Clinical Reasoning Cycle Applied to Mental Health Nursing

Introduction

Clinical reasoning is linked to sound and evidence-based clinical judgment, to problem-solving and decision-making, and to critical thinking. Critical thinking in the nursing profession is defined as the "purposeful, self-regulatory judgment that uses cognitive tools such as interpretation, analysis, evaluation, inference, and explanation" of contextual variables (Benner, Hughes & Sutphen, 2008, p. 1). Therefore, clinical reasoning is central to promoting a high quality of patient care and to ensuring positive, goal-driven patient outcomes.

The clinical reasoning cycle provides a standard framework for critical thought in healthcare and can be used by nurses across every patient sector. This case study illustrates the importance of taking into account a multitude of variables in order to achieve patient outcomes in a holistic manner. The clinical reasoning cycle minimizes biases, assumptions, and prejudices, allowing healthcare providers to remain open to a range of different options and possibilities. The essential components of the cycle are: description of the facts at hand, collection of information, information processing, identification of main problems or issues, establishment of goals, taking action, assessing outcomes, and reflecting on the process. This critical appraisal applies the clinical reasoning cycle to the case study of Emily and identifies core nursing priorities.

Emily's case study highlights specific issues related to mental health and psychiatric care. Mental health issues do not occur in isolation from ancillary events, circumstances, or concerns. Social, physiological, and situational variables all impact a patient's mental health and externalizing behaviours. In this case, Emily demonstrates suicidal ideation, suicidal behaviour, anxiety, self-harm, and disordered eating. Rather than focusing on the symptoms of Emily's behaviour, a skilled mental health care worker would address the totality of Emily's experiences, including her healthcare background, her family and social history, and her physical health.

Emily's case also demonstrates that mental illness does not always occur as a singular event. Presenting symptoms may be misread or misunderstood, and confused with other physical or mental health issues. The rigidity of the medical model often entails leaping to conclusions before making a full investigation of the patient's background and current context. Emily's case therefore highlights how important differential diagnoses are for providing the highest possible quality of care. Particularly when working within the holistic nursing model, the emphasis should not be placed solely on initial presenting symptoms or prodromal presentation, but on problem-solving and solutions that address root causes and patient-centric goals. The recovery model of care must also be considered as the ultimate objective in healthcare treatment, offering nurses an effective framework for patient advocacy, autonomy, and self-determination.

Step 1: Description of Patient Situation

Emily is a 19-year-old female brought into the Emergency Department at 1700 by her parents and with her consent. Vital signs are normal and stable. Initial presenting symptoms indicate a high degree of anxiety or agitation, linked to her having taken an overdose of over-the-counter analgesics including paracetamol and ibuprofen. Emily is compliant and, although distressed, cooperative. However, her speech is agitated and she has difficulty completing sentences, speaking negatively and self-deprecatingly.

During the intake interview, Emily freely admitted she had taken an overdose of nine paracetamol tablets and five ibuprofen tablets at 1600 on the day of admission. Further questioning by the nurse revealed that Emily has a history of suicidal ideation and suicidal behaviour. For example, Emily stated that she had been considering the overdose for the past week and that she had made the decision to take the overdose that day if her end-of-semester results were not "good." When she was displeased with her academic results, Emily followed through with her decision to take the over-the-counter medications, which she had purchased the day before her admission. Furthermore, Emily admitted that her intention in taking paracetamol and ibuprofen was not actually to commit suicide per se, but to gain attention and to "make others know how she was feeling." Emily also stated that she felt "embarrassed" for having taken the drugs.

Emily lives with her mother, her father, and her younger brother, who has mild autism. Emily also has a boyfriend whom she phoned immediately after receiving her failing grades. She told him that she intended to kill herself, which prompted him to call Emily's parents.

Steps 2 and 3: Collecting Cues and Processing Information

Emily has seen a psychologist in the past, but her counselling sessions are no longer covered under her parents' insurance policy. She also used the Headspace program, but completed only six of ten sessions and was told the program may not be sufficient for her needs.

Emily remains financially dependent on her parents, with a job that offers only twelve hours of work per week. She has felt pressure from her parents to find a more viable career or personal development path, and from her friends, who want to travel with her during a gap year. Emily has no history of drug or alcohol abuse. She is not sexually active, does not take birth control, and has never been pregnant. Emily reports no sleep problems. She presents with a flat affect upon assessment, but when asked, states that she "thinks too much" at night when alone in her room.

Emily weighs 55.4 kg and is 165 cm tall, giving her a BMI of 20.3 kg/m². She has lost 2 kilograms in the past month. When asked, Emily states she has not been hungry; however, further inquiry reveals she has been purging to consciously lose weight, and that the frequency of her purging behaviours has increased over the past week. She states a goal weight of 49 kilograms. Emily has no prior history of an eating disorder. Emily has also been self-harming: she began cutting herself two years ago and has also bruised and burnt herself. She claims that she currently does not self-harm and does not feel the need to cut herself or take overdoses.

The disordered eating and self-harming behaviours are externalizations of internal issues, including acute but undiagnosed anxiety and depression. A mood disorder is suspected, based on the patient's expressed extreme lack of energy and motivation as well as a sense of being overwhelmed. Social pressures and a lack of direction are compounding Emily's high level of anxiety. At the same time, Emily does have a significant degree of social support, including her family and her boyfriend. The presenting symptoms and behaviours — including disordered eating and self-harm — can be mitigated through an effective and holistic intervention and care program. It is also anticipated that initial self-regulation of emotions may help Emily to re-engage with Headspace.

Step 4: Establishing Goals and Nursing Priorities

It is important to note that Emily is willing to change. She understands that she overdosed on over-the-counter analgesics as a "cry for help" more than as a genuine suicide attempt, expresses a desire to change, and needs support in addressing the underlying lack of motivation, low self-efficacy, and morbid outlook.

A key issue in Emily's case is her ability to envision the future. She states she feels worse when she thinks about the future, saying that she does not know what she wants to do, or that she wants to do nothing. She wants to take a gap year but is unfocused and afraid of the financial implications, unsure of where her current academic program is taking her. However, she also says she enjoys her work at an animal shelter. Therefore, nursing priorities should focus on helping Emily develop a career map or personal development plan based on her interest in animal welfare.

Patient advocacy is crucial in Emily's case. "Historically, the Australian health system has failed to meet the needs of young people with mental health problems and mental illness" (Howe, Batchelor, Coates & Cashman, 2013, p. 190). The mental health nurse should therefore take into account all available community and state resources that can be mobilized to help Emily, offering Emily the ultimate say in how her treatment progresses. Emily needs to be an active participant in her recovery-oriented treatment. Using a patient advocacy approach also follows the general principles and philosophies of action research, making advocacy a key component of evidence-based and recovery-oriented mental health practice (Kidd, Kenny & McKinstry, 2014). As Happell, Conwin, Roper, Lakeman, & Cox (2013) point out, patient advocacy entails open dialogue and communication with patients, who become active participants in constructing their own goal-driven recovery priorities.

Emily struggles with feelings of pressure originating from perceived expectations placed on her by others — both friends and family — as well as from demands she places on herself. She admits that much of the pressure to excel is self-enforced, and she understands that this pressure may be preventing her from fulfilling her goals. Emily has a tendency to withdraw and hide, evident in her statements about running away from and withdrawing from social situations rather than tackling problems directly, and internalizing her guilt and anger. It may therefore help to introduce Emily to community-based options including, but not limited to, Headspace, given that "Headspace centres comprise a significant innovation in community-based youth mental health service delivery in Australia" (Rickwood, Van Dyke & Telford, 2013, p. 29).

The ultimate nursing priority is to build Emily's coping skills so that high-stress or high-pressure situations do not overwhelm her. Based on research by Kidd, McKenzie & Virdee (2014), it may also be important to incorporate mentoring and reflective dialogue practices to help Emily develop effective coping strategies. Similarly, it is important for mental health nurses to help Emily self-monitor her thoughts so as to reduce the pressure she places on herself.