Clinical Reasoning / Clinical Care / Nurses / Health Professionals

Combining expertise, evidence, and information to make care decisions

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Clinical reasoning and critical thinking help nurses in assessing, assimilating, evaluating, and/or discarding components of information in order to make a decision(s).

When making clinical decisions and planning care, nurses draw from many sources including their formal nursing education and/or from their experience gained over time in and outside of nursing practice. Critical thinking extends this identification and resolution of care problems to critique the potential solutions or options raised, and potentially the merit of current practice.

Clinical decision-making includes an assessment of a patient's status and their needs and the best way to meet these needs. Clinical decision-making can be analytical whereby the person making a decision uses a set of rules or guiding principles to progress information along a rational logical pathway until a decision can be made. Decision trees, often used in nursing practice, are a good example of this decision-making process.

Intuitive decision-making is a skill that may appear to be less structured. It is based on experience and includes recognition of similarities between comparable situations and their outcomes. This skill is developed over time with experience.

The context of the decision-making situation, knowing the person, interpretation and reflection also form an important part of a nurse’s decision-making process.

Example frameworks to guide reasoning and decision-making

There are a number of frameworks available to guide clinical reasoning and decision-making in different contexts. Here we highlight two examples.

A clinical reasoning cycle

One clinical reasoning cycle that has been developed for nurses represents the ongoing and cyclical nature of clinical encounters and the importance of evaluation and reflection. It includes 8 steps or phases which often overlap:

Consider e.g. what is the patient situation – handover and clinical notes can help with this
Collect cues/information e.g. what the person or family can tell you, use appropriate tool(s) to assess needs, gather additional information
Process the information in the current context including what is most important for the person, what information might be missing
Identify the problem or issue and what it is related to e.g. constipation due to opioid use
Establish goals – what is important in the short-term then, if appropriate, mid- to long-term
Take action – decide on the most important course of action
Evaluate outcomes – look at what has changed following the actions taken
Reflect on what you have learnt

Clinical reasoning

Learning to think like a nurse

The 'Why' Framework

The ‘Why’ Framework was proposed to guide clinical reasoning in the palliative care context. In palliative care, as a person is deteriorating, the question ‘Why?’ arises when the person’s clinical course does not reflect the known or expected course of the illness. The first question becomes:

“Is the deterioration due to the progression in the life-limiting illness OR is the deterioration due to the effects of an acute problem with an easily reversible cause?”

To help answer this and work out whether something can be done, The ‘Why’ Framework next uses three screening questions to monitor and respond to change in the context of the whole person.

These three questions are:

“Why has a change in condition occurred?”
“What is the timeframe for the change?”
“What else has changed in or around the same time period?”

The answers to these in turn prompt the question “Can we do something about the problem?” and before acting on this, consider whether it would be appropriate to do so in the current situation.

This information was drawn from the following resources:

Australian College of Nursing (ACN). Critical thinking [Internet]. 2021 Nov 4 [cited 2022 Aug 11]
Banning M. A review of clinical decision making: models and current research. J Clin Nurs. 2008 Jan;17(2):187-95. doi: 10.1111/j.1365-2702.2006.01791.x. Epub 2007 Mar 1.
Currow D, Clark K. Emergencies in palliative and supportive care. Oxford: Oxford Academic; 2013. Section 1, Frequently encountered symptoms [Internet]. [cited 2022 Aug 11].
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Levett-Jones T, Hoffman K, Dempsey J, Jeong SY, Noble D, Norton CA, et al. The 'five rights' of clinical reasoning: an educational model to enhance nursing students' ability to identify and manage clinically 'at risk' patients. Nurse Educ Today. 2010 Aug;30(6):515-20. doi: 10.1016/j.nedt.2009.10.020. Epub 2009 Nov 30.
Manetti W. Sound clinical judgment in nursing: A concept analysis. Nurs Forum. 2019 Jan;54(1):102-110. doi: 10.1111/nuf.12303. Epub 2018 Oct 31.
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Thompson C, Stapley S. Do educational interventions improve nurses' clinical decision making and judgement? A systematic review. Int J Nurs Stud. 2011 Jul;48(7):881-93. doi: 10.1016/j.ijnurstu.2010.12.005. Epub 2011 Jan 15.
van der Riet P, Pitt V. Caring for a person requiring palliative care (670kb pdf). In: Levett-Jones T, editor. Clinical reasoning: Learning to think like a nurse. 2nd ed. Melbourne: Pearson Education Australia; 2017.