Clinical reasoning and Decision
making
What’s clinical reasoning?
• A term often used interchangeably with decision
making, problem solving, clinical judgement,
critical thinking
• Clinical reasoning describes the process by which
nurses (and other clinicians) collect cues, process
the information, come to an understanding of a
patient problem or situation, plan and implement
interventions, evaluate outcomes, and reflect on
and learn from the process
Why is it important?
• Effective clinical reasoning skills have a
positive impact on patient outcomes
• Poor clinical reasoning skills often fail to
detect impending patient deterioration
• This is significant when viewed against the
background of increasing numbers of adverse
patient outcomes and escalating healthcare
complaints
Clinical reasoning cycle
• Can be seen as look, collect, process, decide, plan,
act, evaluate and reflect in reality, the phases
merge and the boundaries between them are
often blurred
• It’s important to remember that clinical reasoning
is a dynamic process and nurses often combine
one or more phases or move back and forth
between them before reaching a decision, taking
action and evaluating outcomes
Clinical Reasoning Cycle
Consider Patient
Reflect on
process
Collects info &
cues
Evaluate
outcomes
Process info
Identify
problems/issues
Take action
Establishes
goals
Considers patient
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Describe or list facts, context, objects or people
What do you know already about the patient?
Who is involved with the patient?
What is your observation of the patient?
What is and isn’t the patient telling you?
Collects cues and information
• Review current information e.g. handover info,
patient history, patient charts, results of
investigations, nursing/medical assessments
already taken
• Gather new information – nursing assessment.
Who else may be able to add to the information?
E.g. GP, Community nurses, social worker, relative
• Recall knowledge e.g. physiology,
pathophysiology, epidemiology, therapeutics,
context of care, ethics, law
Process information
• Interpret – analyse data. Compare normal vs
abnormal. What’s your understanding of signs
and symptoms?
• Discriminate – distinguish relevant and
irrelevant information; narrow down the
information to what is most important
information and acknowledge where there are
gaps in the information
Process information
• Infer – Consider the subjective information &
objective cues and make deductions or form
opinions that are logical. Could there also be any
alternatives and consequences?
• Match – your present experience to that of the
same in the past (what have you known to be the
case before…or consider what literature/research
has told you
• Predict – an outcome (comes more with
experience)
Identify problems/issues
• Synthesise facts and inferences to make a
definitive diagnosis of the patients problem
• Think about what you have collated, what are the
problems that can be identified? As part of this
you may wish to discuss with colleagues
Goals and action
• Establishes goals
• Take action
• Describe what you want to
happen, a desired outcome,
a time frame This will keep
you focused
• Are these goals the same as
the patient’s? or does the
patient understand these?
• Select a course of action.
There may be several actions
that you could choose but
select the one you feel is
best. It may be relevant to
discuss the possible actions
with a colleague
• Action may include referrals,
consulting with other health
care professionals,
commencing a structured
care plan, etc.
Evaluate outcomes
• Evaluate the effectiveness of actions and
outcomes.
• Ask yourself “has the situation improved
now?”
• If not ask “what now?”
Reflect on process
• Contemplate on what you have learnt from
this process and consider what you could have
done differently
Process
Description
Example
Consider the
patient
situation
Describe or list facts, context, objects or
people
Collect cues/
information
Review current info e.g. handover reports,
patient history, patient charts, results of
investigations/assessments previous done
84 year old patient is on the ward
after a fall with no fracture.
Appears confused unable to answer
simple questions.
Has history of hypertension takes
beta blockers
Some concerns of confusion was
reported in handover but previous
notes do not mention confusion
Gather new info e.g. undertake a patient
assessment
Recall knowledge e.g. physiology,
pathophysiology, context of care etc.
Rechecked BP – 110/50, Temp 38,
Pulse 99 bpm
Skin appears dry as does mouth and
tongue. No recording of micturition
recently. Not taken oral fluids
BP due to fluid status
Is on tramadol for pain relief – this
can cause BP to drop as vasodilation
of blood vessels
Temp is up, considering the age this
is a bigger concern
Pulse is up, considering patient is on
bed rest this is concerning
But patient seems dehydrated
Process
information
Interpret analyse data to come to
understanding of signs and symptoms
Compare normal v abnormal
BP is low for someone of similar
age. Mouth, tongue & skin are dry.
Anuria is not normal
Patient is pyrexic
Pulse is up and considering patient
is on bed rest this is concerning
Discriminate distinguish relevant from
Temp & pulse are up which is a
irrelevant info. What’s most important
concern, BP is low, dry tongue &
skin with anuria and presence of
confusion.
I should do a bladder scan
Relate discover new relationships, patterns Hypotension, pyrexia, tachycardia,
in cues
dry mouth & skin, anuria and
confusion could be signs of a
urinary infection
Infer make deductions or form opinions that A urinary infection may be the
follow logically by interpreting subjective & reason for the fall and NOF
objective cues
Predict an outcome
If patient doesn’t get some fluids
they will become more
dehydrated. If temperature isn’t
managed they could go into shock.
Catheter is needed to get a sample
of urine for analysis
Identify
problem/ issue
Synthesise facts and inferences to make
Patient is confused which may be caused by a urinary
definitive diagnosis of the patient’s problem infection and tramadol may be worsening confusion.
Present of infection can raise temp and pulse
Establish goals
Describe what you want to see happen; an
outcome
I want to improve the dehydration, get BP up over
next few hours. Get a catheter specimen of urine for
urine analysis and a sample to the biochemistry
immediately
Take action
Select a course of action
I will select a suitable catheter for short term use.
Inform the patient & gain consent to catheterisation.
Inform doctor of urine analysis result and ask for IV
fluids to be prescribed on basis of clinical observations
Consider with the doctor PR paracetamol to help
control pyrexia
Evaluate
Evaluate the effectiveness of the outcomes & BP is better with the IV fluids, paracetamol as
actions – “Has things improved now?”
suppository has lowered temperature & pulse is better
CSU showed present of nitrates, leucocytes and blood
– Dr prescribed 2/7 IV antibiotics; hopefully as
confusion subsides patient will continue orally
Will need to observe patient and review the need for
catheter
Reflect on
process and
learning
Think what you have learnt and what might
you do differently
Next time I would….
I should have….
I now understand….
Glossary of terms used
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Cues - Identifiable physiological or psychosocial changes experienced by the
patient, perceived through history or assessment and understood in relation to a
specific body of knowledge and philosophical beliefs. Cues also include the context
of care and the surrounding clinical situation
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Discriminate - To use good judgement ; to note or observe a difference accurately;
to distinguish relevant from irrelevant information; to recognise inconsistencies; to
narrow down the information to what is most important and recognise gaps in
cues collected
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Evaluate - To make a judgement about the worth or value of something
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Goals - A desired outcome and a guidepost to the selection of nursing
interventions
Infer - To make deductions or form opinions that follow logically by interpreting
subjective and objective data; to consider alternatives and consequences
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Glossary continued
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Interpret - Analyse data to come to an understanding; to explain or tell the
meaning of; present in understandable terms
Outcome - A measurable change in a client’s status in response to nursing care
Predict - To envisage or foresee something that may happen
Recall - To remember or recollect a past situation or piece of knowledge
Reflection - A critical review of practice with a view to refinement, improvement
or change; the process of looking back and the careful consideration of an
experience; to explore the understanding of what one did and why and the impact
it has on themselves and others
Relate - To connect or link ; to discover new relationships or patterns; to cluster
cues together to identify relationships between them
Synthesis – The putting together of parts into the whole. Integrating new
knowledge with previous knowledge