Elsevier

Nurse Education Today

Volume 46, November 2016, Pages 75-80
Nurse Education Today

Registered nurses' clinical reasoning skills and reasoning process: A think-aloud study

https://doi.org/10.1016/j.nedt.2016.08.017Get rights and content

Highlights

  • Clinical reasoning is essential cognitive process for the patient care in nursing.

  • Most commonly used reasoning skill was ‘checking accuracy and reliability’ of data.

  • Clinical reasoning process showed a cyclic and clockwise direction.

Abstract

Background

As complex chronic diseases are increasing, nurses' prompt and accurate clinical reasoning skills are essential. However, little is known about the reasoning skills of registered nurses.

Objective

This study aimed to determine how registered nurses use their clinical reasoning skills and to identify how the reasoning process proceeds in the complex clinical situation of hospital setting.

Design

A qualitative exploratory design was used with a think-aloud method.

Methods

A total of 13 registered nurses (mean years of experience = 11.4) participated in the study, solving an ill-structured clinical problem based on complex chronic patients cases in a hospital setting. Data were analyzed using deductive content analysis.

Results

Findings showed that the registered nurses used a variety of clinical reasoning skills. The most commonly used skill was ‘checking accuracy and reliability.’ The reasoning process of registered nurses covered assessment, analysis, diagnosis, planning/implementation, and evaluation phase.

Conclusions

It is critical that registered nurses apply appropriate clinical reasoning skills in complex clinical practice. The main focus of registered nurses' reasoning in this study was assessing a patient's health problem, and their reasoning process was cyclic, rather than linear. There is a need for educational strategy development to enhance registered nurses' competency in determining appropriate interventions in a timely and accurate fashion.

Introduction

Patients with complex chronic diseases, who suffer from at least two or three chronic conditions, are in need of health plans tapping a range of medical resources (Garcia-Fernandez et al., 2014). When a patient with complex chronic disease is admitted to a hospital with an acute condition, the nurse's clinical practices are required not only accurate nursing skills, but complex thinking processes to analyze and integrate a large amount of subjective and objective data (Smith Higuchi and Donald, 2002).

Clinical reasoning is a complex, multi-dimensional, and recursive cognitive process for developing strategies to determine nursing practices appropriate for individual client circumstances (Simmons et al., 2003). Later, Simmons (2010) modified a definition of clinical reasoning as “a complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance and weigh alternative actions” (pp. 1155). Therefore, it is an innovative form of assessment by which nurses focus on clinical reasoning and clinical decision-making (Forsberg et al., 2014), and clinical reasoning skills are a necessary component of expert and competent nursing practices (Banning, 2008). Critical thinking is knowledge based discipline, which does not consider patient contextual situation. Otherwise, clinical reasoning is a combined concept that includes nurses' knowledge with clinical experiences. In other words, clinical reasoning is relevant to patient situation based on critical thinking (Benner, 1984, Jones, 1988). As this process relying on critical thinking, clinical reasoning is affected by professional attitudes and philosophical perspectives, the expertise, experience, and intuition of nurses (Simmons et al., 2003).

Studies on clinical reasoning competency seek to compare novice and expert nurses. Previous research has found experienced nurses to be more proactive in problem solving, collecting varied data and clustering cues, in comparison to novice nurses (Hoffman et al., 2009). Experienced nurses use cognitive strategies such as conversion to form detailed problem representations and to find solutions (Sarsfield, 2013). In addition, expert nurses use working knowledge and patterns (Gerber et al., 2015). They evaluate patients' symptoms and signs, and the results of physical examinations and laboratory tests, to find patterns and generate hypotheses based on their accumulated experience. Experienced nurses have a salient competency in requesting the prioritized questions for the patients and family members. Based on patients' assessment, nurses make a nursing plan and implement appropriate care services for patients (Forsberg et al., 2014).

There is a need to identify what cognitive strategies and reasoning processes nurses use to assess patients' health problems, and to develop and execute solutions in fast-paced complex clinical situations. However, little research has been conducted on this topic. Funkesson et al. (2007) have described that nurses used usual thinking process for the patient wound care. Clinical reasoning content was related to nurses' knowledge, clinical experience although there were differences by individual career background. In 2011, Fossum and colleagues have stated that the most commonly used thinking strategy used in the clinical reasoning of nursing home nurses for the prevention of malnutrition and pressure ulcers was ‘making choices’ for nursing interventions.

Therefore, the aim of this study was to explore what clinical reasoning skills and reasoning processes were used in nurses' problem solving using cases of patients with complex chronic disease admitted to a hospital with an acute condition.

Section snippets

Background

Information processing theory (IPT) was a process of gathering information and making judgments to select an optimal alternative (Newell and Simon, 1972). This theory is based on the assumption that the amount of information that can be stored in short-term memory is limited. IPT has formed the basis of many nursing studies on clinical reasoning using a think-aloud method (Fossum et al., 2011, Hoffman et al., 2009, Simmons et al., 2003). Therefore, IPT served as a methodological framework in

Design

This study entailed qualitative research using the think-aloud method to investigate clinical reasoning strategies and reasoning processes used by nurses for problem solving in caring for complex chronic disease patients.

Participants

The participants were registered nurse with more than five years of clinical experience, who had obtained a master's degree or above and certification as a Korean Advanced Nurse Practitioner. This approach excluded novice nurses and targeted participants who could actively

Clinical Reasoning Skills

The analysis of the verbal data showed that the participants used all 17 of Alfaro-LeFevre's (2013) clinical reasoning skills in problem solving. However, not every participant used every skill. The frequency of use of the clinical reasoning skills is shown in Table 3.

Clinical Reasoning Skills

This study found that ‘checking accuracy and reliability’ was the most commonly used clinical reasoning skill by the participants. This finding was inconsistent compare to a previous study by Fossum et al. (2011). According to this study, registered nurses frequently used ‘making choices’ thinking strategy throughout decision making process. This discrepancy may be explained by the present research scenario, which led the participants to focus heavily on assessment to accurately address the

Conclusions

This study examined the clinical reasoning skills and processes used by nurses to address health problems in complex clinical situation, using the think-aloud method. The findings showed that the most commonly used clinical reasoning skill was ‘checking accuracy and reliability’ to assess the most accurate and meaningful data. Clinical reasoning was shown to be a cyclic process moving in a clockwise direction and consisting of 5 phases: assessment, analysis, diagnosis, planning/implementation,

Acknowledgments

This work was supported by the Yonsei University College of Nursing in 2014.

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