of
  viewing the simulation helpful in thinking aloud
  and often seem to "talk" to the individual.
• Very often the participant spends the remaining
  time thinking aloud while looking at the static
  footage. The footage confirms for participants
  what they have read and some have made remarks
  that it all becomes much more real for them.

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Enhanced Case Scenarios- Footage

• Some participants subject the footage to intense
  scrutiny - facial expression, speed of eye
  blink, grimace and which they used to base
  decisions upon.
• The footage is being used as an integral part of
  the case scenario and not as an adjunct to the
  written information.

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Enhanced Case Scenarios- Speech Sample

• This has been useful in enabling many
  participants to translate the text into something
  meaningful.
• The majority have said that they found the speech
  unintelligible and therefore a communication aid
  would be necessary.
• The SLT's often wanted to pursue further therapy
  to improve clarity.
• Less reliance on the speech sample than the
  footage in progressing ideas and recommendations.

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Summary

• The innovative use of enhanced case scenarios
  and protocol analysis has been a valuable
  methodology in gaining access to the clinical
  reasoning and process and content of clinical
  decision-making by Speech Language Therapists.

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Contact Details

• Kings College London
• Division of Applied Biomedical Research,
• 3.11 Shepherds House,
• Guys Campus,
• London SE1 1UL
•  
• Phone [phone]
• Email sylvia.taylor-goh_at_kcl.ac.uk
•  

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References

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