A framework for understanding clinical reasoning in community nursing


  • Susan M Carr MSc, PhD, RGN, RNT

    1. Research Fellow, Nursing, Midwifery & Allied Health Professions Research & Development Unit, Northumbria University, Benton, Newcastle upon Tyne, UK
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Susan M Carr
Research Fellow
Midwifery & Allied Health Professions
Research & Development Unit
Northumbria University
Coach Lane (East)
Newcastle upon Tyne
Telephone: +44 191 2156217/2156083
E-mail: sue.carr@northumbria.ac.uk


Background.  Clinical reasoning is employed to develop solutions to health needs. The impact of the clinical environment on the organization of knowledge-guiding practice has received limited attention. This gap in the clinical landscape restricts the sharing of decision-making processes.

Aims.  Focusing on the community, and specifically the patient's home as a context for nursing, this paper describes the creation of a collective conceptual map for a group of community nurses. There is a twofold aim of exploring the process of exposing and articulating the clinical framework and enhancing and sharing understanding of the clinical paradigm in this context.

Design.  An interpretive research approach was utilized. Hermeneutic phenomenology guided the level of meaning accessed and constructivism was used to build an educational picture.

Methods.  Multiple methods including focus groups, observation and narrative recordings were utilized to collect and analyse research data.

Results.  All nurses may engage with the same concepts – health, need, care and partnerships – but organized into particular frames by the guiding practice philosophy and service organization. A four-stage framework for understanding clinical reasoning in the community setting is presented. This acknowledges the multi-faceted nature of health, the lived experience of health deficits, and is located in a participation and negotiated model of care. Practice examples are presented to expose the construction of need and response which often occurs in a triadic decision-making process.

Conclusions.  Environment of care has significant implications on need identification and response.

Relevance to clinical practice.  Mechanisms to enhance the sharing of clinical reasoning and decision-making transparency are essential to aid inter- and intra-professional communication. Presentation of a clinical reasoning framework exposes the breath of ‘signals’ encountered in practice and the range of knowledge employed in understanding and responding to patient need.