Clinical reasoning and clinical judgment in nursing research: A bibliometric analysis

AIMS

To characterize the thematic foci, structure, and evolution of nursing research on clinical reasoning and judgment.

DESIGN

Bibliometric analysis.

METHODS

We used a bibliometric method to analyze 1528 articles.

DATA SOURCE

We searched the Scopus bibliographic database on January 7, 2024.

RESULTS

Through a keyword co-occurrence analysis, we found the most frequent keywords to be clinical judgment, clinical reasoning, nursing education, simulation, nursing, clinical decision-making, nursing students, nursing assessment, critical thinking, nursing diagnosis, patient safety, nurses, nursing process, clinical competence, and risk assessment. The focal themes, structure, and evolution of nursing research on clinical reasoning and judgment were revealed by keyword mapping, clustering, and time-tracking.

CONCLUSION

By assessing key nursing research areas, we extend the current discourse on clinical reasoning and clinical judgment for researchers, educators, and practitioners. Critical challenges must still be met by nursing professionals with regard to their use of clinical reasoning and judgment within their clinical practice. Further knowledge and comprehension of the clinical reasoning process and the development of clinical judgment must be successfully translated from research to nursing education and practice.

IMPLICATIONS FOR THE PROFESSION

This study highlights the nursing knowledge gaps with regard to nurses' use of clinical reasoning and judgment and encourages nursing educators and professionals to focus on developing nurses' clinical reasoning and judgment with regard to their patients' safety.

IMPACT

In addressing nurses' use of clinical reasoning and judgment, and with regard to patient safety in particular, this study found that, in certain clinical settings, the use of clinical reasoning and judgment remains a challenge for nursing professionals. This study should thus have an effect on nursing academics' research choices, on nursing educators' teaching practices, and on nurses' clinical practices.

REPORTING METHOD

Relevant EQUATOR guidelines have been adhered to by employing recognized bibliometric reporting methods.

Exploring clinical judgment ability in second-degree baccalaureate of science nursing students: A mixed methods study

BACKGROUND

As they have not yet embarked on clinical practice, most students who already have a bachelor's degree but require a bachelor's degree in nursing occasionally perceive the educator's instruction on clinical situations as abstract and challenging for making accurate clinical judgments.

OBJECTIVES

This study aims to implement a clinical judgment model and case scenarios in classroom teaching to evaluate improvements in students' clinical judgment and critical thinking abilities.

DESIGN

A mixed-method design.

SETTING

A second-degree Bachelor of Science in Nursing at a university in Taiwan.

PARTICIPANTS

First-year undergraduate nursing students.

METHODS

This mixed-methods study featured a survey at the beginning and end of a course, followed by one-on-one online interviews. A purposive sample of sophomore nursing students was recruited from a university in northern Taiwan between March 2020 and May 2021. Semi-structured interviews were conducted after a preliminary analysis of the collected quantitative data.

RESULTS

In total, 48 participants completed the study questionnaire, and 20 were interviewed. The results show that the students' ability to make clinical judgment and identify individual health problems from case scenarios significantly improved after completing the course. However, critical thinking did not differ significantly after the course. Qualitative data analysis revealed three key themes relevant to the participants' learning experiences: (1) establishing the context of clinical judgment, (2) building a bridge between basic medical science and clinical nursing, and (3) having a broader perspective.

CONCLUSIONS

Incorporating clinical judgment measurement model and case scenarios in the curriculum may benefit second-degree Bachelor of Science in Nursing students who have not yet begun their clinical practice. Additionally, the result provides educators with valuable learning goals and evaluation strategies in the classroom and clinical practice.

An integrative review of teaching strategies to support clinical judgment development in clinical education for nurses

OBJECTIVES

Historically, emphasis on task-completion and lack of intentional approaches that develop students' thinking skills have dominated clinical education. One contributing factor may be the limited literature about teaching to develop clinical reasoning and clinical judgment in the clinical environment. This integrative review accessed available literature to answer the question, What strategies are used to develop clinical judgment in the clinical education environment?

DESIGN

The Whittemore and Knafl approach framed the integrative review. The framework includes the following steps 1) problem identification, 2) literature search, 3) data evaluation, 4) data analysis, and 5) presentation.

DATASOURCES

The data bases CINAHL Plus with Full Text, OVID, and ProQuest were searched through the period of January 2000 through July of 2022.

REVIEW METHODS

The PRISMA protocol informed review and screening of the literature. Authors assessed articles for eligibility via first screening by abstract review, followed by review of the full text. Both authors reviewed the articles, assessing qualification for inclusion and evaluating the content. Data from eligible articles were analyzed and synthesized to answer the research question.

RESULTS

Of the initial 427 articles, a total of 20 articles met inclusion criteria for final analysis. Five general themes emerged for clinical judgment during clinical education. The findings identified the teaching strategies nurse educators use. Many of the teaching methods include deliberateness and intentionality in planning and implementing the strategies. In addition to evaluating clinical judgment, nurse educators guided and mentored student thinking. Finally, this review identified reported outcomes and results of the teaching strategies and methods.

CONCLUSIONS

A limited number of articles describing teaching for clinical judgment in clinical environment were found. The articles analyzed found that nurse educators used a variety of teaching strategies for the purpose of developing students' clinical judgment. More research is needed to guide best-practices in clinical education. We must move the science forward to transform and leverage clinical education more deliberately to teach thinking in practice and decision-making about patient care.

Integrating Patient Involvement Interventions within Clinical Practice: A Mixed-Methods Study of Health Care Professional Reasoning

Background. Patient involvement interventions are complex interventions that improve patient involvement in treatment and care in health care systems. Studies report several benefits of patient involvement interventions and that health care professionals are positive about using them. However, they have not been explored as a collected group of interventions throughout the continuum of care and treatment. In addition, the relationship between patient involvement interventions and the clinical reasoning process of health care professionals has not been thoroughly studied. Design. This mixed-methods study was conducted at Aarhus University Hospital in Denmark between April and November 2022 using interview data from 12 health care professionals and survey data from 420 health care professionals. Informants were medical doctors, nurses, midwives, dietitians, physiotherapists, and occupational therapists who had direct contact with patients during their daily care and treatment. Quantitative data were analyzed using descriptive statistics; qualitative data were analyzed via inductive and deductive content analysis. Results. Communication and interaction were seen as overarching aspects of patient involvement, with patient involvement interventions being defined as concrete tools and methods to enhance health care professionals' explicit clinical reasoning process. Limitations. It is unclear if results are representative of all health care professionals at the hospital or only those with a positive view of patient involvement interventions. Conclusions. Patient involvement interventions are viewed as beneficial for patients and fit with the clinical reasoning of health care professionals. Clinical reasoning may be an active ingredient in the development and implementation of patient involvement interventions. Implications. In practice, health care professionals need training in person-centered communication and the ability to articulate their clinical reasoning explicitly. In research, a more in-depth understanding of the interrelations between patient involvement interventions and clinical reasoning is needed.

Highlights

Communication and interaction are the fundamental goals of patient involvement in practice, regardless of which patient involvement intervention is being used.Clinical reasoning is often an unconscious process using tacit knowledge, but the use of patient involvement interventions may be a way for health care professionals (at both individual and group levels) to become more explicit about and aware of their reflections.Clinical reasoning can be viewed as a mechanism of change in the development and implementation of patient involvement interventions.

Psychometric properties of the persian version of the nursing clinical reasoning scale

AIM

The aim of this study was to translate the Nursing Clinical Reasoning Scale (NCRS) into Persian and evaluate its psychometric properties.

DESIGN

This study was a methodological and cross-sectional study.

METHODS

This methodological study was conducted in 2020 in a teaching hospital. After obtaining necessary permission from its developers, NCRS was translated into Persian through the method proposed by the World Health Organization. Then, its face, content, and construct validity and reliability were assessed. For construct validity assessment through exploratory and confirmatory factor analyses, 300 nurses (two 150-nurse samples), who had randomly been selected, completed the instrument. Reliability also assessed through the internal consistency and the stability methods. Data were analysed using the SPSS (v. 20.0) and the AMOS (v. 5.0) software.

RESULTS

The content validity indices of NCRS and its items were 0.97 and more than 0.79, respectively. Exploratory factor analysis revealed an assessment and confirmation factor and an implementation and reflection factor for the scale which together explained 57.30% of the total variance. Confirmatory factor analysis also confirmed this two-factor structure (χ2 /df = 2.11, NNFI = 0.952, RMSEA = 0.053, CFI = 0.91, GFI = 0.94, IFI = 0.95, and NFI = 0.96). The Cronbach's alpha and the intraclass correlation coefficient values of the scale were 0.96 and 0.94, respectively.

PUBLIC CONTRIBUTION

The Persian NCRS can help nursing policy makers and mentors identify the need for developing nurses' and nursing students' CR skills and implement need-based educational courses to improve these skills. Moreover, it helps determine whether the educational programmes are effective in improving nurses' CR skills and clinical competence.

Clinical reasoning: What do nurses, physicians, and students reason about

Clinical reasoning is a core ability in the health professions, but the term is conceptualised in multiple ways within and across professions. For interprofessional teamwork it is indispensable to recognise the differences in understanding between professions. Therefore, our aim was to investigate how nurses, physicians, and medical and nursing students define clinical reasoning. We conducted 43 semi-structured interviews with an interprofessional group from six countries and qualitatively analysed their definitions of clinical reasoning based on a coding guide. Our results showed similarities across professions, such as the emphasis on clinical skills as part of clinical reasoning. But we also revealed differences, such as a more patient-centered view and a broader understanding of the clinical reasoning concept in nurses and nursing students. The explicit sharing and discussion of differences in the understanding of clinical reasoning across health professions can provide valuable insights into the perspectives of different team members on clinical practice and education. This understanding may lead to improved interprofessional collaboration, and our study's categories and themes can serve as a basis for such discussions.

Development of the clinical reasoning competency scale for nurses

BACKGROUND

Clinical reasoning is emphasized as an important component of nursing education, since nurses' lack of clinical reasoning leads to incorrect clinical decision-making. Therefore, a tool for measuring clinical reasoning competency needs to be developed.

METHODS

This methodological study was conducted to develop the Clinical Reasoning Competency Scale (CRCS) and examine its psychometric properties. The attributes and preliminary items of the CRCS were developed based on a systematic literature review and in-depth interviews. The validity and reliability of the scale were evaluated among nurses.

RESULTS

The exploratory factor analysis was conducted for the construct validation. The total explained variance of the CRCS was 52.62%. The CRCS consists of 8 items for plan setting, 11 items for intervention strategy regulation, and 3 items for self-instruction. The Cronbach's α of the CRCS was 0.92. Criterion validity was verified with the Nurse Clinical Reasoning Competence (NCRC). The correlation between the total NCRC and CRCS scores was 0.78, all of which were significant correlations.

CONCLUSION

The CRCS is expected to provide raw scientific and empirical data for various intervention programs to develop and improve nurses' clinical reasoning competency.

Reasoning like a doctor or like a nurse? A systematic integrative review

When physicians and nurses are looking at the same patient, they may not see the same picture. If assuming that the clinical reasoning of both professions is alike and ignoring possible differences, aspects essential for care can be overlooked. Understanding the multifaceted concept of clinical reasoning of both professions may provide insight into the nature and purpose of their practices and benefit patient care, education and research. We aimed to identify, compare and contrast the documented features of clinical reasoning of physicians and nurses through the lens of layered analysis and to conduct a simultaneous concept analysis. The protocol of this systematic integrative review was published doi: 10.1136/bmjopen-2021-049862. A comprehensive search was performed in four databases (PubMed, CINAHL, Psychinfo, and Web of Science) from 30th March 2020 to 27th May 2020. A total of 69 Empirical and theoretical journal articles about clinical reasoning of practitioners were included: 27 nursing, 37 medical, and five combining both perspectives. Two reviewers screened the identified papers for eligibility and assessed the quality of the methodologically diverse articles. We used an onion model, based on three layers: Philosophy, Principles, and Techniques to extract and organize the data. Commonalities and differences were identified on professional paradigms, theories, intentions, content, antecedents, attributes, outcomes, and contextual factors. The detected philosophical differences were located on a care-cure and subjective-objective continuum. We observed four principle contrasts: a broad or narrow focus, consideration of the patient as such or of the patient and his relatives, hypotheses to explain or to understand, and argumentation based on causality or association. In the technical layer a difference in the professional concepts of diagnosis and the degree of patient involvement in the reasoning process were perceived. Clinical reasoning can be analysed by breaking it down into layers, and the onion model resulted in detailed features. Subsequently insight was obtained in the differences between nursing and medical reasoning. The origin of these differences is in the philosophical layer (professional paradigms, intentions). This review can be used as a first step toward gaining a better understanding and collaboration in patient care, education and research across the nursing and medical professions.

Reasoning like a doctor or like a nurse? An integrative review protocol

INTRODUCTION

Clinical reasoning, a major competency for all health professionals, has been defined and studied 'within' each profession. We do not know if content, process and outcomes are comparable 'between' physician and nursing clinical reasoning. This paper aims to set up a protocol for an integrative review to analyse and synthesise the scientific nursing and medical clinical reasoning literature. It builds on the history of nursing and medical clinical reasoning research and aims to create a higher level of conceptual clarity of clinical reasoning, to increase mutual understanding in collaboration in patient care, education and research.

METHODS AND ANALYSIS

This integrative review follows stepwise the methods described by Whittmore and Knafl: problem identification, literature search, data evaluation, data analysis and presentation.The initial systematic and comprehensive search strategy is developed in collaboration with the clinical librarian and is performed in electronic databases, PubMed, CINAHL, PsycInfo and Web of Science from 30 March 2020 to 27 May 2020. Empirical and theoretical studies are included. This search will be accompanied by ancestry searching and purposeful sampling. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart will summarise the selection process. The quality of eligible studies will be evaluated with a checklist, suitable for diverse study methods.The data analysis is inspired by concept analysis of Walker and Avant and layered analysis of an intervention of Cianciolo and Regehr. We will extract the data of the included studies conforming these layers and features, to capture the multifaceted nature of clinical reasoning in both professions. The data will be presented in a validity matrix to facilitate comparing and contrasting.

ETHICS AND DISSEMINATION

Ethics approval is not required. The outcomes will be disseminated through conference presentations and publications.

Illness scripts in nursing: Directed content analysis

Aims

To explore the possible extension of the illness script theory used in medicine to the nursing context.

Design

A qualitative interview study.

Methods

The study was conducted between September 2019 and March 2020. Expert nurses were asked to think aloud about 20 patient problems in nursing. A directed content analysis approach including quantitative data processing was used to analyse the transcribed data.

Results

Through the analysis of 3912 statements, scripts were identified and a nursing script model is proposed; the medical illness script, including enabling conditions, fault and consequences, is extended with management, boundary, impact, occurrence and explicative statements. Nurses often used explicative statements when pathophysiological causes are absent or unknown. To explore the applicability of Illness script theory we analysed scripts’ richness and maturity with descriptive statistics. Expert nurses, like medical experts, had rich knowledge of consequences, explicative statements and management of familiar patient problems.

Conclusion

The knowledge of expert nurses about patient problems can be described in scripts; the components of medical illness scripts are also relevant in nursing. We propose to extend the original illness script concept with management, explicative statements, boundary, impact and occurrence, to enlarge the applicability of illness scripts in the nursing domain.

Impact

Illness scripts guide clinical reasoning in patient care. Insights into illness scripts of nursing experts is a necessary first step to develop goals or guidelines for student nurses’ development of clinical reasoning. It might lay the groundwork for future educational strategies.

Higher psychological distress in patients seeking care for a knee disorder is associated with diagnostic discordance between health care providers: a secondary analysis of a diagnostic concordance study

Background

Knee disorders are highly prevalent and may be a disabling condition. An accurate diagnosis is necessary to guide toward a rapid and efficient management of knee disorders. However, the ability to make a valid diagnosis is often complex for clinicians and evidence is mainly focused on clinician cognitive biases or errors produced during clinical reasoning. The aim of this secondary exploratory analysis is to identify patient-specific characteristics associated with diagnostic discordance between health care providers in making a diagnosis for a new knee disorder.

Methods

We performed a secondary analysis of a diagnostic study comparing the diagnostic ability of a physiotherapist to medical musculoskeletal specialists. Patients’ socio-demographic, psychosocial and clinical characteristics were compared between the concordant and discordant diagnostic groups. Psychosocial symptoms were evaluated using the validated Kessler 6 (K6) questionnaire. We performed multivariable logistic regressions using the Bayesian Information Criterion to identify the most probable model including patients’ characteristics associated with diagnostic discordance. Overall probability of identified variables to explain diagnostic discordance and associated odd ratios (OR) with 95% credibility intervals (95% CrI) were calculated.

Results

Overall, 279 participants were evaluated by a physiotherapist and medical musculoskeletal specialists. The mean age of the participants was 49.1 ± 15.8 years and 57.7% were female. The most common disorder was osteoarthritis (n = 117, 18.8% of cases were discordant). The most probable model explaining diagnostic discordance (11.13%) included having depressive symptoms, which was associated with an increased probability of diagnostic discordance (OR: 3.9; 95% CrI: 1.9 – 8.0) and having a higher number of comorbidities, which was associated with a decreased probability of diagnostic discordance (OR: 0.6; 95% CrI: 0.5 – 0.9). The depression item of the K6 questionnaire had a 99.4% chance to be included in a model explaining diagnostic discordance. Other variables taken separately had less than 50% chance to be included in a model explaining diagnostic discordance and cannot be considered significant.

Conclusion

Our results suggest that depressive symptoms may increase the risk of knee diagnostic discordance. Clinicians may be more likely to make diagnostic errors and should be more cautious when evaluating patients with knee disorders suffering from psychological distress.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04534-9.

Content validation of the symptom control outcome for heart failure patients in palliative care

OBJECTIVES

To estimate the content validity of the Symptom Control nursing outcome for heart failure patients in palliative care and to analyze the influence of experts' experience in the judgment of the relevance of indicators.

METHODS

A methodological study conducted in São Paulo in 2018, with an adaptation of Fehring's validation model. The relevance of the 11 outcome indicators was assessed by 19 experts by means of an electronically submitted survey. The influence of the experts' experience on judgment was analyzed by the Wilcoxon-Mann-Whitney test and by Kendall's Tau correlation.

RESULTS

The indicators were considered pertinent; with 54.5% classified as critical. There was no association between the weighted means of the indicators and the experts' experience.

CONCLUSIONS

The indicators analyzed are relevant for the evaluation of the Symptom Control outcome in this group of patients. The experts' judgment was not influenced by their area of clinical experience or by their experience with the Nursing Outcomes Classification (NOC).

The need for longitudinal clinical reasoning teaching and assessment: Results of an international survey

Background: Clinical reasoning is a key ability essential for practising health professionals. However, little is known about the current global adoption of clinical reasoning teaching and assessment.Purpose: We aimed to provide insights into how clinical reasoning is deliberately taught and assessed in curricula worldwide and to identify needs and perceived barriers for teaching clinical reasoning to students and educators.Methods: A questionnaire was devised by an international expert group and distributed in a large international medical education community. Data were collected in 2018 and analysed using descriptive statistics. We identified themes in free-text responses using content analysis.Results: Three hundred and thirteen responses from 76 countries were collected. Most respondents were from Europe (34%). While the presence of a longitudinal clinical reasoning curriculum was only reported by 28%, 85% stated that such a curriculum was needed. The lack of awareness of the need to explicitly teach clinical reasoning was the most commonly identified barrier. For assessment, the greatest need identified was for more workplace-based assessment.Conclusions: Global respondents indicate the need to implement explicit longitudinal clinical reasoning curricula. Our findings suggest that efforts should be put into improving faculty development, including evidence-based materials on how to teach and assess clinical reasoning.