Clinical reasoning is the process healthcare staff use to collect indicators and information, understand the patient’s situation or problem, plan interventions and evaluate and reflect. The critical reasoning process depends on critical thinking and is influenced by the person’s attitude, perspective and assumptions. Clinical reasoning is represented by a series of interconnected clinical encounters.
Why is clinical reasoning important?
When nurses have clinical reasoning skills, there is a positive impact on patient outcomes. A lack of these skills can mean imminent patient deterioration is not detected. Research has shown that adverse patient outcomes are most likely due to misdiagnosis, inappropriate treatment and mismanagement of complications. All of these relate to poor clinical reasoning. Education must begin with undergraduates learning to recognize and manage patient deterioration, use escalation systems and communicate effectively.
Experienced nurses will use clinical reasoning while giving patient care. When they enter the patient’s room, they can observe significant data straightaway, draw conclusions about the patient and provide appropriate care. Their knowledge, skills and experience can make this process seem automatic. Despite this, clinical reasoning does have to be taught. For nursing students to learn how to manage complex clinical situations, they must understand the steps and processes of clinical reasoning. Nursing students must learn how cues affect clinical decisions and the relationship between cues and outcomes. Clinical reasoning can be difficult and requires a different approach to routine nursing procedures. Learning to reason effectively takes ongoing practice and reflection.
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The clinical reasoning cycle
There are eight main steps in the clinical reasoning cycle, which are:
- Consider the patient’s situation.
The first step involves considering the patient’s situation, describing the person and why they have been admitted to the hospital.
- Collect cues/information.
The second step is collecting cues and information. The healthcare worker can review current information, including patient charts, patient history, handover reports, investigation results and assessments. New information can be gathered, such as patient assessments. Knowledge can be recalled from past clinical experiences and linked to the current patient.
- Process information.
Process information is the third step and has six sub-sections. Number one is interpretation, which involves analyzing data to understand signs and symptoms and compare normal with abnormal. Staff will consider if the results are normal for the person and the time and place. Step two is discriminate, pinpointing relevant information, recognizing inconsistency, summarising the main information and identifying gaps in cues collected. This can help to determine the priorities for the patient’s health. Step three is relate — finding new relationships or patterns, and forming opinions by interpreting the cues and consequences. At this time, staff can identify what the main problems are. The fourth step is making deductions and forming opinions about what is actually happening with the patient. The fifth step is matching patients to past situations or patients, and the sixth is predicting an outcome based on the information gathered so far.
- Identify problems/issues.
The fourth step is identifying problems or issues and using facts and inferences to diagnose the patient’s problem.
- Establish goals.
The fifth step is to establish goals which is a desired outcome with SMART (specific, measurable, achievable, relevant and timely) objectives.
- Take action.
Step six is when a course of action is selected from the alternatives available. Actions will be to try and prevent deterioration and ensure good patient outcomes.
- Evaluate outcomes.
The seventh step is evaluating effectiveness and outcomes. There will be consideration of whether the patient has improved or deteriorated.
- Reflect on the process and new learning.
Finally, step eight is the reflection and new learning, thinking about what has been learned and what could have been done differently.
This process represents the ongoing nature of clinical interventions and the importance of evaluation and reflection. Clinical reasoning is a dynamic process — nurses often combine phases or move back and forth between them. There are not clear divisions between each step as they can merge, and boundaries can blur. This process should come from the concerned, engaged approach of nurses. They use their knowledge and rational processes but not in a detached, objective way. Nursing students must learn to work through each phase and not make assumptions about patients or introduce interventions that have not been properly considered.
Student nurses use clinical reasoning
A YouTube video shows a meeting with Michael McGivern, nursing tutor, and two of his nursing students. They have been learning about the clinical reasoning cycle and have followed it for the first time with a patient. They were given a laminated diagram of the cycle to keep in their pocket for reference.The nursing students are giving him feedback on how they have followed the cycle of clinical reasoning when caring for a particular patient. Michael explains that the cycle is all about preventing the patient deteriorating, looking at a much wider picture and using critical thinking.
Consider the patient situation: the two students say that the patient is 74 years old and was admitted to the emergency department (ED) by ambulance that morning. He was short of breath, a bit confused and feeling anxious. As far as they know, he had had a fall at home with no skeletal injuries or loss of consciousness. He has edema going from his feet to his hips.
Collect cues/information: he lives alone, and his family does not live nearby. He would like to be resuscitated if he has a critical incident or deteriorates. The nurses took his vital signs. He is being given oxygen through a nasal prong. He was given a catheter in ED. He has heart failure, so an electrocardiogram was done and there were no changes from his last admission.
Process information: he is still confused and short of breath. This could be due to hypoxia and heart failure. Three assessments were carried out, including a pressure area assessment that was done as he cannot move in bed so is at risk of getting pressure sores.
Identify problems/issues: the patient is at risk of deep vein thrombosis, which could lead to pulmonary embolism. The catheter means there is an increased risk of urine infection. The patient has shortness of breath and is confused and anxious. He is not mobile because of the edema. He has a history of hypertension, gout and heart failure. He is taking beta blockers to lower cholesterol and medication for gout. He is hypertensive, and his heart muscles have become weaker. He has fluid in his lungs because his heart is not pumping correctly. His oxygen saturation has dropped. He has pulmonary edema, which is causing the shortness of breath.
Establish goals: medication for anxiety and edema. To lose weight every day. Elevate feet in bed. Hourly turns in bed and try to get him to sit in a chair. See him hourly and give reassurance.
Take action: tell nursing sister his vital signs. Talk to the doctor about his oxygen levels. Contact medical outreach. He has been seeing them already, so inform them he is in hospital and find out how he has been before admission. Contact social workers and occupational therapist about his future care. Ask him if he has a belief and, if so, if he would he like to see the hospital minister.
Evaluation: make sure his blood pressure is maintained and stable. Make sure his urine output is maintained.
Reflect: the two nursing students have learned more about what they should be looking for and focusing on. They said that the more knowledge they gathered the more confident they felt. Following the cycle showed how much they need to know about patients and how they should be prepared if the patient does deteriorate. It helped them to look at the big picture.
Aspects of clinical reasoning
Clinical reasoning and critical thinking are mental processes nurses use to ensure quality thinking and decision making. Nurses use both of these skills when making decisions about patient care. Critical thinking is the higher-level thinking process that identifies a patient’s problem, examines evidence-based practice, and makes decisions about care delivery. It involves understanding the difference between fact, judgment and opinion and thinking creatively, reflecting and analyzing. When nurses use thinking skills, there is a merging of the skills, knowledge and attitudes that connect to critical thinking and clinical reasoning, nursing and problem solving.
Clinical reasoning requires critical thinking in identifying the most suitable interventions for improving the patient’s condition. Clinical reasoning has been described as applying critical thinking to a clinical situation. It is a process that uses thinking strategies to collect and analyze patient information, evaluate data and decide on actions to improve the patient’s outcomes. The most appropriate interventions must be selected to improve the patient’s condition. Clinical reasoning is analyzing the clinical situation as it moves on and develops. Nurses will understand and apply the content they have learned previously. They will reflect on the patient’s status and use critical thinking skills to build an effective care plan. The nurse must be aware of the patient’s concerns and experiences.
Nurses will assess the client and notice any changes so they can select interventions that will improve health outcomes. Changes in a patient’s condition can happen quickly. The nurse is responsible for detecting changes, carrying out assessments and interventions, notifying the healthcare team and evaluating the patient’s response. Nurses work in fast-paced environments and work quickly to deal with problems. They must know what tasks, assessments, concerns and requests must be prioritised.
Clinical situations can change rapidly, requiring priorities to change. Nurses spend more time with patients than other healthcare staff, so they must notice changes in the patient’s condition, recognize changes in priority, adapt nursing care and make sure other healthcare professionals are aware. Clinical reasoning involves assessing and understanding the patient’s history and present condition and detecting changes. The nurse monitors the patient and compares past and present assessment data, so recognizing and avoiding adverse outcomes.
After assessing the data and deciding what is relevant to the patient, the nurse identifies interventions and sets priorities for the most urgent care. The nurse uses their nursing knowledge to support the plan of care. Clinical reasoning can be used to recognize minimal changes in the patient’s condition.
Nurses must take note of the patient’s religious and cultural background. An example is that for Muslims, it is traditional for female relatives to look after the baby while the mother rests. If nurses do not understand this practice, they may not adapt their care, which means critical thinking has not been used during the clinical reasoning process.
Nurses must consider if their knowledge when caring for patients is based on up-to-date, evidence-based theory. Nurses must review the most current nursing and healthcare literature to be aware of best practice. Education and training add to professional competence and enhance clinical reasoning.
Reflection is essential to the success of clinical reasoning. Nurses can identify factors that improve patient care and those that should be changed or removed. They can reflect on whether the patient was assessed accurately and within correct timescales. They can look back at interventions and whether they were beneficial. Nurses must reflect on the outcome of care and consider previous similar experiences so they can achieve continual improvement.
Clinical reasoning can be used throughout patient care by healthcare staff to improve outcomes. Nursing students must be taught how to use clinical reasoning. The clinical reasoning cycle is a tool that gives a step-by-step process for healthcare staff to use to guide their practice. It includes using thinking strategies to collect and process information, evaluate it, and decide on actions to improve the patient outcomes. Nursing staff use critical thinking, ensure patients do not deteriorate, and see the bigger picture. They use the most appropriate interventions to improve the patient’s condition. Clinical reasoning is vital to healthcare practice and helps ensure patients receive the best possible care.