We ask ourselves this question in relation to the Careful Nursing professional practice model concept, clinical reasoning and decision-making, a key concept of the Practice Competence and Excellence (PCE) dimension. 

Those of us in clinical practice engage in clinical reasoning and decision-making every working day, especially teams of nurses practicing together on wards. It is widely recognised that critical thinking, skilled clinical reasoning and decision-making by hospital ward nurses' is crucial to the earliest possible detection of physiological deterioration in patients.

Ireland was the first country internationally to implement the National Early Warning Score designed to detect as immediately as possible physiological deterioration in patients; it is prominent in most Irish public hospitals and well supported by the Australian Capital Territory Compass Education Programme adopted by the Health Service Executive (2011).

Yet, it is very worrying that international research tells us that hospital ward nurses' clinical reasoning and decision-making skills may not be as up to scratch as they could be (Lee et al., 2016; Kavanagh & Szweda, 2017; Jessee, 2018).

Kavanagh and Szweda (2017) warn that, at least in the United States, nursing is facing a crisis in clinical reasoning competency; they conclude that a "preparation-to-practice gap" is widening in newly practicing nurses' ability to think critically and engage in clinical reasoning and decision-making (p.58.).

The problem being highlighted is not about passing academic tests and professional licencing exams; the problem is that knowledge about critical thinking, clinical reasoning and decision-making taught in education programmes is not transferring into our practice culture and clinical relationships with the people we care for. 

What can we do to check on our critical thinking, and clinical reasoning and decision-making competence?

Until we can test ourselves regularly using a valid and reliable, easily accessible, self-administered critical thinking, clinical reasoning and decision-making assessment tool, such as the Performance-Based Development System^© (2015), we can do a self-rating:

Firstly,

• On a scale of 1 to 10, how do I rate my ability to make early intuitive decisions about patients' status and actions required, that are later validated by objective evidence?

Secondly,

Following the Performance-Based Development System© (2015), developed to test critical thinking, clinical reasoning and decision-making, we can rate ourselves as follows: 

• On a scale of 1 to 10, how do I rate my ability to identify correctly all possible causes of physiological deterioration in my speciality patient group?
•  On a scale of 1 to 10, how to I rate my ability to identify correctly the level of urgency of physiological deterioration in patients?
• On a scale of 1 to 10, how do I rate my ability to identify correctly nursing interventions to minimise deterioration in patients' physiological status?
• On a scale of 1 to 10, how do I rate my ability to identify correctly appropriate medical orders I expect physicians/surgeons/medical interns to write for deteriorating patients in my specialty practice group?
• On a scale of 1 to 10 how do I rate my ability to justify the actions I take to prevent/reverse physiological deterioration in patients?

Based on my assessment of my current skill in critical thinking, clinical reasoning and decision-making, what I will do to further develop my competency in this area?

References

Health Service Executive (2011). Australian Capital Territory Training Manual for The National Early Warning Score and associated Education Programme. Health Service Executive, Dublin, Ireland.

Jessee, M.A. (2018) Pursuing improvement in clinical reasoning: The integrated clinical education theory. Journal of Nursing Education, 57, 7-13.

Kavanagh, J.M. & Szweda, C. (2017). A crisis in competency: The strategic and ethical imperative to assessing new graduate nurses' clinical reasoning. Nursing Education Perspectives, 38, 57-62.

Lee, J.H., Lee, Y.J., Bae, J.Y. & Seo, M. (2016). Registered nurses' clinical reasoning skills and reasoning process: A think-aloud study. Nurse Education Today, 46: 75-80. 

Performance Management Services, Inc. (2015). PBDS RN Initial Assessments by Credential. Anaheim, CA, USA. 

Therese Meehan