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Nurse Education in Practice (2008) 8, 177183

Nurse
Education
in Practice
www.elsevierhealth.com/journals/nepr

Clinical reasoning and its application to nursing:


Concepts and research studies
Maggi Banning

Brunel University, School of Health Sciences and Social Care, Mary Seacole Building,
Uxbridge UB8 3PH, Middlesex, United Kingdom
Accepted 7 June 2007

KEYWORDS

Summary Clinical reasoning may be defined as the process of applying knowledge and expertise to a clinical situation to develop a solution [Carr, S., 2004. A
framework for understanding clinical reasoning in community nursing. J. Clin. Nursing 13 (7), 850857]. Several forms of reasoning exist each has its own merits and
uses. Reasoning involves the processes of cognition or thinking and metacognition.
In nursing, clinical reasoning skills are an expected component of expert and competent practise. Nurse research studies have identified concepts, processes and
thinking strategies that might underpin the clinical reasoning used by pre-registration nurses and experienced nurses. Much of the available research on reasoning
is based on the use of the think aloud approach. Although this is a useful method,
it is dependent on ability to describe and verbalise the reasoning process. More nursing research is needed to explore the clinical reasoning process. Investment in
teaching and learning methods is needed to enhance clinical reasoning skills in
nurses.
c 2007 Elsevier Ltd. All rights reserved.

Clinical reasoning;
Professional
judgement;
Clinical reasoning
strategies;
Nursing practice

Introduction
Clinical reasoning is an essential feature of health
care practise that focuses on the assimilation and
analysis of health care evidence that is differenti-

* Tel.: +44 018952 68819.


E-mail address: maggi.banning@brunel.ac.uk

ated according to its usefulness, efficacy and application to a selective group of patients. This process
then informs the decisions that are made pertinent
to patient management (Matteson and Hawkins,
1990; Simmons et al., 2003).
Clinical reasoning may be viewed as the
hallmark of the expert nurse (Fowler, 1997) and
an essential component of nursing competence
which is often demonstrated in experienced nurses

1471-5953/$ - see front matter c 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nepr.2007.06.004

178
working in various nursing specialisms. The alternative view is that clinical reasoning skills are used by
nurses at all levels to inform decisions about the level of nursing care offered to patients (Fisher and
Fonteyn, 1995). There are merits of both positions.
This paper aims to explore the concept of clinical
reasoning and to provide some analysis of the reasoning strategies used by nurses, how clinical reasoning has been examined in nursing research
through the use of the think aloud approach.

Reasoning
Reasoning is a process that pertains to the thought
processes, organisation of ideas and exploration of
experiences to reach conclusions. Reasoning may
be viewed as a form of thinking that is often apparent during the presentation of ideas or discourse in
which the logistics of an argument are collated in a
logical manner in order to reach a rational
conclusion.
There are several forms of clinical reasoning;
each has its own merits (Burns and Higgs, 2000; Burns
and Grove, 2005). Problematic reasoning involves
identifying a problem and its influential factors and
recognising solutions that may be used to solve the
problem (Burns and Grove, 2005). This approach to
clinical reasoning can be used to assist nurses to
identify nursing diagnoses and to implement nursing
interventions that can be used to solve problems.
Theoretical reasoning begins inductively considers a hypothesis using a hypothetico-deductive
stance and terminates in a conclusion or a decision
(Carr, 1981). In contrast practical reasoning usually
terminates in an action, e.g. the result of care planning (Greenwood and King, 1995). The procedure
involved is similar to theoretical reasoning as the
process begins logically but only through the
hypothetico-deductive manipulation of propositions at progressively decreasing levels of inclusiveness and generality (Greenwood, 1998, p. 845).
Operational reasoning focuses on the identification of and discrimination along many alternatives and viewpoints (Burns and Grove, 2005,
p. 7). The focus of this form of reasoning is on the actual process and the identification of opposing views
that may be used to determine a solution to the
problem (Barnum, 1998). In nursing research operational reasoning can be used to assess and debate
the suitability of research methods or data analysis
techniques to the research question (Kerlinger and
Lee, 2000). This approach to clinical reasoning can
be used by nurses to assist patients and their families
to develop realistic and measurable goals with
respect to their management and nursing care.

M. Banning
Inductive reasoning is a reasoning approach that
moves from the specific to the general where instances are combined to form purposive statements (Chin and Kramer, 1999) and where the
premises of an argument are believed to support
the conclusion, but do not ensure it (Wikipedia,
2007). Inductive reasoning can be used to assess
the nursing care of orthopaedic patients who have
an altered health state due to sustaining a fracture. The presence of the fracture is stressful for
the patient. In this instance, inductive reasoning
is used to illustrate that the presence of the fracture is stressful and can be viewed as an altered
state of health.
Dialectic reasoning involves looking at situations
in a holistic way. A dialectic thinker believes that
the whole is greater than the sum of the parts and
that the whole organises the parts (Burns and
Grove, 2005, p. 7). This form of reasoning focuses
on the identification and exploration of opposing
factors that are then combined in order to explore
problems. The merger of factors into a single solution is thought to be more a powerful tactic than
the independent assessment of factors. In nursing,
dialectic reasoning would involve assessing the
strengths and weaknesses of a patients problem
rather than identifying the patient according to
their pathophysiological condition(s).
Clinical reasoning in nursing revolves around the
process of making professional judgements, evaluating the quality and contribution of available evidence to enhance problem solving and to consider
to what extent the evidence available is sufficient
to make decisions on diagnostics and treatment options relevant to the nursing care requirements of
the individual (Higgs et al., 2001). It is viewed as a
multidimensional, recursive cognitive process that
employs formal and informal strategies to assemble
and analyse patient information that is then evaluated relative to its significance and contribution
to patient management (Simmons et al., 2003).
According to Higgs et al. (2001) the decisions that
nurses make relevant to the individual health care
needs of the patient can be facilitated by the merger of professional judgment and clinical reasoning.
Both of which are supported by intuition and knowledge gained from professional experience.

Reasoning strategies
Clinical reasoning pertinent to nursing depends on
the development of cognition or critical thinking
and metacognition or thinking about thinking. Both
of these are inextricably linked to the process of
clinical reasoning (Kuiper and Pesut, 2004).

Clinical reasoning and its application to nursing: Concepts and research studies
Metacognition refers to higher order thinking
process that involves the active control of cognitive (thinking) processes and the assessment of to
what extent cognitive outcomes have been
achieved in relation to learning situations (Flavell,
1987; Wikipedia, 2006). Metacognition is generally
thought of as thinking about thinking and comprises metacognitive regulation or strategies that
are used to control or oversee cognitive activities
and goals. Metacognitive knowledge can be factual, explicit or implicit (Wikipedia, 2006); these
knowledge forms are used in metacognitive processing to enhance participation in cognitive activities to achieve cognitive goals and outcomes
(Brown, 1987). During this process individuals will
use inductive logic to simultaneously assemble
and evaluate patient information and supportive
evidence before making judgements about nursing
care (Higgs et al., 2001; Simmons et al., 2003).
During clinical reasoning, there is an interaction among the individuals cognition, the subject
matter, and the context of the situation where the
thinking occurs (Fowler, 1997, p. 349; Lewis,
2007). Nurses use multiple cognitive processes such
as making judgements on the use of evidence based
on past experience but also on underpinning
knowledge, judging client situations, hypotheses
generation, diagnostic reasoning and reflection.
Metacognition is thought to control cognitive processes (Pesut and Herman, 1992). Although the
importance of clinical reasoning cannot be underestimated, it continues to be a poorly defined construct which has been assessed using limited
measurement tools. Current nursing research has
used a variety of approaches to differentiate the
variety of clinical reasoning strategies employed
by nurses at varying stages of professional development. The available evidence demonstrates that
the clinical reasoning skills employed by nurses have
also been labelled as problem solving, clinical
judgement, information processing, diagnostic reasoning, and decision-making (Farrell and Bramadat,
1990).
The clinical decision making processes of experienced nurses (Bucknall, 2003; Lauder et al., 2001;
Carr, 2004) and pre-registration student nurses
(Thompson et al., 2005) has been assessed using a
variety of research approaches.
Thompson et al. (2005) and Lauder et al. (2001)
used a factorial design to assess student and qualified nurses ability to make judgements. Both studies
illustrate the usefulness of using this research approach to assess the ability of nurses to make judgements in relation to patient self-neglect (Lauder
et al., 2001) and response to stimulated hypovolemic shock (Thompson et al., 2005). Although Thomp-

179

son et al. (2005) study illustrated the variability of


student responses to clinical data; the small sample
size is reflected in the rather high standard deviation
data. The results of study may reflect the insufficient time provided for students to assimilate information and apply new theory to clinical examples.
Larger replicative studies are needed to justify the
results found and to assess the merits of using this
approach to investigate clinical decision making.
In her study of community-based nurses, Carr
(2004) identified a clinical reasoning strategy that
embedded a four-stage framework that is dependent on the underpinning philosophy of care provided and the service organisation involved. The
strategy is imbued by signalling responses employed when undertaking a patients needs assessment. Relevant signals are filtered and patient
assessment skills are reviewed. A framing procedure is used to negotiate patients needs and for
need identification. The patients needs are interpreted and collaborative decisions are made. The
final stage involves of the development of action
options and whether interventions are needed.
These stages reflect the practical reasoning response identified by Greenwood (1998).
Bucknall (2003) assessed clinical decision-making strategies employed by critical care nurses
and found these to be context specific. This is in
agreement with the view of Fisher and Fonteyn
(1995). The physiological assessment of patients
in critical care situations is highly dependent on
technology, so it is not surprising that critical care
nurses relied on the precise information provided
by the intensive technologies used in critical care
settings. Decision making was positively enhanced
by role models and peer support.

Intuition
Benner (1984) was among the first nurse theorists to
highlight the relevance of intuition to reasoning
skills and to correlate forms of knowledge such as
experiential and theoretical to the trajectory of
professional nursing practise. It was subsequently
proposed that clinical reasoning centres on the synthesis of specific knowledge forms; empirical, aesthetic, personal and ethical forms (Rew, 2000),
experience and intuition (White et al., 1992; Radwin, 1998; Claxton et al., 2002), task complexity,
education, and level of risk (Fonteyn and Grobe,
1992; Fonteyn, 1995). Proficient clinical reasoning
skills can enhance the quality of nursing practise
provided through the precision of decision-making.
Professionals make decisions using a variety of
pre-existing knowledge forms which are supported

180
by the use and integration of evidence. Such knowledge forms include; propositional, process,
personal, functional (Eraut, 1994), technical, experiential, empirical, ethical/moral, aesthetic, emancipatory and intellectual (Higgs et al., 2001). Nurses
use these forms of knowledge interchangeably to inform reasoning and decision making processes that
are employed on a daily basis.
Intuition is viewed an insight or understanding of
a situation or event as a whole that usually cannot
be logically explained (Rew and Barron, 1987). Schrader and Fischer (1987) also refer to intuition as a
type of knowing that seems to come unbidden, and
is often described as a hunch or gut feeling or
the immediate knowing of something without the
conscious use of reason.The intuitive individual
may identify a problem, its existing variables and
the relationship between the variables in order to
offer explanations and to make associations between the variables.
Intuitive thoughts may arise when the nurse
knows something about a patient that cannot be verbalized, that is verbalized with difficulty or for
which the source of knowledge cannot be determined (Young, 1987). The lack of scientific rationale
behind these hunches or decisions may devalue and
cause discomfort with the process and highlight
the difficulties encountered communicating the basis of intuitive decisions (Thompson and Dowding,
2001). As a result of these difficulties, there is no
way of knowing whether sophisticated conceptualisations . . . are actually used in the cognitive methods individuals deploy (Thompson and Dowding,
2001, p. 612). Such conceptualisations may not have
a scientific relevance (Luker and Kendrick, 1992) but
are imbued by a combination of tacit and personal
knowledge (Benner, 1984). Although the knowledge
that underpins intuition can be context specific
(Fisher and Fonteyn, 1995), competence based and
is often difficult to articulate (Reber, 1993), it is an
effective method which underpins expert-led decision making (Benner et al., 1998).
Experienced nurse clinicians develop a sense of
saliency with regard to intuitive thought and problem-solving which is based on the utilisation of considerable quantities of personal knowledge and
experience (Jacavone and Dostal, 1992), but is also
related to the complexity of judgements to be
made and the time available to make clinical decisions (Hammond et al., 1964). Decision making may
involve matching prototypes from initial observations to generate a diagnostic hypothesis (Gilhooly,
1990) and amalgamating information together to
form concrete patterns which are then stored in
the long term memory and used to inform reasoning (Greenwood, 2000).

M. Banning

Studies using the think-aloud analysis


The think aloud approach is a qualitative tool that is
employed to access cognitive processes used in clinical reasoning. It focuses on the collection of verbal
data about cognitive processes pertinent to the solving of a problem. Thinking aloud is an indication of
information being concentrated on at that time
(Newell and Simon, 1972; Taylor, 2000). This approach has been successfully used to collect accessible information about cognitive processing using
nursing and medical clinical scenarios (Corcoran
and Moreland, 1988; Kuipers et al., 1988; Lee and
Ryan-Wenger, 1997; Aitken and Mardegan, 2000;
Greenwood et al., 2000; Offredy and Meerabeau,
2005). Inferences can be drawn from the concepts
generated, information processing skills and cognitive processing prevalent in the reasoning process
(Fonteyn et al., 1993) but can also be used to identify
faulty reasoning (Offredy and Meerabeau, 2005).
Daly (2001) explored the clinical reasoning skills
in pre-registration nurses using patient simulation
and the think aloud approach. Although some students showed evidence of metacognitive processing, the majority had difficulties expressing
themselves. This difficulty may result from problems of teaching reasoning and the lack of definition, testing and development of clinical reasoning
skills associated with nurse education and training.
Although simulations are thought to present lifelike
situations (Topf, 1990), their use has been criticised
for their inability to represent the complexity and
unpredictability of the real-life setting and the
thought processes that practitioners utilise in natural settings (Fonteyn and Fisher, 1995).
The think aloud approach has also been used to
assess the reasoning skills of qualified nurses in a
variety of clinical settings (Aitken and Mardegan,
2000; Simmons et al., 2003; Offredy and Meerabeau, 2005). Fowler (1997) found that nurses used
a combination or multiple cognitive operators to
describe the nursing care they offered, e.g. connecting, evaluating, judging, planning and explaining care. They also used an array of cognitive
strategies to clinically reason, plan and implement
nursing care. These focused on hypothesizing and
framing using salient cues to direct thinking, inductive logic and metacognition. Fowlers work concurs with published data (Farrell and Bramadat,
1990; Gordon, 1994). Gordon (1994) also identified
additional cognitive operators such as clarifying,
and verifying information or reflexive comparison.
Protocol analysis is a common method of data
analysis used to analyse findings from the think
aloud approach (Fonteyn et al., 1993; Aitken and
Mardegan, 2000; Greenwood et al., 2000; Simmons

Clinical reasoning and its application to nursing: Concepts and research studies
et al., 2003). The method uses assertional analysis
to extrapolate statements offered, connect concepts together in order to facilitate clinical reasoning, script analysis is used to provide an overview
of the cognitive process and thinking strategies
that participants use during the reasoning task
and finally referring phase analysis is employed to
capture the vocabulary of concepts used by subjects during the reasoning process and to isolate
the information that nurses used when reasoning
about the assessment process (Greenwood et al.,
2000). In Simmon et al.s study nurses used thinking
strategies and heuristics (mental short cuts)
(Tversky and Kahnemann, 1974) to consolidate patient information and apply knowledge gained from
work experience and education. Commonly used
heuristics involved recognising a pattern, judging
the value, providing explanations, forming relationships and drawing conclusions. Simmons et al. identified six main concepts; plan, rationale, status,
test, treatment and value. Each of these moved
the reasoning process forward and is linked to specific assertions; cause and effect relationships,
declarative or statements of facts, evaluative
judgements of significance and anticipative expectations of action. These reasoning processes and
thinking strategies enabled nurses to quickly review
and analyse patient information, evaluate its significance and formulate alterative actions. The data
yielded support the view that the informationprocessing theory is the underlying conceptual
framework for clinical reasoning in experienced
nurses whereby the individual uses knowledge and
experience to merge the information gleaned from
assessment into manageable concepts as illustrated
previously (Newell and Simon, 1972).
Although this view agrees with published literature (Farrell and Bramadat, 1990; ONeill, 1994,
1995; ONeill et al., 2005), the metacognitive aspects of clinical reasoning thinking were not apparent (Kuiper and Pesut, 2004). Simmons et al. (2003)
concluded that experienced nurses could be differentiated by clinical reasoning skills rather than
years of nursing experience. One should not negate
the value and contribution of experience and experiential learning as both are essential components
of advanced clinician practise (ONeill and Dluhy,
1997) and are a recognised stimulus to clinical reasoning (Fowler, 1997).
This feature is consistent with medical colleagues who use cumulative experience, in conjunction with script analysis (networks of prior
knowledge) to augment the development of elaborate cognitive prototypes when managing patients
(Schmidt et al., 1990; Charlin et al., 2000). Scripts
are equivalent to schema; goal directed knowledge

181

structures which are adapted to efficiently perform


tasks (Johnson and Haser, 1987). Scripts are activated in order to enhance reasoning built on the
process of deduction (Charlin et al., 2000; Grant
and Marsden, 1987). Nurses also use schema theory
to construct mental models for problem solving
(Offredy and Meerabeau, 2005; Greenwood et al.,
2000). Experienced nurses working in a speciality
use schema and cognitive prototypes to manage
care (Ferrario, 2004). Prototype formation will enhance the development of a sense of saliency in
experienced nurses; a hallmark of clinical reasoning and expert practise (Jacavone and Dostal,
1992). Prototypes reduce cognitive processing time
and result in cognitive shortcuts which allow nurses
to progress from rule-based thinking and a step-bystep analysis to more focused reasoning style which
alleviates cognitive strain (Benner et al., 1996;
Ferrario, 2004). Cognitive shortcuts are induced
by the automatic cognitive processes and higher
order thinking of experienced nurses (Tabek et al.,
1996) which are built on clinical knowledge and
experiential learning (Ferrario, 2003).
Evidence to support the use of cognitive operators and cognitive strategies to underpin clinical
reasoning is limited. In order to inform nurse education and training more research is needed to explore the characteristics, use and application of
clinical reasoning processes and strategies used
during the planning and implementation of nursing
care. Ribbons (1998) and Thompson et al. (2005)
have shown how nurses can benefit from the use
of computers as cognitive tools to aid clinical reasoning skills. However, for this educational approach to be of benefit, students need time to
sufficiently assimilate taught knowledge before
they can apply it to clinical exemplars.
The think aloud approach is an underused teaching and learning method which can create the environment for developing clinical reasoning skills in
nursing students (Lee and Ryan-Wenger, 1997). A
criticism of the approach is that the cues that
may actually influence the respondents ability to
verbalise their thoughts may not be the cues that
are reported, as cues are often difficult to verbalise (Thompson et al., 2005). Given the importance
of clinical reasoning in nursing, it is necessary for
nurse educators to develop alternative teaching
and learning approaches that foster the development of this skill.

Conclusions
Clinical reasoning is a cognitive process that is
underpinned by cognition and metacognition

182
(Kuiper and Pesut, 2004) In nursing, definitions of
clinical reasoning appear to revolve around the
processes involved in making professional judgements, evaluating the quality of evidence to solve
problems and to make diagnostic and patient management decisions (Higgs et al., 2001). Although
experienced and inexperienced nurses use clinical
reasoning processes to make judgements and decisions about the nursing care that they provide to
patients, the alacrity of the thinking process and
the outcomes may differ. Experienced nurses use
patient centred prototypes to undertake cognitive
shortcuts during the thinking process but also rely
on schema, experience and intuition.
Protocol analysis and the think aloud approach
are common methods of assessing clinical reasoning. A drawback of using the think aloud approach
is the accuracy of findings on thought processes
and cognitive strategies are prohibited by the proposed difficulties that nurses can have verbalising
their reasoning.
More research and educational development is
needed to develop current understanding of cognitive operators and cognitive strategies that are
used by nurses during the thinking process and to
develop tools that can be used to accurately assess
clinical reasoning strategies.

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