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Chapter 14 Thoughtful practice: Clinical reasoning, clinical judgement, actions and the process of care
problems often overlap in any given situation, so the process
may occur in concurrent cycles.
Now that you have completed the explanation of thought-
ful practice, you can concentrate on learning the skills
required for clinical reasoning. Refer back to Figure 14-1 to
refresh your understanding of the relationship between the
components of clinical reasoning in preparation for the next
section of this chapter, which describes how to develop and
apply your clinical reasoning skills.
APPLYING CLINICAL REASONING
SKILLS
Throughout this text you have been participating in exer-
cises that are preparing you for thoughtful practice by
building your skills in clinical reasoning and reflection. You
have encountered short critical-thinking exercises at the end
of each chapter, focusing on what you were learning at the
time. These exercises required you to think in a systematic,
focused way to answer a question about a particular situa-
tion. These exercises have been preparing you for clinical
reasoning by developing your ability to analyse a situation
and apply the knowledge you have acquired. In addition,
you have encountered reflective cues that require you to
draw on your own experiences and examine your own
thoughts and feelings relating to an encounter with a patient.
These reflective cues have been developing your ability to
look within and understand how reflection can help you to
grow professionally and to improve your practice.
This chapter now consolidates your learning in clinical
reasoning through a demonstration of how to apply a clinical
reasoning framework to a particular clinical situation that has
greater scope than the small-scale exercises you have com-
pleted so far. In real life, each particular clinical situation will
present its own challenges, so it will be helpful for you to
develop a method of thinking through a problem in order to
arrive at a clinical judgement and decide on a course of
action. Although there are a number of methods available,
the method shown in Figure 14-3 is uncomplicated and is
particularly suitable for the developing nurse or midwife.
Developing the method of clinical
reasoning
Clinical reasoning is the process of analysing a situation,
deciding on possible alternative reasons for it, making a
judgement and choosing an action to be taken. Clinicians
who wish to develop the clinical reasoning skills essential to
thoughtful practice will find it helpful when posed with a
clinical challenge to work methodically through the set of
five types of considerations shown in Figure 14-3. These
relate to the purpose of the thinking (the question), the
adequacy of your knowledge about the issue, the potential
problems, where helpful resources may be found, and finally
making a judgement and deciding on a course of action.
Focus on the question about the particular issue
The first step in clinical reasoning is to focus on the ques-
tion in order to identify the purpose or goal of your thinking.
This helps to discipline your thinking by directing all your
thoughts towards the goal. For example, the purpose of clin-
ical reasoning might be to make a judgement about a
particular person or situation or to make a decision about
how best to intervene.
Consider what knowledge you have about the
issue
At the outset of clinical reasoning, it is important for you to
judge whether the knowledge you have is accurate, com-
plete and relevant. If you are reasoning with false
information or with limited data, it will be impossible to
draw a sound conclusion. You also need to be sure that you
understand all of the details relevant to the issue. What is at
stake? How much time do you have to make a decision?
How much scope is there for error?
Identify and address potential problems
As you become skilled in clinical reasoning, you will learn
to ‘flag’ and remedy the pitfalls to sound reasoning.
Common problems include working with untested or faulty
assumptions, accepting an unproven claim or line of argu-
ment, allowing bias to colour your thinking and applying
illogical reasoning (that is, making a generalisation on the
basis of a single experience or case, or allowing emotion to
overrule reason). The more familiar you are with these
common impediments to clinical reasoning, and the more
self-aware you are, the easier it will be to detect them in
your own thinking.
Seek appropriate resources to assist you
Wise professionals are good reflectors and are quick to
recognise their limitations and to seek help in remedying
Figure 14-3
Clinical reasoning framework
Consider what
knowledge
you have about
the issue
Identify and
address
potential
problems
Seek
approptiate
resources to
assist you
Make clinical
decisions
and
judgements
Focus on the
question about
a particular
issue
