community. These knowledge requirements are essential for
the development of clinical reasoning and judgement, which
will be discussed later in this chapter.
Clinical experience
The experience that the clinician brings to the situation has a
profound effect on the clinician’s ability to reason and make
decisions about what action to take (Benner, Hughes &
Sutphen, 2008). Experience influences the type and number
of cues that are collected—experienced clinicians appear to
be able to focus on the most important cues and anticipate
others, whereas less-experienced clinicians tend to collect
cues according to rules that have been learnt (Hoffman,
Aitken & Duffield, 2009). These cues can be clustered into
patterns that the clinician can draw upon so that the cues col-
lected in this current situation can be compared with those
previously encountered (Martin, 2002). Through
clinical
experience
, the clinician retains memories of previous
patients and clinical situations. Similarities and differences
between the situations can be compared and contrasted to aid
in the reasoning process. This is called
pattern recognition
and, as more experience is gained, more patterns are retained
in the clinician’s memory bank (Buckingham & Adams,
2000b). For example, an experienced community nurse who
has performed many wound dressings has developed a bank
of memories to draw on in order to assess the progress of
wound healing. These memories enable the nurse to compare
the management of the current wound with the management
of those wounds dealt with in the past, consolidated by what
the nurse has learnt from the evidenced-based literature. New
practitioners may need to rely on advice from more experi-
enced nurses, as this memory bank has not yet developed.
Unit III Thoughtful practice and the process of care
258
CLINICAL REASONING
Clinical reasoning
, the thinking that occurs in response to a
clinical situation, occurs within a specific context. It is not a
pure process that occurs independently of the clinician or
the context. It rests on a foundation of the clinician’s per-
sonal knowledge base and clinical experiences. It is also
heavily influenced by the personal attributes that the clini-
cian brings to the reasoning process. In your nursing or
midwifery course you have been building your knowledge
base, consolidating what you have learnt through your expe-
riences in clinical placements and, through reflection,
becoming more aware of your own strengths and weak-
nesses. As this foundation grows and develops, so does your
ability to clinically reason.
Clinical reasoning occurs within the context of a disci-
pline or practice. (See Figure U3-1 for how clinical
reasoning fits within the model of thoughtful practice.) It
includes the ability to recognise clinical problems and to
solve them using the cognitive skills of critical thinking, cre-
ative thinking and intuitive thinking. Using all these skills,
the clinician in the nursing context is capable of ‘thinking
like a nurse’ (Tanner, 2006, p. 204) in order to make a clin-
ical judgement and come to a decision that results in a
nursing action. The demand on nurses and midwives to
execute higher-order reasoning skills is increasing, as the
clinical environment in which they practise has become
intensely complex and is constantly changing (Simmons,
2010). This complexity and constant change require the cli-
nician to be capable of clear and ordered thinking, accurate
identification of problems and effective decision making
that demonstrates good clinical judgement. Tanner (2006,
p. 204) states that clinical reasoning refers to:
the processes by which nurses and other clinicians make
their judgements, and includes both the deliberate process
of generating alternatives, weighing them against the evi-
dence, and choosing the most appropriate, and those
patterns that might be characterised as engaged in practi-
cal reasoning (e.g. recognition of a pattern, an intuitive
clinical grasp, a response without evident forethought).
Problem solving
In the literature, the terms
clinical reasoning
,
problem
solving
,
clinical judgement
and
decision making
are often
used interchangeably (Simmons, 2010). Indeed, it could be
said that all care is driven by a problem; therefore, problem
solving is fundamental to the processes of care.
Problem
solving
is a basic life skill that involves identifying a
problem and then taking steps to resolve it. However, differ-
ent approaches to problem solving yield different results,
some of which are more appropriate than others in a given
context. Unfortunately, problem solving does not always
involve clinical reasoning, which means that the solution
to a problem may be limited to traditional solutions, with
other potential solutions being ignored (Duchscher, 1999).
BOX 14-3 Knowledge required for clinical
reasoning in nursing or midwifery
practice
•
Nursing/midwifery and medical terminology
•
Roles and responsibilities of each healthcare
discipline
•
Signs and symptoms of common problems and
complications
•
Factors that promote or inhibit normal function
(biological, psychological, social, cultural, spiritual)
•
Related pharmacology (actions, indications, side
effects, care implications)
•
Reasons behind interventions and diagnostic studies
•
Processes of care, theories, research principles and
evidence-based practice
•
Applicable standards, ethical codes of conduct, laws
and practice acts
•
Policies and procedures and the reasons behind them
•
Where information resources can be found.
Source: Adapted from Alfaro-LeFevre, 2012.
