Nurse Education in Practice (2008) 8, 177–183

Nurse

www.elsevierhealth.com/journals/nepr

Educationin Practice

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

Summary Clinical reasoning may be defined as ‘‘the process of applying knowl-edge and expertise to a clinical situation to develop a solution’’ [Carr, S., 2004. Aframework for understanding clinical reasoning in community nursing. J. Clin. Nurs-ing 13 (7), 850–857]. Several forms of reasoning exist each has its own merits anduses. Reasoning involves the processes of cognition or thinking and metacognition.In nursing, clinical reasoning skills are an expected component of expert and com-petent practise. Nurse research studies have identified concepts, processes andthinking strategies that might underpin the clinical reasoning used by pre-registra-tion nurses and experienced nurses. Much of the available research on reasoningis 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 nurs-ing research is needed to explore the clinical reasoning process. Investment inteaching and learning methods is needed to enhance clinical reasoning skills innurses.

�c 2007 Elsevier Ltd. All rights reserved.

KEYWORDSClinical reasoning;Professionaljudgement;Clinical reasoningstrategies;Nursing practice

1d

Introduction

Clinical reasoning is an essential feature of healthcare practise that focuses on the assimilation andanalysis of health care evidence that is differenti-

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* Tel.: +44 018952 68819.E-mail address: maggi.banning@brunel.ac.uk

ated according to its usefulness, efficacy and appli-cation to a selective group of patients. This processthen informs the decisions that are made pertinentto patient management (Matteson and Hawkins,1990; Simmons et al., 2003).

Clinical reasoning may be viewed as thehallmark of the expert nurse (Fowler, 1997) andan essential component of nursing competencewhich is often demonstrated in experienced nurses

rved.

178 M. Banning

working in various nursing specialisms. The alterna-tive view is that clinical reasoning skills are used bynurses at all levels to inform decisions about the le-vel of nursing care offered to patients (Fisher andFonteyn, 1995). There are merits of both positions.This paper aims to explore the concept of clinicalreasoning and to provide some analysis of the rea-soning strategies used by nurses, how clinical rea-soning has been examined in nursing researchthrough the use of the think aloud approach.

Reasoning

Reasoning is a process that pertains to the thoughtprocesses, organisation of ideas and exploration ofexperiences to reach conclusions. Reasoning maybe viewed as a form of thinking that is often appar-ent during the presentation of ideas or discourse inwhich the logistics of an argument are collated in alogical manner in order to reach a rationalconclusion.

There are several forms of clinical reasoning;eachhas its ownmerits (Burns andHiggs, 2000; Burnsand Grove, 2005). Problematic reasoning involvesidentifying a problem and its influential factors andrecognising solutions that may be used to solve theproblem (Burns and Grove, 2005). This approach toclinical reasoning can be used to assist nurses toidentify nursing diagnoses and to implement nursinginterventions that can be used to solve problems.

Theoretical reasoning begins inductively consid-ers a hypothesis using a hypothetico-deductivestance and terminates in a conclusion or a decision(Carr, 1981). In contrast practical reasoning usuallyterminates in an action, e.g. the result of care plan-ning (Greenwood and King, 1995). The procedureinvolved is similar to theoretical reasoning as theprocess begins ‘‘logically but only through thehypothetico-deductive manipulation of proposi-tions at progressively decreasing levels of inclusive-ness and generality’’ (Greenwood, 1998, p. 845).

Operational reasoning focuses on the ‘‘identifi-cation of and discrimination along many alterna-tives and viewpoints’’ (Burns and Grove, 2005,p. 7). The focus of this formof reasoning is on the ac-tual process and the identification of opposing viewsthat may be used to determine a solution to theproblem (Barnum, 1998). In nursing research opera-tional reasoning can be used to assess and debatethe suitability of research methods or data analysistechniques to the research question (Kerlinger andLee, 2000). This approach to clinical reasoning canbe used by nurses to assist patients and their familiesto develop realistic and measurable goals withrespect to their management and nursing care.

Inductive reasoning is a reasoning approach thatmoves from the specific to the general where in-stances are combined to form purposive state-ments (Chin and Kramer, 1999) and where thepremises of an argument are believed to supportthe conclusion, but do not ensure it (Wikipedia,2007). Inductive reasoning can be used to assessthe nursing care of orthopaedic patients who havean altered health state due to sustaining a frac-ture. The presence of the fracture is stressful forthe patient. In this instance, inductive reasoningis used to illustrate that the presence of the frac-ture is stressful and can be viewed as an alteredstate of health.

Dialectic reasoning involves looking at situationsin a holistic way. ‘‘A dialectic thinker believes thatthe whole is greater than the sum of the parts andthat the whole organises the parts’’ (Burns andGrove, 2005, p. 7). This form of reasoning focuseson the identification and exploration of opposingfactors that are then combined in order to exploreproblems. The merger of factors into a single solu-tion is thought to be more a powerful tactic thanthe independent assessment of factors. In nursing,dialectic reasoning would involve assessing thestrengths and weaknesses of a patient’s problemrather than identifying the patient according totheir pathophysiological condition(s).

Clinical reasoning in nursing revolves around theprocess of making professional judgements, evalu-ating the quality and contribution of available evi-dence to enhance problem solving and to considerto what extent the evidence available is sufficientto make decisions on diagnostics and treatment op-tions relevant to the nursing care requirements ofthe individual (Higgs et al., 2001). It is viewed as amultidimensional, recursive cognitive process thatemploys formal and informal strategies to assembleand analyse patient information that is then evalu-ated relative to its significance and contributionto patient management (Simmons et al., 2003).According to Higgs et al. (2001) the decisions thatnurses make relevant to the individual health careneeds of the patient can be facilitated by the mer-ger of professional judgment and clinical reasoning.Both of which are supported by intuition and knowl-edge gained from professional experience.

Reasoning strategies

Clinical reasoning pertinent to nursing depends onthe development of cognition or critical thinkingand metacognition or thinking about thinking. Bothof these are inextricably linked to the process ofclinical reasoning (Kuiper and Pesut, 2004).

Clinical reasoning and its application to nursing: Concepts and research studies 179

Metacognition refers to higher order thinkingprocess that involves the active control of cogni-tive (thinking) processes and the assessment of towhat extent cognitive outcomes have beenachieved in relation to learning situations (Flavell,1987; Wikipedia, 2006). Metacognition is generallythought of as ‘thinking about thinking’ and com-prises metacognitive regulation or strategies thatare used to control or oversee cognitive activitiesand goals. Metacognitive knowledge can be fac-tual, explicit or implicit (Wikipedia, 2006); theseknowledge forms are used in metacognitive pro-cessing to enhance participation in cognitive activ-ities to achieve cognitive goals and outcomes(Brown, 1987). During this process individuals willuse inductive logic to simultaneously assembleand evaluate patient information and supportiveevidence before making judgements about nursingcare (Higgs et al., 2001; Simmons et al., 2003).

During clinical reasoning, there is ‘‘an interac-tion among the individual’s cognition, the subjectmatter, and the context of the situation where thethinking occurs’’ (Fowler, 1997, p. 349; Lewis,2007). Nurses use multiple cognitive processes suchas making judgements on the use of evidence basedon past experience but also on underpinningknowledge, judging client situations, hypothesesgeneration, diagnostic reasoning and reflection.Metacognition is thought to control cognitive pro-cesses (Pesut and Herman, 1992). Although theimportance of clinical reasoning cannot be underes-timated, it continues to be a poorly defined con-struct which has been assessed using limitedmeasurement tools. Current nursing research hasused a variety of approaches to differentiate thevariety of clinical reasoning strategies employedby nurses at varying stages of professional develop-ment. The available evidence demonstrates thatthe clinical reasoning skills employed by nurses havealso been labelled as problem solving, clinicaljudgement, information processing, diagnostic rea-soning, and decision-making (Farrell and Bramadat,1990).

The clinical decision making processes of experi-enced nurses (Bucknall, 2003; Lauder et al., 2001;Carr, 2004) and pre-registration student nurses(Thompson et al., 2005) has been assessed using avariety of research approaches.

Thompson et al. (2005) and Lauder et al. (2001)used a factorial design to assess student and quali-fied nurses ability to make judgements. Both studiesillustrate the usefulness of using this research ap-proach to assess the ability of nurses to make judge-ments in relation to patient self-neglect (Lauderet al., 2001) and response to stimulated hypovole-mic shock (Thompsonet al., 2005). AlthoughThomp-

son et al. (2005) study illustrated the variability ofstudent responses to clinical data; the small samplesize is reflected in the rather high standard deviationdata. The results of study may reflect the insuffi-cient time provided for students to assimilate infor-mation and apply new theory to clinical examples.Larger replicative studies are needed to justify theresults found and to assess the merits of using thisapproach to investigate clinical decision making.

In her study of community-based nurses, Carr(2004) identified a clinical reasoning strategy thatembedded a four-stage framework that is depen-dent on the underpinning philosophy of care pro-vided and the service organisation involved. Thestrategy is imbued by signalling responses em-ployed when undertaking a patient’s needs assess-ment. Relevant signals are filtered and patientassessment skills are reviewed. A framing proce-dure is used to negotiate patients’ needs and forneed identification. The patient’s needs are inter-preted and collaborative decisions are made. Thefinal stage involves of the development of actionoptions and whether interventions are needed.These stages reflect the practical reasoning re-sponse identified by Greenwood (1998).

Bucknall (2003) assessed clinical decision-mak-ing strategies employed by critical care nursesand found these to be context specific. This is inagreement with the view of Fisher and Fonteyn(1995). The physiological assessment of patientsin critical care situations is highly dependent ontechnology, so it is not surprising that critical carenurses relied on the precise information providedby the intensive technologies used in critical caresettings. Decision making was positively enhancedby role models and peer support.

Intuition

Benner (1984) was among the first nurse theorists tohighlight the relevance of intuition to reasoningskills and to correlate forms of knowledge such asexperiential and theoretical to the trajectory ofprofessional nursing practise. It was subsequentlyproposed that clinical reasoning centres on the syn-thesis of specific knowledge forms; empirical, aes-thetic, personal and ethical forms (Rew, 2000),experience and intuition (White et al., 1992; Rad-win, 1998; Claxton et al., 2002), task complexity,education, and level of risk (Fonteyn and Grobe,1992; Fonteyn, 1995). Proficient clinical reasoningskills can enhance the quality of nursing practiseprovided through the precision of decision-making.Professionals make decisions using a variety ofpre-existing knowledge forms which are supported

180 M. Banning

by the use and integration of evidence. Such knowl-edge forms include; propositional, process,personal, functional (Eraut, 1994), technical, expe-riential, empirical, ethical/moral, aesthetic, eman-cipatory and intellectual (Higgs et al., 2001). Nursesuse these forms of knowledge interchangeably to in-form reasoning and decision making processes thatare employed on a daily basis.

Intuition is viewed an insight or understanding ofa situation or event as a whole that usually cannotbe logically explained (Rew and Barron, 1987). Sch-rader and Fischer (1987) also refer to intuition as atype of knowing that seems to come unbidden, andis often described as a ‘hunch’ or ‘gut feeling’ orthe immediate knowing of something without theconscious use of reason.The intuitive individualmay identify a problem, its existing variables andthe relationship between the variables in order tooffer explanations and to make associations be-tween the variables.

Intuitive thoughts may arise when the nurseknows something about a patient that cannot be ver-balized, that is verbalized with difficulty or forwhich the source of knowledge cannot be deter-mined (Young, 1987). The lack of scientific rationalebehind these hunches or decisions may devalue andcause discomfort with the process and highlightthe difficulties encountered communicating the ba-sis of intuitive decisions (Thompson and Dowding,2001). As a result of these difficulties, there is noway of knowing whether ‘‘sophisticated conceptu-alisations . . . are actually used in the cognitivemeth-ods individuals deploy’’ (Thompson and Dowding,2001, p. 612). Such conceptualisations may not havea scientific relevance (Luker and Kendrick, 1992) butare imbued by a combination of tacit and personalknowledge (Benner, 1984). Although the knowledgethat underpins intuition can be context specific(Fisher and Fonteyn, 1995), competence based andis often difficult to articulate (Reber, 1993), it is aneffective method which underpins expert-led deci-sion making (Benner et al., 1998).

Experienced nurse clinicians develop a sense ofsaliency with regard to intuitive thought and prob-lem-solving which is based on the utilisation of con-siderable quantities of personal knowledge andexperience (Jacavone and Dostal, 1992), but is alsorelated to the complexity of judgements to bemade and the time available to make clinical deci-sions (Hammond et al., 1964). Decision making mayinvolve matching prototypes from initial observa-tions to generate a diagnostic hypothesis (Gilhooly,1990) and amalgamating information together toform concrete patterns which are then stored inthe long term memory and used to inform reason-ing (Greenwood, 2000).

Studies using the think-aloud analysis

The think aloud approach is a qualitative tool that isemployed to access cognitive processes used in clin-ical reasoning. It focuses on the collection of verbaldata about cognitive processes pertinent to the solv-ing of a problem. Thinking aloud is an indication ofinformation being concentrated on at that time(Newell and Simon, 1972; Taylor, 2000). This ap-proach has been successfully used to collect accessi-ble information about cognitive processing usingnursing and medical clinical scenarios (Corcoranand Moreland, 1988; Kuipers et al., 1988; Lee andRyan-Wenger, 1997; Aitken and Mardegan, 2000;Greenwood et al., 2000; Offredy and Meerabeau,2005). Inferences can be drawn from the conceptsgenerated, information processing skills and cogni-tive processing prevalent in the reasoning process(Fonteyn et al., 1993) but can also beused to identifyfaulty reasoning (Offredy and Meerabeau, 2005).

Daly (2001) explored the clinical reasoning skillsin pre-registration nurses using patient simulationand the think aloud approach. Although some stu-dents showed evidence of metacognitive process-ing, the majority had difficulties expressingthemselves. This difficulty may result from prob-lems of teaching reasoning and the lack of defini-tion, testing and development of clinical reasoningskills associated with nurse education and training.Although simulations are thought to present lifelikesituations (Topf, 1990), their use has been criticisedfor their inability to represent the complexity andunpredictability of the real-life setting and thethought processes that practitioners utilise in natu-ral settings (Fonteyn and Fisher, 1995).

The think aloud approach has also been used toassess the reasoning skills of qualified nurses in avariety of clinical settings (Aitken and Mardegan,2000; Simmons et al., 2003; Offredy and Meera-beau, 2005). Fowler (1997) found that nurses useda combination or multiple cognitive operators todescribe the nursing care they offered, e.g. con-necting, evaluating, judging, planning and explain-ing care. They also used an array of cognitivestrategies to clinically reason, plan and implementnursing care. These focused on hypothesizing andframing using salient cues to direct thinking, induc-tive logic and metacognition. Fowler’s work con-curs with published data (Farrell and Bramadat,1990; Gordon, 1994). Gordon (1994) also identifiedadditional cognitive operators such as clarifying,and verifying information or reflexive comparison.

Protocol analysis is a common method of dataanalysis used to analyse findings from the thinkaloud approach (Fonteyn et al., 1993; Aitken andMardegan, 2000; Greenwood et al., 2000; Simmons

Clinical reasoning and its application to nursing: Concepts and research studies 181

et al., 2003). The method uses assertional analysisto extrapolate statements offered, connect con-cepts together in order to facilitate clinical reason-ing, script analysis is used to provide an overviewof the cognitive process and thinking strategiesthat participants use during the reasoning taskand finally referring phase analysis is employed tocapture the vocabulary of concepts used by sub-jects during the reasoning process and to isolatethe information that nurses used when reasoningabout the assessment process (Greenwood et al.,2000). In Simmon et al.’s study nurses used thinkingstrategies and heuristics (mental short cuts)(Tversky and Kahnemann, 1974) to consolidate pa-tient information and apply knowledge gained fromwork experience and education. Commonly usedheuristics involved recognising a pattern, judgingthe value, providing explanations, forming relation-ships and drawing conclusions. Simmons et al. iden-tified six main concepts; plan, rationale, status,test, treatment and value. Each of these movedthe reasoning process forward and is linked to spe-cific assertions; cause and effect relationships,declarative or statements of facts, evaluativejudgements of significance and anticipative expec-tations of action. These reasoning processes andthinking strategies enabled nurses to quickly reviewand analyse patient information, evaluate its signif-icance and formulate alterative actions. The datayielded support the view that the information-processing theory is the underlying conceptualframework for clinical reasoning in experiencednurses whereby the individual uses knowledge andexperience to merge the information gleaned fromassessment into manageable concepts as illustratedpreviously (Newell and Simon, 1972).

Although this view agrees with published litera-ture (Farrell and Bramadat, 1990; O’Neill, 1994,1995; O’Neill et al., 2005), the metacognitive as-pects of clinical reasoning thinking were not appar-ent (Kuiper and Pesut, 2004). Simmons et al. (2003)concluded that experienced nurses could be differ-entiated by clinical reasoning skills rather thanyears of nursing experience. One should not negatethe value and contribution of experience and expe-riential learning as both are essential componentsof advanced clinician practise (O’Neill and Dluhy,1997) and are a recognised stimulus to clinical rea-soning (Fowler, 1997).

This feature is consistent with medical col-leagues who use cumulative experience, in con-junction with script analysis (networks of priorknowledge) to augment the development of elabo-rate cognitive prototypes when managing patients(Schmidt et al., 1990; Charlin et al., 2000). Scriptsare equivalent to schema; goal directed knowledge

structures which are adapted to efficiently performtasks (Johnson and Haser, 1987). Scripts are acti-vated in order to enhance reasoning built on theprocess of deduction (Charlin et al., 2000; Grantand Marsden, 1987). Nurses also use schema theoryto construct mental models for problem solving(Offredy and Meerabeau, 2005; Greenwood et al.,2000). Experienced nurses working in a specialityuse schema and cognitive prototypes to managecare (Ferrario, 2004). Prototype formation will en-hance the development of a sense of saliency inexperienced nurses; a hallmark of clinical reason-ing and expert practise (Jacavone and Dostal,1992). Prototypes reduce cognitive processing timeand result in cognitive shortcuts which allow nursesto progress from rule-based thinking and a step-by-step analysis to more focused reasoning style whichalleviates cognitive strain (Benner et al., 1996;Ferrario, 2004). Cognitive shortcuts are inducedby the automatic cognitive processes and higherorder thinking of experienced nurses (Tabek et al.,1996) which are built on clinical knowledge andexperiential learning (Ferrario, 2003).

Evidence to support the use of cognitive opera-tors and cognitive strategies to underpin clinicalreasoning is limited. In order to inform nurse edu-cation and training more research is needed to ex-plore the characteristics, use and application ofclinical reasoning processes and strategies usedduring the planning and implementation of nursingcare. Ribbons (1998) and Thompson et al. (2005)have shown how nurses can benefit from the useof computers as cognitive tools to aid clinical rea-soning skills. However, for this educational ap-proach to be of benefit, students need time tosufficiently assimilate taught knowledge beforethey can apply it to clinical exemplars.

The think aloud approach is an underused teach-ing and learning method which can create the envi-ronment for developing clinical reasoning skills innursing students (Lee and Ryan-Wenger, 1997). Acriticism of the approach is that the cues thatmay actually influence the respondent’s ability toverbalise their thoughts may not be the cues thatare reported, as cues are often difficult to verba-lise (Thompson et al., 2005). Given the importanceof clinical reasoning in nursing, it is necessary fornurse educators to develop alternative teachingand learning approaches that foster the develop-ment of this skill.

Conclusions

Clinical reasoning is a cognitive process that isunderpinned by cognition and metacognition

182 M. Banning

(Kuiper and Pesut, 2004) In nursing, definitions ofclinical reasoning appear to revolve around theprocesses involved in making professional judge-ments, evaluating the quality of evidence to solveproblems and to make diagnostic and patient man-agement decisions (Higgs et al., 2001). Althoughexperienced and inexperienced nurses use clinicalreasoning processes to make judgements and deci-sions about the nursing care that they provide topatients, the alacrity of the thinking process andthe outcomes may differ. Experienced nurses usepatient centred prototypes to undertake cognitiveshortcuts during the thinking process but also relyon schema, experience and intuition.

Protocol analysis and the think aloud approachare common methods of assessing clinical reason-ing. A drawback of using the think aloud approachis the accuracy of findings on thought processesand cognitive strategies are prohibited by the pro-posed difficulties that nurses can have verbalisingtheir reasoning.

More research and educational development isneeded to develop current understanding of cogni-tive operators and cognitive strategies that areused by nurses during the thinking process and todevelop tools that can be used to accurately assessclinical reasoning strategies.

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