In a nutshell . . . .

In this page you're introduced to the Clinical reasoning and decision-making idea of the Practice Competence & Excellence (PCE) dimension. This idea is the second of the four ideas that make up the PCE critical circle of clinical responsibility. You'll see that the idea of Clinical reasoning and decision-making is intertwined with and follows directly from the idea of watching-assessment-recognition.

You'll read about the main purposes of Clinical reasoning and decision-making and how it works hand in hand with the Intellectual engagement idea of the Therapeutic Milieu dimension. You'll be encouraged to think about how the philosophy of science and the philosophy of holism contribute to our understanding of Clinical reasoning and decision-making.

You'll find a summary of nursing literature and research on Clinical reasoning and decision-making and its key components. Finally, you'll be asked to consider the complexity of Clinical reasoning and decision-making in nursing, how difficult it is to measure and evaluate, and recent research that indicates that we may not be doing very well in implementing this important idea. 

Introduction

Clinical reasoning and decision-making is the fourth concept of the Practice Competence and Excellence (PCE) dimension and the second of the four PCE concepts that form the Careful Nursing critical circle of clinical responsibility. This concept is intertwined with and follows directly from the concept of watching-assessment-recognition. Before continuing, please take a minute to review the two figures on the PCE Introduction page above to remind yourself how this concept relates to the other seven PCE concepts (first Figure) and where it fits in the critical circle of clinical responsibility (second Figure).

In Careful Nursing clinical reasoning and decision-making is understood as one concept because reasoning and decision-making processes are so closely interrelated. This concept highlights our distinctively human capacity to reason; it is central to our purposeful application of nursing knowledge; to how our critical thinking guides our practice. Clinical decision-making is considered synonymous with clinical judgement (Manetti, 2019).Clinical reasoning and decision-making are the thinking processes and strategies we use to understand data and choose between alternatives with regard to identifying patient problems in preparation for making nursing diagnoses and selecting nursing outcomes and interventions. Using the different types of clinical reasoning we plan, direct, perform and reflect on patient care.

Purposes of clinical reasoning and decision-making

Purposes are critical to patient safety and the visibility of professional nursing practice:

1) to make decisions based on objective evidence and intuition about actions to be taken to treat as immediately as possible potential or actual physiological deterioration in patients and to collaborate with medicine to manage such deterioration, i.e., identification and management of collaborative problems (see collaborative problems, watching-assessment-recognition previous page)

2) to select nursing diagnoses, nursing-sensitive patient outcomes, and nursing interventions to achieve desired outcomes, in collaboration with patients to the extent that they wish to and are able to be involved (see diagnoses-outcomes-interventions following page) 

In reasoning and decision-making we draw on all relevant knowledge but are concerned particularly with knowledge related to Careful Nursing philosophical principles and professional practice model dimensions and concepts. Clinical reasoning and decision-making is a very complex process and only a brief overview is provided here. 

Relationship between clinical reasoning and decision-making, and intellectual engagement 

Clearly, the concepts of clinical reasoning and decision-making, and intellectual engagement are closely linked. So why is intellectual engagement in the Therapeutic Milieu dimension and clinical reasoning and decision-making in the PCE dimension?

Placement of concepts in the professional practice model dimensions is guided by the Careful Nursing philosophy. According to Aquinas's philosophy of the human person, the human mind and spirit are intimately linked in the inward life and essence of persons (see the philosophical principles pages above).

The intellectual engagement concept intimately concerns the human mind, spirit and inward life of persons, thus is more closely aligned with the spiritual aspect of the Therapeutic Milieu dimension.

The clinical reasoning and decision-making concept is primarily related to the outward bio-physical reality of the human body and senses and objective nursing practice, thus is more closely aligned with the PCE dimension. 

Philosophical foundations of clinical reasoning and decision-making

The distinctive relational nature of nursing and its emphasis on both science-based and holistic practice gives nurses a broad awareness of both scientific and holistic processes of reasoning and making decisions about patients' care.

Philosophy of science

Philosophers of science argue that reasoning concerns the rational consideration of objective facts and that this alone provides all that is necessary to form judgements. Any role for subjective experiences in this process, such as intuition or imagination, is firmly rejected (Honderich, 2005). We know this view very well as the scientific method. 

Some philosophers of science argue from the somewhat broader position that reasoning is any process of drawing a conclusion from a set of ideas where the ideas can be shown to verify the conclusion (Blackburn, 2016). Again, verification must be objective.

We are well aware that the scientific approach to reasoning dominates contemporary knowledge development and that it is very useful. The evidence base it provides is objective so it can be considered probably true or probably false, and it can be measured. As nurses we use scientific reasoning to develop nursing theory, frame our research, and support evidence-based practice. But it is also widely recognised in nursing that philosophy of science does not address all aspects of nursing practice (Krishnan. 2018).

Philosophy of holism

If we understand ourselves and the people we care for as unitary or holistic beings, thus it stands to reason that our reasoning and decision-making involves holistic, subjective processes at some level. For example, factors such as length of practice experience, intuition, matching recognised patterns of patient behaviour, practice confidence, interaction with colleagues, and ward/organisation culture are known to influence nurses' reasoning and decision-making (Cappelletti et al. 2014, Nibbelink & Brewer 2018). One such factor, intuition, is frequently mentioned in the literature as an aspect of reasoning and decision-making. 

Intuition has been defined as "understanding without a rationale" Benner & Tanner (1987), in other words, understanding without reasoning. Although intuition is broadly considered to contribute to decision-making in nursing, theorists have difficulty explaining how intuition works. Nurses in practice commonly describe use of what they call intuition to make often critical clinical decisions about actions to be taken for patients, but for a variety of purposes do not write about these events. However, the validity and trustworthiness of intuitive reasoning processes are not widely accepted (Cappelletti et al. 2014, Nibbelink & Brewer 2018) and decisions based on intuition can be biased and inaccurate (Tiffen et al. (2014). 

Use of intuition in nursing practice is usually explained within a psychological humanist framework (Krishnan, 2018). However, Jacques Maritain, an influential 20^th-century interpreter of the philosophy of Aquinas, argues that human intelligence is in its essence intuitive. Maritain offers a philosophical explanation of intuition as a type of reasoning; he proposes that a natural, semi-conscious, intuitive reasoning is deeply embedded in human persons. As a fundamental human quality, Maritain writes that:

". . . reason possess a life both deeper and less conscious than its articulate logical life. For reason indeed does not only articulate, connect, and infer, it also sees; and reason's intuitive grasping, intuitus rationis, is the primary act and function of that one and single power which is called intellect or reason. In other words, there is not only logical reason, but also, and prior to it, intuitive reason" (Maritain, 1953, p.75, italics original).

Maritain's explanation of human reasoning is detailed and complex and requires reading and reflection over time. But, even an attempt to read his work, or read about it, is likely to produce an "oh, yes" response because he explains what many nurses see and experience in nursing practice but find it hard to describe and explain. Maritain's explanation offers a structure for rethinking clinical reasoning, with Maritain's "intuitive grasp" proposed as the source of what emerges as both objective logical reasoning and subjective intuitive and analogical reasoning. 

Nursing literature on clinical reasoning and decision-making

In simple terms, reasoning is defined as the power of the mind to think and understand in a logical way in order to form a conclusion or judgement (Reasoning, 2019). Drawing on previous research and analysis, Koharchik et al. (2015) define clinical reasoning as applying formal and informal nursing and other related knowledge to experience in practice for the purpose of analysing and understanding as accurately as possible patients' condition. Nursing decision-making refers to the judgements nurses make regarding treatment of the people they care for; that is, their choice of one course of action rather than another.

Based on a concept analysis of decision-making in nursing, Johansen and O'Brien (2016) likewise define decision-making as a complex process of applying knowledge, analytical and critical thinking, intuition, experience, clinical reasoning and applying rules of thumb, all of which may be influenced by a number of factors, including the following;

Critical thinking. The cognitive process of critical thinking is central to how we draw on and use knowledge developed according to the scientific philosophy of reasoning (Zuriguel Pérez, et al., 2015). Because we use scientific knowledge so widely in decision-making about risks to patient safety and in making precise judgements about patient care, it is vital that we evaluate it as we use it. However, in their scoping review of critical thinking in nursing, Zuriguel Pérez, et al., found that its use in practice, as opposed to educational settings, is limited. This limitation requires on-going examination and possible solutions tested.

Intuition and experience. It is well established that, in addition to using objective ways of reasoning, we use a multiplicity of subjective ways of reasoning, particularly intuition. In a concept analysis of intuition in clinical nursing practice, Robert, et al, (2014) concluded that many nurses experience intuition spontaneously and use it in clinical reasoning. However, little is actually known about nurses' clinical reasoning processes (Simmons, 2010), primarily due to lack of discipline-specific approaches to nursing assessment (Griffits et al. 2017).

Situational awareness. Of particular interest for our clinical reasoning and decision-making is that Maritain, in The Range of Reason (1952), emphasizes that how human persons interact with one another and the context in which they interact has an important influence on their perception and understanding.

Maritain suggests that reason's seeing and intuitive grasp is enhanced by what we would call attending to patients with benevolent affection and kindness. A therapeutic nurse-patient relationship, and the Therapeutic Milieu of the practice setting, may enhance clinical reasoning and decision-making skill. This context could enhance our capacity to experience 'reason's seeing' and an 'intuitive grasp' of key elements of patients' condition in order to best inform our clinical reasoning and decision-making. 

Practical issues. Situational awareness raises the importance of practical reasoning, that is, deliberating on the best course of action attainable in a given clinical practice situation where there is lack of clarity, uncertainty, and likelihood of on-going change based on particular concrete realities. Practical reasoning also influences how research findings are implemented in practice (French 2005). Knowledge underlying practical reasoning is usually accumulated from experience over time in aiming to make the best possible practical decisions. Practical reasoning is contrasted with theoretical reasoning and often linked back to the virtue theory of Aristotle (350BCE/1998).

Values. Values enter our clinical reasoning and decision-making as ethical reasoning. In ethical reasoning we deliberate on values held by patients, ourselves and others related to what is right or wrong, good or bad, for patients, in deciding which actions will best foster their health. Our reasoning is guided by a national nursing professional code of ethics.

In Careful Nursing, ethical reasoning is especially concerned with inherent human dignity, natural justice, and health as human flourishing. Ethical reasoning is widely recognized as an especially complex and difficult process often made more so by competing values in practice settings (Goethals et al., 2010). 

Urgent need for on-going evaluation of practicing nurses' clinical reasoning and decision-making skills 

Despite the vitally importance of clinical reasoning and decision-making in nursing practice, studies suggest that limitations exist in the scope of nurses' clinical reasoning skills in practice settings which require on-going attention (Lee et al., 2016).

Kavanagh & Szweda (2017) examined critical thinking, clinical reasoning and decision-making in over 5,000 newly graduated nurses in the Unites States. They found that compared with similar previous studies these skills were decreasing; in 2015 only 23% of new graduates demonstrated an acceptable ability to recognise physiological problems in patients, their level of urgency, or how the problems should be managed. They concluded that a "preparation-to-practice gap" in nurses ability to think critically and engage in clinical reasoning and decision-making is widening and must be more effectively addressed.

These findings serve to alert all nurses in practice to constantly work to attain and maintain the highest possible levels of critical thinking and clinical reasoning and decision-making skills. 

These findings serve to alert all nurses in practice to constantly work to attain and maintain the highest possible levels of critical thinking and clinical reasoning and decision-making skills. 

Revised Careful Nursing definition of clinical reasoning and decision-making

An earlier definition of clinical reasoning and decision-making in Careful Nursing (Meehan, 2012) requires revision, as follows:

the objective, logical and subjective, intuitive processes used by nurses to understand patient data, apprehend patients' status, and choose one course of action rather than another to address actual or potential threats to patients' physiological safety. Such decision-making is also used to identify needs for assessment and intervention by the medical profession and, or, other members of the multi-professional patient care team. Reasoning and decision-making concerning nursing diagnoses includes patient participation if possible, and is based on objective, evidence-based reasoning using the NANDA-I nursing diagnosis (Herdman & Kamitsuru, 2018), the Nursing Outcomes Classification Moorhead et al., 2018), and the Nursing Interventions Classification (Bucher et al., 2018) standardised nursing languages.

Clinical reasoning and decision-making summary 

Neither the scientific nor the holistic approach to reasoning are adequate in themselves as a basis for decision-making (Krishnan, 2019). Rather, use of both scientific and holistic methods of reasoning best enable nurses to understand and meet the needs of the people they care for.

The central role of clinical reasoning and decision-making in our application of nursing and other knowledge is a complex and vital component of our practice. Powered by intellectual engagement and together with watching-assessment-recognition it directs how we implement the other concepts of the Careful Nursing critical circle of clinical responsibility. 

Your clinical reasoning and decision-making self-rating:

On a scale of 1 to 10, rate your ability to make intuitive decisions about patients' status and actions required that are later validated by objective evidence? Following the Performance-Based Development System^© widely used to test critical thinking, clinical reasoning and decision-making, rate yourself: 

On a scale of 1 to 10, rate your ability to identify correctly all possible causes of physiological deterioration in particular patients?

On a scale of 1 to 10, rate your ability to identify correctly the level of urgency of physiological deterioration in patients?

On a scale of 1 to 10, rate your ability to identify correctly nursing interventions to minimise deterioration in particular patients' physiological status?

On a scale of 1 to 10, rate your ability to identify correctly appropriate medical orders you expect medical doctors to prescribe for particular deteriorating patients?

On a scale of 1to 10 rate your ability to justify your actions?

Based on your assessment of your current skill in clinical reasoning and decision-making decide what you will do to further develop your skill in implementing this concept.

Make your own 'I will' statements . . .

Examples of clinical reasoning and decision-making 'I will' statements:

 . . . arrange with a school of nursing or clinical nursing education department to periodically take a critical thinking test

. . . keep a personal record of my clinical decisions and critically review them once a month

. . . identify times that I have used intuition to make a decision about patients' care and reflect critically on my use of intuition once a month

. . . critically reflect on how I justify my nursing decision-making actions once a month 

 

References

Aristotle (350BCE/1998). Nicomachean Ethics. (W. D. Ross trans) Oxford: Oxford University Press. http://classics.mit.edu/Aristotle/nicomachaen.html

Benner, P. & Tanner, C. (1987) Clinical judgment: How expert nurses use intuition. The American Journal of Nursing, 87, 23-31.

Blackburn S. (2016). The Oxford Dictionary of Philosophy (3 ed.) Oxford; Oxford University Press.

Butcher, H. K., Bulechek, G. M., Dochterman, J. M. M., & Wagne, C. (Eds). (2018). Nursing Interventions Classification (NIC) (7th ed.). St. Louis, MI: Elsevier Inc.

Cappelletti, A., Engel, J. K., & Prentice, D. (2014). Systematic review of clinical judgment and reasoning in nursing. Journal of Nursing Education, 53(8), 453–458.

French, B. (2005). Contextual factors influencing research use in nursing. Worldviews on Evidence-Based Nursing, 172-183.

Goethals, S., Gastmans, C. & de Casterle, B. (2010). Nurses' ethical reasoning and behaviour: A literature review. International Journal of Nursing Studies, 47, 635–650.

Griffits, S., Hines, S., Moloney, C. & Ralph, N. (2017) Characteristics and processes of clinical reasoning in nurses and factors related to its use: a scoping review protocol. JBI Database of Systematic Reviews and Implementation Reports, The Joanna Briggs Institute, 2832-2835.

Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing Diagnoses Definitions and Classifications 2018–2020. New York, NY: Thieme Publishers.

Honderich, T. (2005). The Oxford Companion to Philosophy (2nd ed.). Oxford: Oxford University Press.

Johansen, M.L. & O'Brien, J.L. (2016). Decision making in nursing practice: a concept analysis. Nursing Forum, 51, 40-48.

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.

Koharchik, L., Caputi, L., Robb, M. & Culleiton, A.L. (2015). Fostering clinical reasoning in nursing students. American Journal of Nursing, 115, 58-61.

Krishnan, P. (2018) A philosophical analysis of clinical decision making in nursing. Journal of Nursing Education, 57, 73-78.

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. 

Manetti, W. (2019 Sound clinical judgment in nursing: A concept analysis. Nursing Forum, 54, 102-110.

Maritain, J. (1952). The Range of Reason. New York: Charles Scribner's Sons.

Maritain, J. (1953). Creative Intuition in Art and Poetry. New York: Pantheon Books.

Meehan TC. (2012). The Careful Nursing philosophy and professional practice model. Journal of Clinical Nursing, 21, 2905-2916.

Moorhead, S., Swanson, E., Johnson, M. & Maas, M. L. (Eds.). (2018) Nursing Outcomes Classification (NOC), (6th ed.). St. Louis, MI: Elsevier Inc.

Nibbelink, C.W. and Brewer, B.B. (2018) Decision-making in nursing practice: An integrative literature review. Journal of Clinical Nursing, 27, 917–928.

"Reasoning" (2019)." Merriam-Webster.com. Retrieved from http://www. merriam-webster.com/dictionary/reasoning 

Robert, R. R., Scott Tilley, D., & Petersen, S. (2014). A power in clinical nursing practice: concept analysis on nursing intuition. Medsurg Nursing, 23, 343-349.

Simmons, B. (2010). Clinical reasoning: concept analysis. Journal of Advanced Nursing, 66, 1151–1158.

Tiffen, J., Corbridge, S.J. and Slimmer, L. (2014) Enhancing clinical decision making: Development of a contiguous definition and conceptual framework. Journal of Professional Nursing, 30, 399-405.

Zuriguel Pérez, E., Lluch Canut, M.T., Falcó Pegueroles, A., Puig Llobet, M., Moreno Arroyo C. & Roldán Merino J. (2015). Critical thinking in nursing: scoping review of the literature. International Journal of Nursing Practice, 21: 820–830. 

 

Therese C. Meehan ©    July 2020