Diagnostic Reasoning Free

Diagnostic reasoning (DR) is an essential competency for advanced practice registered nurses. By definition, DR is “a dynamic thinking process that leads to the identification of a hypothesis that best explains the clinical evidence.”^1(p291) In 2015, the National Academies of Sciences, Engineering and Medicine highlighted the need for honing the diagnostic process among health care providers in its report Improving Diagnosis in Health Care.²  Effective DR has been linked to improved diagnostic accuracy, quality of care, and care outcomes^2,3  and is necessary for accurate clinical problem definition, reducing diagnostic error, and determining appropriate management.

The basic principles of DR include foundational knowledge acquisition and retrieval, hypothesis-driven data collection, articulation of the problem representation statement, differential diagnosis generation, high-value testing determination and interpretation, working diagnosis determination, and metacognition. Additionally, attention to an evidence-based, patient-centered management plan is derived from accurate diagnosis and requires clear and timely communication. Competent DR embodies both system 1 and system 2 thinking (also known as type 1 and type 2 thinking) requiring practitioners to recognize patterns as well as reason through data to most accurately determine the working diagnosis.

Diagnostic error is most commonly defined as determining a wrong diagnosis, delayed diagnosis, or missed diagnosis. It may result in harmful treatments, unnecessary treatments, treatment delays, adverse patient physical or psychological outcomes, and professional or financial repercussions. Diagnostic error arises from cognitive errors or errors in thinking as well as systemic errors. It may be rooted in individual cognitive biases or knowledge deficits, or it may be impacted by systemic factors such as time pressures, complexity, emergent situations, or miscommunication.

For the acute care nurse practitioner (NP), inherent characteristics of the hospital environment may affect the quality of DR. Patient acuity and dynamic physiologic change, disease complexity, or incomplete database or iatrogenic complications may all complicate diagnostic accuracy in the hospital setting.¹  The acute setting often requires simultaneous diagnosis and treatment, further complicating accurate diagnosis.

In this symposium, authors emphasize the importance of mastering diagnostic reasoning by providing information about the foundations of DR, reviewing the extent to which DR appears in NP education, offering a description of diagnostic error and its origins, examining the teaching of DR, exploring an application of DR to acute care NP practice, and reviewing methods of evaluating DR competencies.

Theoretical and scientific foundations of diagnostic reasoning are provided in the article by Smith, Benbenek, and Petersen, together with suggested competencies for NP practice across 8 DR components. A glossary of DR terms is included, and an evidence-based model of DR is described. The article also cites essential ways that registered nurses (RNs) participate in DR and advocates for increased RN participation through increased use of team-based DR.

Diagnostic error is thoroughly explored by Benbenek, who describes types of diagnostic error, as well as diagnostic error prevalence, settings, and resultant preventable harms. Diagnostic error contributes in known and unknown ways to patient harms and can be mitigated through educational, individual provider, and system improvement strategies. The article includes discussion of cognitive factors contributing to diagnostic error and outlines several types of cognitive bias that can be monitored through intentional metacognitive practices.

Strategies for teaching diagnostic reasoning are discussed by Petersen et al. The article explores dual-process reasoning and outlines teaching approaches for several components of DR, including the use of illness scripts, structured problem representation, determining and prioritizing the differential diagnosis, cognitive debiasing, and the metacognitive approach of structured reflection. Through the intentional use of evidence-based educational strategies, the complex process of DR becomes a teachable competency for scaffolded incorporation into NP education nationally and internationally.

McCarthy and Smith provide an acute care application of diagnostic reasoning that demonstrates essential DR skills and component processes. They outline DR for the acute care NP as required for evaluation and management of a patient with acute headache. Detailed step-by-step cognitive and patient evaluation processes are described, providing exemplars of the process for application in multiple other scenarios, settings, presenting concerns, or population groups. Clarity on the real-time application of DR cognitive skills and components is fostered through this high-stakes acute care encounter.

Findings from the extension of a scoping review on the DR literature in NP education are provided in the article by Smith et al. The scoping review includes primary research studies, reports of case-based teaching innovations, evaluative measures and tool development, and model development for teaching DR, reflecting 24 DR initiatives specific to NP education. Results of the review show the advancement of a robust scholarship of DR in NP education, with particular growth in the adoption of DR frameworks in NP education programs, DR educational research, and tool and model development. Within the short time frame of the review, a shared understanding of DR for NP education and practice has emerged.

Finally, Burt et al provide a first-of-its-kind integrative review of competency assessment tools for diagnostic reasoning, including tools and assessment approaches developed specifically for use in NP education. Consistent with the call for increased competency-based assessment in NP education, this review provides NP educators with an evidence-based roadmap for evaluating DR competencies and developing assessment strategies for use with students at a variety of stages of learner development; it also provides methods for evaluating competency in differing components of the DR process. The 12 assessment tools included in the review can be used for formative and/or summative assessment and align with both American Association of Colleges of Nursing⁴  and National Organization of Nurse Practitioner Faculty⁵  education program competencies.

Together, these 6 articles provide a first-ever extensive overview of diagnostic reasoning for NP education and practice. We hope you find this symposium instructive, useful, and helpful in advancing the disciplinary dialogue around DR in nursing.