Fundamentals of Nursing and Midwifery 2e

Unit III Thoughtful practice and the process of care

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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).

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. 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.