Textbook of Medical-Surgical Nursing 3e

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Unit 1 Contemporary concepts in nursing

Clinical reasoning

Personal attributes

Clinician’s actions

Clinical judgement Decision making

Problem solving Critical thinking Creative thinking Intuitive thinking

Context of thoughtful nursing and midwifery practice

Knowledge base

Process of care

Clinical experience

Evaluation and reflection

Figure 2-2  Clinical reasoning and the process of care trajectory (Dempsey, J., Hillege, S. & Hill, R. (2013). Fundamentals of nursing and midwifery: A person-centred approach to care (2nd ed., Figure 14-1). Sydney: Lippincott Williams & Wilkins.)

fundamental to the processes of care. Unfortunately, problem solving does not always involve clinical reasoning, so the solution to a problem may be limited to traditional solutions with other potential solutions being ignored. Therefore the reasoning process must be expansive and unlimited exploring all possibilities in order to solve a problem. Problem solving Problem solving is a basic life skill which involves identifying a problem and then taking steps to resolve it. However, different approaches to problem solving yield different results. Problem solving that takes into account critical thinking, creative, non-traditional and reflective approaches enables additional solutions to be formulated (Chabelli, 2007). Trial-and-error problem solving involves testing a number of solutions until one is found that works for that particular problem. This type of problem solving in healthcare is limited to those situations where the wrong option that may harm the patient can be eliminated. Scientific problem solving is closely related to this more general problem-solving process; however, it involves identifying a problem, collecting some data, interpreting the results to form a hypothesis that is based on previously acquired scientific knowledge that in turn drives the action. This is often the point at which research commences. It can be informed by intuitive problem solving in which experienced clinicians act upon a ‘gut feeling’ or an ‘inner prompting.’ The type of knowledge that underpins this form of problem solving is referred to as tacit knowledge, and is built up over years

take (Chang et al., 2011). Cue acquisition is when the impor- tance of these pieces of data are recognised and collected. Experience influences the type and number of cues that are collected as experienced clinicians appear to be able to focus on the most important cues and anticipate others, whereas less experienced clinicians collect cues according to rules that are learnt. These cues can be clustered into patterns that can be compared with those previously encountered. Through clinical experience, the clinician retains memories of previous patients and clinical situations. Similarities and differences between the situations is called pattern recognition, and as the clini- cian gains more experience, more patterns are retained in the memory bank (Buckingham & Adams, 2000b). For example, experienced nurses who have performed many respiratory assessments have memory banks that enable comparing the current breath sounds with others they have heard in the past consolidated by what they have learnt from the evidence-based literature. New practitioners may have to rely initially on assis- tance with assimilation of ideas from other more experienced nurses, as this memory bank has not yet developed. Reasoning process The terms clinical reasoning, problem solving, clinical judge- ment and decision making are often used interchangeably (Simmons, 2010); however, most acknowledge this cyclical process of cue collection, interpretation, pattern matching and decision making. Indeed, it could be said that the need to reason is driven by a problem; therefore, problem solving is