Clinical reasoning in experienced nurses

Abstract

<p>This qualitative descriptive study was designed to explore the cognitive strategies used by experienced nurses as they think about assessment findings on their assigned patients. As an essential component of nursing practice, clinical reasoning is used to assimilate information, analyze data, and make decisions regarding patient care. Changes in health care settings and patient acuity challenge nurses to make complex decisions under conditions of uncertainty and risk. With fewer expert nurses available to act as mentors, experienced nurses who are not yet experts must utilize varied reasoning strategies to care for acutely ill patients. Few studies of nurses' clinical reasoning have been conducted in a practice setting during actual patient care. Information processing theory provided the theoretical framework for the study. Fifteen experienced nurses were asked to &lsquo;think aloud&rsquo; about their beginning shift assessments. An experienced nurse was defined as a registered nurse with no advanced degree or certification who had worked full time on a medical-surgical unit more than 2 years but less than 10 years. Think aloud data were audiotaped and transcribed. Three steps of protocol analysis were used to analyze the data. These included referring phrase, assertional, and script analysis. Referring phrase analysis organized data according to concepts. Assertional analysis identified the links that were made between concepts, and script analysis revealed the heuristics that nurses used while reasoning. The results of this study indicated that experienced nurses used a conceptual language to reason about patient assessments, linked these concepts together to make sense of the information, and consistently used heuristics to reason more quickly and efficiently. Secondary findings included support for the definition and model of clinical reasoning used in this study, as well as support for information processing theory as the underlying theoretical framework used by nurses. A serendipitous finding was that experienced nurses used reasoning strategies that have previously been identified only in experts. Results of this study have implication for practice, education, and further research. The classic work of Benner may need to be revisited in order to identify current skill levels in practice.</p>