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Reconceptualizing Clinical Priority as Relational Influence: Derivation of Drawing Reasoning From a Sequential Programme of Research.

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Τίτλος: Reconceptualizing Clinical Priority as Relational Influence: Derivation of Drawing Reasoning From a Sequential Programme of Research.
Συγγραφείς: Milani A; IEO Academy, European Institute of Oncology IRCCS, Milan, Italy., Misurelli E; IEO Academy, European Institute of Oncology IRCCS, Milan, Italy., Mazzocco K; Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy.; Division of Applied Research for Cognitive and Psychological Sciences, European Institute of Oncology IRCCS, Milan, Italy.
Πηγή: Journal of evaluation in clinical practice [J Eval Clin Pract] 2026 Sep; Vol. 32 (6), pp. e70602.
Τύπος έκδοσης: Journal Article
Γλώσσα: English
Στοιχεία περιοδικού: Publisher: Wiley-Blackwell Country of Publication: England NLM ID: 9609066 Publication Model: Print Cited Medium: Internet ISSN: 1365-2753 (Electronic) Linking ISSN: 13561294 NLM ISO Abbreviation: J Eval Clin Pract Subsets: MEDLINE
Imprint Name(s): Original Publication: Oxford, England : Wiley-Blackwell, c1995-
Ιατρικοί όροι (MeSH): Clinical Reasoning*, Humans ; Cognition ; Patient Safety ; Qualitative Research
Περίληψη: Rationale: Determining which patient problem requires attention first is a continuous cognitive task with direct consequences for patient safety. Despite its centrality, clinical prioritization remains conceptually underdeveloped. Organizational models frame it as protocol-driven; experiential models assume it improves with clinical exposure. Neither addresses the specific cognitive challenge that prioritization poses when patients present with multiple interacting conditions.
Aims and Objectives: To reconceptualize clinical prioritization as a distinct cognitive task requiring relational integration under uncertainty, and to derive drawing reasoning, a structured visual method designed to support this process, from a three-study sequential programme of research.
Method: Conceptual development through sequential derivation. Three linked studies provided inputs: a theoretical integration combining complexity science, psychoneuroendocrinoimmunology, dual-process theory, and the Theory of Event Coding; a qualitative study documenting how clinicians define priority (N = 104); and an experimental study identifying cognitive biases and accuracy collapse when clinical data conflicted with expectations (N = 130). Cross-study findings were synthesized to produce definitions, an operationalized method, and testable propositions.
Results: The programme produced two conceptual outputs and one methodological output. Systemic priority is defined as the variable exerting the strongest relational influence within the patient's clinical configuration. Iterative reasoning is specified as a safety-critical cognitive operation whose interruption is empirically linked to systematic errors in prioritization. Drawing reasoning translates these outputs into a three-phase method, variable elicitation, relational mapping, and priority identification with conflict check, that directly targets the cognitive vulnerabilities documented experimentally.
Conclusion: Clinical prioritization under complexity is a distinct cognitive task that is not reducible to urgency ranking or accumulated experience. Drawing reasoning provides a teachable and testable method warranting empirical evaluation, particularly in chronic, multimorbid, and educational contexts.
(© 2026 John Wiley & Sons Ltd.)
References: J Emerg Nurs. 2023 Nov;49(6):814-825. (PMID: 37925222)
Psychother Psychosom. 2021;90(1):11-27. (PMID: 32799204)
Brain Res. 2000 Dec 15;886(1-2):172-189. (PMID: 11119695)
BMJ Open. 2019 May 28;9(5):e026471. (PMID: 31142524)
PLoS Genet. 2014 Aug 28;10(8):e1004601. (PMID: 25166010)
BMJ Qual Saf. 2016 Oct;25(10):808-20. (PMID: 26873253)
BMC Med Res Methodol. 2020 Jun 30;20(1):173. (PMID: 32605535)
Med Educ. 2007 Dec;41(12):1178-84. (PMID: 18045370)
Curr Opin Behav Sci. 2019 Aug;28:31-37. (PMID: 31592179)
Nurse Educ Today. 2010 Aug;30(6):515-20. (PMID: 19948370)
Int J Nurs Stud. 2022 Sep;133:104284. (PMID: 35696809)
Cancer Control. 2025 Jan-Dec;32:10732748251382300. (PMID: 41172984)
Front Behav Neurosci. 2019 Jul 10;13:154. (PMID: 31354446)
Acad Med. 1990 Oct;65(10):611-21. (PMID: 2261032)
J Adv Nurs. 2022 Aug;78(8):2290-2303. (PMID: 35533090)
Acad Med. 2017 Jan;92(1):23-30. (PMID: 27782919)
West J Med. 2000 Jun;172(6):393-6. (PMID: 10854390)
Med Educ. 2005 Jan;39(1):98-106. (PMID: 15612906)
Kaohsiung J Med Sci. 2021 Feb;37(2):82-91. (PMID: 33022855)
J Eval Clin Pract. 2021 Oct;27(5):1168-1171. (PMID: 34216085)
Commun Psychol. 2024 Jan 11;2(1):7. (PMID: 39242844)
J Adv Nurs. 2004 Aug;47(4):427-36. (PMID: 15271162)
Healthcare (Basel). 2024 Jan 16;12(2):. (PMID: 38255111)
Public Health Rev. 2026 May 01;47:1608853. (PMID: 42148430)
Front Pharmacol. 2023 Jan 13;13:1029067. (PMID: 36712658)
BMJ Qual Saf. 2012 Jul;21(7):535-57. (PMID: 22543420)
Support Care Cancer. 2024 Jun 25;32(7):458. (PMID: 38916761)
Proc Natl Acad Sci U S A. 2010 Oct 26;107(43):18243-50. (PMID: 20956326)
Front Med (Lausanne). 2019 Mar 28;6:59. (PMID: 30984762)
Diagnosis (Berl). 2026 Mar 13;13(3):439-450. (PMID: 41832612)
J Eval Clin Pract. 2021 Oct;27(5):1187-1193. (PMID: 33588522)
BMC Med. 2022 Jul 19;20(1):234. (PMID: 35850686)
BMC Med Educ. 2010 Sep 16;10:61. (PMID: 20846442)
Int Nurs Rev. 2025 Mar;72(1):e13096. (PMID: 39789750)
Front Psychol. 2023 Feb 28;14:1129835. (PMID: 37026083)
J Nurs Educ. 2016 Nov 1;55(11):631-639. (PMID: 27783817)
Adv Health Sci Educ Theory Pract. 2009 Sep;14 Suppl 1:27-35. (PMID: 19669918)
Science. 1974 Sep 27;185(4157):1124-31. (PMID: 17835457)
Health Aff (Millwood). 2018 Nov;37(11):1736-1743. (PMID: 30395508)
J Adv Nurs. 2024 Jul;80(7):2943-2957. (PMID: 38318634)
Appl Psychol Health Well Being. 2021 Nov;13(4):835-852. (PMID: 33855817)
Int J Nurs Stud. 2020 Sep;109:103688. (PMID: 32668336)
BMC Med Educ. 2020 Apr 7;20(1):107. (PMID: 32264895)
BMJ Open. 2024 Feb 12;14(2):e079931. (PMID: 38346890)
J Nurs Educ. 2006 Jun;45(6):204-11. (PMID: 16780008)
J Clin Nurs. 2020 Aug;29(15-16):3097-3107. (PMID: 32129522)
Contributed Indexing: Keywords: clinical decision‐making; clinical reasoning; cognitive bias; complexity; nursing; patient safety; prioritization
Entry Date(s): Date Created: 20260913 Date Completed: 20260913 Latest Revision: 20260915
Update Code: 20260915
PubMed Central ID: PMC13571805
DOI: 10.1111/jep.70602
PMID: 42732561
Βάση Δεδομένων: MEDLINE
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  Data: <searchLink fieldCode="AU" term="%22Milani+A%22">Milani A</searchLink>; IEO Academy, European Institute of Oncology IRCCS, Milan, Italy.<br /><searchLink fieldCode="AU" term="%22Misurelli+E%22">Misurelli E</searchLink>; IEO Academy, European Institute of Oncology IRCCS, Milan, Italy.<br /><searchLink fieldCode="AU" term="%22Mazzocco+K%22">Mazzocco K</searchLink>; Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy.; Division of Applied Research for Cognitive and Psychological Sciences, European Institute of Oncology IRCCS, Milan, Italy.
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  Data: Rationale: Determining which patient problem requires attention first is a continuous cognitive task with direct consequences for patient safety. Despite its centrality, clinical prioritization remains conceptually underdeveloped. Organizational models frame it as protocol-driven; experiential models assume it improves with clinical exposure. Neither addresses the specific cognitive challenge that prioritization poses when patients present with multiple interacting conditions.<br />Aims and Objectives: To reconceptualize clinical prioritization as a distinct cognitive task requiring relational integration under uncertainty, and to derive drawing reasoning, a structured visual method designed to support this process, from a three-study sequential programme of research.<br />Method: Conceptual development through sequential derivation. Three linked studies provided inputs: a theoretical integration combining complexity science, psychoneuroendocrinoimmunology, dual-process theory, and the Theory of Event Coding; a qualitative study documenting how clinicians define priority (N = 104); and an experimental study identifying cognitive biases and accuracy collapse when clinical data conflicted with expectations (N = 130). Cross-study findings were synthesized to produce definitions, an operationalized method, and testable propositions.<br />Results: The programme produced two conceptual outputs and one methodological output. Systemic priority is defined as the variable exerting the strongest relational influence within the patient's clinical configuration. Iterative reasoning is specified as a safety-critical cognitive operation whose interruption is empirically linked to systematic errors in prioritization. Drawing reasoning translates these outputs into a three-phase method, variable elicitation, relational mapping, and priority identification with conflict check, that directly targets the cognitive vulnerabilities documented experimentally.<br />Conclusion: Clinical prioritization under complexity is a distinct cognitive task that is not reducible to urgency ranking or accumulated experience. Drawing reasoning provides a teachable and testable method warranting empirical evaluation, particularly in chronic, multimorbid, and educational contexts.<br /> (© 2026 John Wiley & Sons Ltd.)
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  Data: J Emerg Nurs. 2023 Nov;49(6):814-825. (PMID: <searchLink fieldCode="PM" term="%2237925222%22">37925222)</searchLink><br />Psychother Psychosom. 2021;90(1):11-27. (PMID: <searchLink fieldCode="PM" term="%2232799204%22">32799204)</searchLink><br />Brain Res. 2000 Dec 15;886(1-2):172-189. (PMID: <searchLink fieldCode="PM" term="%2211119695%22">11119695)</searchLink><br />BMJ Open. 2019 May 28;9(5):e026471. (PMID: <searchLink fieldCode="PM" term="%2231142524%22">31142524)</searchLink><br />PLoS Genet. 2014 Aug 28;10(8):e1004601. (PMID: <searchLink fieldCode="PM" term="%2225166010%22">25166010)</searchLink><br />BMJ Qual Saf. 2016 Oct;25(10):808-20. (PMID: <searchLink fieldCode="PM" term="%2226873253%22">26873253)</searchLink><br />BMC Med Res Methodol. 2020 Jun 30;20(1):173. (PMID: <searchLink fieldCode="PM" term="%2232605535%22">32605535)</searchLink><br />Med Educ. 2007 Dec;41(12):1178-84. (PMID: <searchLink fieldCode="PM" term="%2218045370%22">18045370)</searchLink><br />Curr Opin Behav Sci. 2019 Aug;28:31-37. (PMID: <searchLink fieldCode="PM" term="%2231592179%22">31592179)</searchLink><br />Nurse Educ Today. 2010 Aug;30(6):515-20. (PMID: <searchLink fieldCode="PM" term="%2219948370%22">19948370)</searchLink><br />Int J Nurs Stud. 2022 Sep;133:104284. (PMID: <searchLink fieldCode="PM" term="%2235696809%22">35696809)</searchLink><br />Cancer Control. 2025 Jan-Dec;32:10732748251382300. (PMID: <searchLink fieldCode="PM" term="%2241172984%22">41172984)</searchLink><br />Front Behav Neurosci. 2019 Jul 10;13:154. (PMID: <searchLink fieldCode="PM" term="%2231354446%22">31354446)</searchLink><br />Acad Med. 1990 Oct;65(10):611-21. (PMID: <searchLink fieldCode="PM" term="%222261032%22">2261032)</searchLink><br />J Adv Nurs. 2022 Aug;78(8):2290-2303. (PMID: <searchLink fieldCode="PM" term="%2235533090%22">35533090)</searchLink><br />Acad Med. 2017 Jan;92(1):23-30. (PMID: <searchLink fieldCode="PM" term="%2227782919%22">27782919)</searchLink><br />West J Med. 2000 Jun;172(6):393-6. (PMID: <searchLink fieldCode="PM" term="%2210854390%22">10854390)</searchLink><br />Med Educ. 2005 Jan;39(1):98-106. (PMID: <searchLink fieldCode="PM" term="%2215612906%22">15612906)</searchLink><br />Kaohsiung J Med Sci. 2021 Feb;37(2):82-91. (PMID: <searchLink fieldCode="PM" term="%2233022855%22">33022855)</searchLink><br />J Eval Clin Pract. 2021 Oct;27(5):1168-1171. (PMID: <searchLink fieldCode="PM" term="%2234216085%22">34216085)</searchLink><br />Commun Psychol. 2024 Jan 11;2(1):7. (PMID: <searchLink fieldCode="PM" term="%2239242844%22">39242844)</searchLink><br />J Adv Nurs. 2004 Aug;47(4):427-36. (PMID: <searchLink fieldCode="PM" term="%2215271162%22">15271162)</searchLink><br />Healthcare (Basel). 2024 Jan 16;12(2):. (PMID: <searchLink fieldCode="PM" term="%2238255111%22">38255111)</searchLink><br />Public Health Rev. 2026 May 01;47:1608853. (PMID: <searchLink fieldCode="PM" term="%2242148430%22">42148430)</searchLink><br />Front Pharmacol. 2023 Jan 13;13:1029067. (PMID: <searchLink fieldCode="PM" term="%2236712658%22">36712658)</searchLink><br />BMJ Qual Saf. 2012 Jul;21(7):535-57. (PMID: <searchLink fieldCode="PM" term="%2222543420%22">22543420)</searchLink><br />Support Care Cancer. 2024 Jun 25;32(7):458. (PMID: <searchLink fieldCode="PM" term="%2238916761%22">38916761)</searchLink><br />Proc Natl Acad Sci U S A. 2010 Oct 26;107(43):18243-50. (PMID: <searchLink fieldCode="PM" term="%2220956326%22">20956326)</searchLink><br />Front Med (Lausanne). 2019 Mar 28;6:59. (PMID: <searchLink fieldCode="PM" term="%2230984762%22">30984762)</searchLink><br />Diagnosis (Berl). 2026 Mar 13;13(3):439-450. (PMID: <searchLink fieldCode="PM" term="%2241832612%22">41832612)</searchLink><br />J Eval Clin Pract. 2021 Oct;27(5):1187-1193. (PMID: <searchLink fieldCode="PM" term="%2233588522%22">33588522)</searchLink><br />BMC Med. 2022 Jul 19;20(1):234. (PMID: <searchLink fieldCode="PM" term="%2235850686%22">35850686)</searchLink><br />BMC Med Educ. 2010 Sep 16;10:61. (PMID: <searchLink fieldCode="PM" term="%2220846442%22">20846442)</searchLink><br />Int Nurs Rev. 2025 Mar;72(1):e13096. (PMID: <searchLink fieldCode="PM" term="%2239789750%22">39789750)</searchLink><br />Front Psychol. 2023 Feb 28;14:1129835. (PMID: <searchLink fieldCode="PM" term="%2237026083%22">37026083)</searchLink><br />J Nurs Educ. 2016 Nov 1;55(11):631-639. (PMID: <searchLink fieldCode="PM" term="%2227783817%22">27783817)</searchLink><br />Adv Health Sci Educ Theory Pract. 2009 Sep;14 Suppl 1:27-35. (PMID: <searchLink fieldCode="PM" term="%2219669918%22">19669918)</searchLink><br />Science. 1974 Sep 27;185(4157):1124-31. (PMID: <searchLink fieldCode="PM" term="%2217835457%22">17835457)</searchLink><br />Health Aff (Millwood). 2018 Nov;37(11):1736-1743. (PMID: <searchLink fieldCode="PM" term="%2230395508%22">30395508)</searchLink><br />J Adv Nurs. 2024 Jul;80(7):2943-2957. (PMID: <searchLink fieldCode="PM" term="%2238318634%22">38318634)</searchLink><br />Appl Psychol Health Well Being. 2021 Nov;13(4):835-852. (PMID: <searchLink fieldCode="PM" term="%2233855817%22">33855817)</searchLink><br />Int J Nurs Stud. 2020 Sep;109:103688. (PMID: <searchLink fieldCode="PM" term="%2232668336%22">32668336)</searchLink><br />BMC Med Educ. 2020 Apr 7;20(1):107. (PMID: <searchLink fieldCode="PM" term="%2232264895%22">32264895)</searchLink><br />BMJ Open. 2024 Feb 12;14(2):e079931. (PMID: <searchLink fieldCode="PM" term="%2238346890%22">38346890)</searchLink><br />J Nurs Educ. 2006 Jun;45(6):204-11. (PMID: <searchLink fieldCode="PM" term="%2216780008%22">16780008)</searchLink><br />J Clin Nurs. 2020 Aug;29(15-16):3097-3107. (PMID: <searchLink fieldCode="PM" term="%2232129522%22">32129522)</searchLink>
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