Personal attributes
All people think or reason as they go about their daily lives.
Reasoning has a logical or cognitive (thinking) component
as well as an emotional or affective (feeling) component,
and is affected by the personal attributes of the thinker
(Hoffman, Duffield & Donoghue, 2004). Clinical reasoning
is also affected by the beliefs and values held by the clini-
cian (da Silva et al., 2010). The personal attributes that
affect clinical reasoning are summarised in Box 14-1 and
explained in the following section.
Willingness to learn
Reasoning ‘starts with an inquiring mind, proceeds with per-
sistent thinking, and results in multiple possible answers to a
recognised problem’ (Fowler, 1998, p. 184). Chapter 13 dis-
cusses how reflection is used to help us to learn from practice.
While all clinicians need to learn from reflection and experi-
ence, the ability to reason well begins with the building of the
individual clinician’s knowledge base. The extensive know-
ledge base that is required for practice is discussed previously
(Chapters 1, 9 and 13). However, clinicians not only need to
recall facts, they also need to recognise the cues that inform
them of a problem.
Cues
are the pieces of data that the clini-
cian collects through observation, reading records and talking
to patients and others.
Cue acquisition
is when the clinician
recognises the importance of these pieces of data and collects
them (Levett-Jones et al., 2010). For this reason, clinical rea-
soning is taught in most undergraduate programs, often using
case studies or scenarios. This learning is consolidated in clin-
ical placements. You need to learn from each clinical
encounter so that you can relate the significance of the cues
that you have collected to the knowledge that you have been
building, and apply these cues to new and often complex
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Chapter 14 Thoughtful practice: Clinical reasoning, clinical judgement, actions and the process of care
situations (Alfaro-LeFevre, 2012). This then adds further to
your knowledge base, growing it exponentially, helping you to
build patterns and providing templates for problem solving in
the future. This in turns builds better reasoning processes. As
learners we are all different, but we are all alike in our need to
make learning an active and lifelong exercise, and in the need
to base our reasoning processes on learnt material based on
current, evidence-based practice and the associated literature.
This learning is then consolidated and shaped by reflection.
Willingness to develop self-awareness
In Chapter 13, the seminal place of self-awareness in
thoughtful practice is outlined. What the concept of health
means to each individual influences their expectations and
desires in relation to healthcare. These expectations and
desires in turn influence the reasoning process, through the
beliefs and values that the person doing the reasoning brings
to the reasoning process. For this reason, clinicians must
develop great self-awareness of their own beliefs and value
systems, and an understanding of how their prejudices and
assumptions can affect their decisions. This may occur
through reflection, which can help to expose any biases or
preconceptions.
Prejudice
literally means ‘pre-judging’ or
‘judging in advance’, which is a process that destroys rea-
soning by forming premature conclusions that may be
incorrect or not in the person’s best interests. An example of
this occurs when a clinician is influenced by preconceptions
of what older people should be like. This can affect the cues
collected, the judgements made and the behaviour of the cli-
nician through the actions taken (McCarthy, 2003).
We can identify and deal with our own prejudices
through reflection and examination of our own thought
processes (Paul, 1995). Self-awareness enables us to clarify
our own biases, inclinations, strengths and limitations, and
thus helps us to acknowledge when our thinking may be
influenced by our emotions or by self-interest. Sound clini-
cal reasoning must accommodate the values and beliefs of
both parties in the relationship because person-centred care
adopts a shared model, with the patient truly involved in the
choice of care options (Tanner, 2006). We need to enable
reasoning that is not based on erroneous assumptions
about the person for whom we are caring. As Alfaro-LeFevre
(2012) states, clinical reasoning must overcome the powerful
influences of reasoning that is curious and inquisitive, and
that seeks reasons, explanations and meanings for the problem
that is the subject of the reasoning. Freedom from prejudice
enables the person doing the reasoning to seek new informa-
tion to broaden understanding, and removes constraints to
reasoning. Confronting prejudice leads to sensitivity to diver-
sity and an appreciation of human differences in terms of
values, culture and personality. When reasoning is also under-
taken with the engagement of the patient, the reasoning is
person centred.
Willingness to know the person (engagement)
The degree of reasoning that the clinician brings to the
processes of care is also influenced by the degree of
BOX 14-1 Personal attributes that affect
clinical reasoning
Willingness to learn
•
Problem solving
•
Reflection
Willingness to develop self-awareness
•
Beliefs and values
•
Prejudices and assumptions
Willingness to know the person (engagement)
•
Full or partial engagement, disengagement
Willingness to put all the pieces together
•
Motivation
•
Moral agency
Willingness to make a decision
•
Confidence
•
Support roles and responsibilities
Responsiveness to the environment
•
Culture and power
•
Behaviour
