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Chapter 14 Thoughtful practice: Clinical reasoning, clinical judgement, actions and the process of care
•
Keep a record of these thoughts, as it may be helpful
to revisit them as you progress through your learning
about using clinical reasoning in thoughtful
practice.
All of these factors influence the quality of the clinical
reasoning engaged in by the clinician. The following section
explains in greater detail the individual components of clini-
cal reasoning.
Discipline-specific knowledge base
In order to reason through a clinical situation, you must be
able to draw upon a body of nursing or midwifery knowl-
edge that emanates from the sources of knowledge
discussed in Chapter 9. Added to this must be evidence that
emanates from research. Chapter 1 summarises the know-
ledge that is required for care to have a holistic focus. These
discussions demonstrate that the discipline-specific know-
ledge required is extensive. Contextual knowledge is also
required, as can be seen in Box 14-3, which outlines the
additional knowledge required for competent clinical rea-
soning in nursing or midwifery practice. The specific
knowledge required for clinical reasoning will determined
by the actual clinical situation. For example, if the situation
calls for reasoning related to the manifestation of a physical
problem, reasoning will require an understanding of the
disease or condition, its epidemiology, the mechanisms of
its pathophysiology, its physical and psychological manifes-
tations, signs and symptoms, and the probabilities of its
progression or outcome (Szaflarski, 1997). If the clinical sit-
uation relates to the problematic discharge from hospital of
a patient with disabilities, the knowledge base must include
local knowledge of support services available in the specific
BOX 14-2 Summary of behaviours that demonstrate the effect of personal attributes on reasoning
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Use of healthy strategies to manage stress and enable
clear thinking, by being proactive, anticipating
consequences, planning ahead and taking advantage
of opportunities
•
Confidence in own ability to reason and learn
effectively, being courageous, standing up for own
beliefs, advocating on behalf of others and rising to
challenges
•
Acceptance of autonomy and responsibility for
thoughts and actions, ability to regulate own activities,
beginning and completing tasks without being
reminded, expressing ownership of accountability,
being self-disciplined and focused on priorities
•
Resilience by overcoming disappointments, being
patient and persistent and persevering for the best
outcome
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Being analytical and insightful, identifying relationships,
expressing deep understanding, being improvement-
oriented for self (identifying learning needs, finding ways
to overcome limitations, seeking out new knowledge),
patients (promoting health, maximising function,
comfort and convenience) and systems (identifying risks
and problems with healthcare systems, promoting
safety, quality, satisfaction and cost containment)
•
Being alert to context, looking for changes in
circumstances that warrant modification of thinking or
approaches, drawing reasonable conclusions (if this is
so, then it follows that … because), using intuition as a
guide to search for evidence, acting on intuition only
with knowledge of the risks involved, seeking help
when needed, suspending or revising judgement
when indicated by new or incomplete data
•
Being realistic, practical and creative, admitting when
things are not feasible and looking for user-friendly
solutions, offering alternative solutions and
approaches, coming up with useful ideas.
Source: Adapted from Alfaro-LeFevre, 2012.
Responsiveness to the environment
The complexity and organisation of the healthcare envi-
ronment can also affect the reasoning of clinicians
(Raterink, 2008). The way work is organised, the number
of interruptions experienced by the clinician and the
culture of the healthcare environment can all affect the rea-
soning undertaken by clinicians, especially if greater value
is placed on activities such as the completion of tasks than
on the reasoning process (Ebright et al., 2003). In health-
care environments where sound reasoning is valued and
time is taken to reason well, better reasoning processes are
exhibited by clinicians and fewer errors occur in the
processes of care. Conversely, as discussed in Chapter 13,
in environments where the work itself, rather than the people,
has precedence, practice may be ritualised and reasoning
compromised.
The personal attributes that affect clinical reasoning,
however, are often not expressed but rather are revealed in
people’s behaviour. A summary of some of the optimal
behaviours that demonstrate the effect of important personal
attributes on reasoning processes are presented in Box 14-2.
Revisit the personal attributes required for person-
centred care discussed in Chapter 1, and examine the
parallels with the attributes outlined in Box 14-1. Then
reflect on the personal attributes or characteristics that
you bring to practice.
•
Do you think there is a particular personal attribute
that might influence the way you approach a
situation and thus potentially affect your reasoning?
•
Think about something you believe in strongly, and
reflect on whether this could affect the way you
reason through a problem.
