In order to critically reflect upon problem solving skills in health assessment, the motivations and processes entailed in Egan’s skilled helper approach and clinical reasoning will be identified. This will be followed by an evaluation of their contrasting motivations and comparisons of their initial inquiry positions. It will be identified how these positions inform the collection of patient history data. Subsequent to this, appropriate applications of the approaches will be discussed followed by a dissemination of the influence of both upon humanistic nursing processes. It will be identified that both the skilled helper and clinical reasoning approaches encourage reflective practice, which in turn informs health assessment processes.
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Egan’s (1997) skilled helper approach is implemented across counselling and health care professions in order to facilitate the patient’s identification of problems. Furthermore, the approach is designed to enable the patient to identify and implement self-identified coping strategies in order to deal with the identified problem. There are two primary motivations behind skilled-helper approach implementation. These are to enable the patient to live effectively and to maximise opportunities, and to enable patient’s ability to manage their own health (Manning, 2000).
The approach is broadly composed of three interactive stages (Egan, 1997). Firstly, the patient is led through the generation of history data, until enough has been collected so that both the nurse and patient are able to fully conceptualise the current problem. The client and nurse identify major cognitive and behavioural features that may have led to the current scenario. The second stage entails the detailing of the client’s preferred scenario; the nurse assists the patient in identification of an ideal future position, and develops patient courage and confidence in order to pursue the ideal scenario. Lastly, the nurse and patient brainstorm specific actions that would realistically lead to the desired solution. The result is a formulation of specific goals and strategies that the patient will work to achieve.
Clinical reasoning; or problem based learning (Barrows & Pickell, 1991) employs two knowledge types in order to identify and diagnose patient problems. The authors propose that effective clinical reasoning uses both content and process knowledge in order to achieve diagnosis and health assessment. Content knowledge refers to what knowledge the nurse practitioner has achieved through training and practice. The second form, process knowledge, relates to how the content knowledge is used in health assessment. The approach employs the scientific inductive method in order to achieve a health assessment and diagnosis.
The nurse interacts with the patient over a series of steps to achieve the health assessment. Similarly to Egan (1997), the nurse develops an initial concept through a primary discussion with the patient regarding their problem concept (Barrows & Pickell, 1991). The problem concept and primary perceptions are used to generate multiple hypotheses of possible diagnoses for the patient’s condition. A focused patient history is conducted in order to discount hypotheses. Critical deductive skills and physical examination are also employed to falsify or support inferred hypotheses. New hypotheses are generated with the assimilation of further information or when the current line of enquiry becomes unproductive. Inquiries should occur in conjunction with an understanding of the pathophysiological mechanism that is operative in the patient’s condition. Inquiry continues until a single remaining hypothesis is supported.
The skilled helper and clinical reasoning approaches differ in their motivations. Egan’s (1997) skilled helper model aims to enable the patient to identify problems within their current situation while clinical reasoning (Barrows & Pickell, 1991) aims to use the patient concept to motivate a line of enquiry which will result in the clinician making a diagnosis. While the skilled helper model relies upon facilitation of patient concepts, clinical reasoning approaches incorporate physical examination (Seidel, Dains & Benedict, 1994). Despite this, both approaches begin with a similar concept. Formulations of the skilled helper and clinical reasoning approaches both begin with a generation of patient history data. Acquisition of the contextual data relating to the impact of the patient’s background upon the current problem concept, in conjunction with personal and family history (Epstein, Perkins, Cookson, Watt, & Rakhit, 2008) allows for the formulation of further inquiries in both health assessment approaches.
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As Egan’s (1997) skilled helper model facilitates the client’s management of their own problem concepts, it is arguably a more fruitful strategy within community based mental health nursing (Hannigan, 1997). When the patient presents with minor ailments requiring diagnosis and short term treatment, clinical reasoning is potentially a more effective approach to employ (Jones, 2006). However, both approaches share in the benefit of facilitating a patient-centred approach to health assessment and treatment management. For example, a rating study of student nurses’ interviewing skills found that the utilisation of both approaches facilitated humanistic inquiry strategies (Arthur, 1999). This benefits nurse-patient communication processes, ensuring a positive experience of health assessment and care provision for the patient (McCabe, 2004).
Both approaches benefit from the opportunity to engage the nurse in reflective practice. By structuring the health assessment process, the approaches enable nurse practitioners to evaluate successive stages. This provides a structure to reflect upon the successes and limitations of their health assessment behaviours (Schon, 1991). For example, the interactive nature of both processes can be utilised by nurses to adjust health assessment practice in line with self-evaluation strategies. Furthermore, Egan’s (1997) skilled helper approach benefits reflective practice by equipping nurses to utilise the approach upon their own health assessment processes (Kuiper & Pesut, 2004). Concurrently, clinical reasoning skills facilitate skills of critical judgement and limitation identification (Higgs & Jones, 2000).
Egan’s skilled helper approach aims to facilitate patients’ self-management of problem concepts, while clinical reasoning uses the patient’s problem concept in order to inform inductive inquiries. These inquiries result in a diagnosis presented by the clinician. Both approaches begin inquiries with the patient’s formulation of the problem concept which motivates further inquiry. Egan’s skilled helper approach is more appropriate within the context of mental health nursing, while clinical reasoning is useful in the diagnosis and treatment of minor ailments. Both approaches facilitate communication styles that support humanistic nursing processes. Furthermore, both approaches enable reflective nursing practice, informing the health assessment process.
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