Clinical reasoning, clinical judgment and critical thinking are terms that are used interchangeably in literature to represent a cognitive process which underpins safe and effective care delivery.1 While they share certain characteristics, each have their own distinctive components. Tanner describes clinical judgment as “an interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response”.1(p.204) Clinical reasoning is defined by Simmons as “a complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information and weigh alternative actions”.2(p.1155) The cyclical process of clinical reasoning involves cue acquisition and analysis to identify clients who require attention.3,4 These cues then stimulate the nurse to instigate an appropriate course of action at the required time to assist these clients.3,4 This meta-cognitive process relies on the use of critical thinking, experience and knowledge to make well-reasoned professional judgments and to resolve issues.1,2,5 Critical thinking is thought to be essential for effective clinical reasoning.2 It is an intellectual process involving: the ability to analyze, use logic, seek information, discriminate, apply standards, predict and transform knowledge.6,7 Critical thinking is affected by habits of the mind including: confidence, perseverance, inquisitiveness, intuition, flexibility, creativity, intellectual integrity, contextual perspective, open-mindedness and reflection.6,7
Registered nurses are at the forefront of interactions with healthcare consumers and work in dynamic situations which require a level of clinical reasoning supportive of safe and proficient clinical practice.8,9 Several studies highlight factors which influence the use of clinical reasoning including: communication and relationships, educational level, knowledge and ability to use critical thinking, familiarity with the environment and the context of care, experience and exposure to a variety of situations as well as professionalism.3,4,6,8-14 Ideally, graduate registered nurses should enter the profession with a safe level of clinical reasoning. A ten-year longitudinal study of the clinical judgment capabilities of graduate registered nurses found that between 26% and 35% of participants entered the workforce with the expected level of clinical judgment.14 These results were consistent over 10 years, with the study using the Performance Based Development System to assess the critical thinking ability and interpersonal skills of these graduate nurses.14
Measurement of clinical reasoning in nurses and the potential impacts on client outcomes is currently limited by the lack of discipline-specific assessment tools for nursing. Domain specific testing of clinical reasoning is available within the medical, occupational therapy and physical therapy fields with various tools being trialed. The Del Buenos’ Performance Based System,14 Lasaters’ Clinical Judgment Rubric,15 Tanners’ Clinical Judgment Model,5 California Critical Thinking Skills Test,16 California Critical Thinking Disposition Inventory,17 structured oral interviews and script concordance testing have all been used to evaluate critical thinking, reasoning and decision-making in nurses and other health professionals.18,19 None of these tools specifically measure the clinical reasoning process inherent in nursing. There is a clear need for a clinically-validated nursing assessment tool, benchmarked against client outcomes, which identifies and measures the clinical reasoning process expected of registered nurses.
This scoping review is the initial stage of a multi-phase research project aimed at developing a professionally contextualized framework for assessing the clinical reasoning abilities of undergraduate Bachelor of Nursing students. It is anticipated that the outcomes of this review will enable the systematic identification of clinical reasoning characteristics and processes which will be used to stimulate discussion as part of a later Delphi-study. These characteristics and processes will be developed into an achievement-based clinical reasoning assessment framework for use in measuring clinical reasoning against the Nursing and Midwifery Board of Australia's (2016) Registered Nurse Standards for Practice.20 This assessment framework will be applicable to multiple contexts, including assessing pre-registration nursing students, graduate registered nurses and possibly international registered nurses seeking registration in Australia. Possessing a valid, reliable and rigorously developed assessment framework for clinical reasoning is anticipated to have strong benefits for nursing education in Australia, particularly for undergraduate nursing students.
A search of CINAHL, JBI Database of Systematic Reviews and Implementation Reports, The Cochrane Database of Systematic Reviews, PubMed, Google Scholar and ProQuest Dissertations and Theses was undertaken by the authors to identify if other scoping reviews on clinical reasoning in nursing existed. No scoping reviews specifically examining the concept of clinical reasoning use by registered nurses in clinical practice were identified, however a scoping review by Perez et al.5 did analyze the state of knowledge of critical thinking in nursing. The review by Perez et al. however did not evaluate characteristics and processes of clinical reasoning inherent in nursing.
Types of participants
This scoping review will consider studies that include registered nurses working in all clinical practice environments.
The following will be excluded from the review:
- Students enrolled in a pre-registration nursing program
- Non-nursing health care providers
- Enrolled nurses
- Unlicensed health care providers
- Personal care providers
- Advanced practice nurses (e.g. nurse practitioners).
This review will consider studies that investigate clinical reasoning use by registered nurses in clinical practice settings, including factors reported to relate to its use.
Clinical practice environments and activities in which registered nurses use clinical reasoning processes to provide care to individuals, families and communities will be considered for this study. These environments and activities may include, but are not limited to, acute and long-term healthcare facilities, aged care facilities, facilities with incarcerated individuals, community care centers and community services provision.
Types of studies
This research will consider primary research studies of the clinical reasoning of registered nurses in clinical practice settings. Quantitative and qualitative research designs will be considered. In the absence of research studies, other text such as opinion papers, text and reports will not be considered.
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English language will be considered for inclusion in this review. Studies published from 2000 onwards will be considered for this review to ensure seminal works are identified within the searches and that data collected is representative of recent evidence and understanding of clinical reasoning.
The databases to be searched include:
- Science Direct
The search for unpublished studies will include: ProQuest Dissertations and Theses
Initial keywords to be used will be: space required Clinical reasoning; critical thinking; clinical judgment; nurs∗
NOT: nurs∗ practitioner or medical personnel or doctor or enrolled nurs∗ or nurs∗ aide or nurs∗ assistant or health-care worker or student nurs∗ or nurs∗ student
Studies identified during the search of all included databases will be screened for duplicates. Duplicates will be removed during the initial and the review phases to ensure double-reporting does not occur. Based on the information in the title and abstract, two independent reviewers will screen the studies identified from the database search for relevance to the review. The full article will be retrieved for studies deemed relevant to the inclusion criteria and for studies whose relevance is unclear from the abstract.21 Two reviewers will independently review these articles for their ability to meet the inclusion criteria. Disagreements will be resolved through discussion or through a third reviewer. The reference lists of the identified articles will be reviewed for relevance to the study through the title and abstract.21,22
Data will be extracted from research papers included in the review using the draft charting tool that has been developed by the authors (Appendix I). This tool will allow for the full description of clinical reasoning in practice. Specific data extracted (not limited to) will include:
- Year of publication
- Country of origin
- Study population and sample size (if applicable)
- Characteristics of clinical reasoning
- Processes of clinical reasoning
- Factors reported to relate to clinical reasoning use
- Interventions and duration of interventions (if applicable)
- Impact of clinical reasoning on client outcomes (if applicable).
As per the JBI Reviewers Manual Methodology for Scoping Reviews 201521 guidelines, the results will be presented in diagrammatical and tabular format, with a narrative summary discussing how the results relate to the review objectives and question including highlighting areas for further research. Results will be categorized according to key conceptual findings obtained during the data extraction process and mapped using tabular/diagrammatical presentations. These categories will relate back to the specific review objectives on the characteristics and processes of, and factors reported to relate to clinical reasoning use by registered nurses in clinical practice.
Appendix I: Data extraction instruments
Characteristics and processes of clinical reasoning
The lead author, Susan Griffits, would like to acknowledge the University of Southern Queensland's Office of Research Graduate Studies and the Queensland Centre for Evidence-Based Nursing and Midwifery for their support. This scoping review will contribute to a Doctor of Philosophy for the principal reviewer.
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