Your views and letters

Authors

  • Jacqueline Fawcett PhD RN FAAN,

  • Betsy McDowell PhD RN CNE,

  • Diana M. L. Newman EdD RN


In response to: Simmons (2010) Clinical reasoning: concept analysis. Journal of Advanced Nursing66 (5), 1151–1158.

A context and structure for clinical reasoning

Simmons’ (2010) concept analysis revealed that clinical reasoning can be defined as ‘a complex process that uses formal and informal thinking strategies to gather and analyse patient information, evaluate the significance of this information, and weigh alternative actions’ (p. 1155). Benner et al. (2010) defined clinical reasoning as ‘the ability to reason as a clinical situation changes, taking into account the context and concerns of the patient and family’ (p. 85). They went on to explain, ‘When nurses use clinical reasoning, they capture patients’ trends and trajectories’ (p. 85). Capturing patients’ trends and trajectories can be thought of as clinical reasoning-in-transition, which is a way of thinking that the nurse uses to keep ‘track of the particular patient, how the illness or illnesses are unfolding, and the meaning of the patient’s responses. It requires keeping track of a narrative of what has been tried and what has or has not worked with the patient. [It] requires from the [nurse] a thoughtful stance of attentiveness, respect, curiosity, inquiry and willingness to be ‘pulled up short’ in [his or] her thinking, all framed by the [nurse’s] concern for the good of the patient’ (Benner et al. 2010, p. 55). Clinical reasoning also requires other inputs from the client and additional members of the healthcare team.

Neither Simmons nor Benner et al. identified an intellectual context or a structure for clinical reasoning, which limits the value of the concept to the advancement of distinctive nursing knowledge and practice. We offer the Neuman Systems Model (NSM; Neuman & Fawcett 2011) as one intellectual context and structure for clinical reasoning.

With regard to an intellectual context, the NSM provides a holistic systems approach for clinical reasoning that helps the nurse see the whole pathway of clinical reasoning from the parts, which are made up of the interactions among the antecedents, attributes, and consequences of the concept of clinical reasoning. Understanding the entire pathway enables the nurse to make subsequent care decisions in a coordinated manner rather than in a piecemeal way.

The NSM provides a structure for clinical reasoning by directing the nurse’s attention to the concerns of the individual, family or community client system by focusing on who the client system is, in what environments the client system dwells, and the health status of the client system. In particular, the NSM directs the nurse to assess the client’s and his/her own perceptions of internal and external physiological, psychological, sociocultural, developmental and spiritual stressors that are impinging on the client and the client’s strengths and defenses against noxious stressors. Following assessment, clinical reasoning is used to determine the primary, secondary or tertiary prevention interventions that are needed to retain, attain or maintain client wellness.

Other nursing conceptual models provide different contexts and structures for clinical reasoning. We submit that regardless of the conceptual model selected, both an identified context and a specific structure for clinical reasoning are required if clinical reasoning is to be translated from a theoretical analysis to the reality of nursing practice.

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