Clinical reasoning is fundamental to clinical decision making in that it is the antecedent to a decision and action (Simmons, 2010 ). Several common or core features of clinical reasoning across health disciplines have been identified in the research (Higgs & Jones, 2008 ). One core element is clin- ical knowledge that is interdependent and fundamental to clinical rea- soning. As clinical knowledge expands, the complexity of knowledge structures increases (Higgs & Jones, 2008 ) resulting in refinement of clin- ical reasoning skills.
A second core feature of clinical reasoning is an array of higher- order cognitive skills and processes. Various theorists identify these higher order cognitive skills differently, but some that are emphasized include clinical appraisal (Brookfield, 2008 ), categorization (Loftus & Higgs, 2008 ), and prop- ositional knowledge (Titchen & Higgs, 2000 ). "Clinical appraisal" consists of critically evaluating the totality of presenting information for the most rel- evant clinical features and accurately defining what those features repre- sent. An example of critical appraisal is assessing a patient to determine the pertinent positives or negatives. "Categorization" is a way of both learning complex content and using relevant features and pattern recognition to re- late novel instances to known categories. For instance, categorization would be used to judge the level of severity or acuity of patient presentation. Risk stratification is an important application of categorization, selecting man- agement approaches based on the level of severity or risk and statistically predicted patient care outcomes. "Propositional knowledge" incorporates hypothesis generation and the development of plausible and probabilistic relationships between events. For example, the APRN uses propositional knowledge to hypothesize the most probable diagnosis, given a certain pa- tient presentation. When clinicians make prospective predictions about the likely course of a condition based on clinical signs and symptoms, they are engaging in a combination of categorization and probabilistic reasoning.
The third feature associated with clinical reasoning is that it is highly context dependent. The context within which clinical reasoning occurs is
determined by the patient’s health concern(s), the specific health setting, the care provider’s disciplinary background and level of experience, the patient’s unique personal context, the stage of case management (e.g., in- itial diagnosis vs. long- term stabilization vs. exacerbation management), and elements of the wider healthcare environment (Higgs & Jones, 2008 ).
Research attending to context- specific factors demonstrates that expert clin- ical reasoning is complex, interpretive, and personalized. Other clinicians have likened this to good clinical jazz (Hamm Flynn & Becker, 2004). Good jazz needs structure and improvisation. Structure in healthcare is the clin- ical evidence, and improvisation is the patient’s personal situation. A good clinician blends these two components uniquely for each patient as a part of clinical reasoning and decision making.
Finally, information storage and retrieval or script theory (Lubarsky, Dory, Audétat, Custers, & Charlin, 2015 ) can be applied to clinical reasoning.
Script theory offers a means to explain how information is saved and recovered to be used in the interpretation of events. Healthcare providers use “illness scripts” to identify symptom patterns, recognize similarities and differences in disease states, and make predictions (Lubarsky et al., 2015). As with all elements of clinical reasoning, knowledge organization or networks are expanded through experience and education.
Clinical Decision Making
Multiple approaches have been used to study clinical decision making.
Repeated themes in the literature include information processing model, intuitive- humanistic model, and cognitive continuum model (Tanner, 2006 ).
Information processing model uses hypothetico- deductive approach (Banning, 2008 ), which uses rational logic. This process includes cue rec- ognition and interpretation, hypothesis generation, and evaluation (Chen, Hsu, Chang, & Lin, 2016 ; Thompson, Moorley, & Barratt, 2017 ). This model requires using propositional representation (i.e., if A then X; Abuzour, Lewis, & Tully, 2018). The process begins with identifying facts (history), generating a hypothesis based on observations combined with know- ledge and experience, then assessment (physical examination) resulting in the final hypothesis. Information processing provides a better theoretical match for the dynamic environments and ambiguity of decisions in clinical practice, because it logically moves from identification of cues, step- by- step analysis, evaluation, and reevaluation until the problem is solved (Chen et al., 2016 ; Thompson et al., 2017 ).
The intuitive- humanistic model uses intuition and experience. Intuition refers to the capacity of the expert clinician to process quickly large amounts of complex data, simultaneously discern patterns, and act on hypotheses without consciously naming all the factors involved in his or her decision making. An intuitive decision is made on the basis of sudden awareness of knowledge, which is based on cues and pattern recognition (Banning, 2008 ; Hedberg & Larsson, 2003 ). It is the highly expert application of rational
processes and cue analysis, occurring at a pace too rapid for each step to be discretely named or recognized.
How different professionals use intuition varies. For example, nurse- midwives use intuition as a way of knowing, while physicians use intu- ition when analytical thinking is inadequate (Rosciano, Lindell, Bryer, &
DiMarco, 2016; Woolley & Kostopoulou, 2013 ).
Cognitive continuum model suggests a range of analytical thinking approaches with varying combinations of intuitive and analytical thinking (Rycroft- Malone, Fontenla, Seers, & Bick, 2009 ). In this theory, the task struc- ture (weighing and combining information to make judgments) and cog- nitive processes determine the degree of intuition and/or analysis used by the decision maker (Cader, Campbell, & Watson, 2005 ). Particularly salient here are these three features of task properties: (a) the complexity of task structure (number and redundancy of cues, form of an accurate organizing principle), (b) the ambiguity of task content (availability of organizing principles, familiarity with the task, and possibility of high accuracy), and (c) the form of task presentation (task decomposition, cue definition, and response time). The task structure (well structured vs. ill structured) governs the mode cognition. If a person weighs certain cues incorrectly (ill- structured task structure) then the judgment is flawed (Cader et al., 2005 ).
For example, a patient presents with normal vital signs, no acute distress but is having indigestion. Here if the clinician weighs the vital signs and presentation greater than the history or risk factors then the clinician could miss the acute myocardial infarction (MI ) because of the atypical presen- tation. In this model, greater analytical thinking is assumed to be related to fewer cues, less redundancy of cues, and more complex procedures for combining evidence to result in correct answers. The availability of orga- nizing principles, greater task familiarity, and the possibility for high accu- racy also contribute to greater use of formal reasoning.
Analytical decision making as related to clinical decision making relies on a more structured process of identifying options and possible outcomes, assigning values to the outcomes, and determining probability relationships between the options and anticipated outcomes. Formal (mathematically based) or informal (conceptually based) models are used to systematize decision making using decision trees, grids, or decision flow diagrams (Narayan, Corcoran- Perry, Drew, Hoyman, & Lewis, 2003 ). Decision anal- ysis is useful for evaluation of medical treatment options, cost analysis, sensitivity analysis, quality improvement decisions, and policy decisions (Narayan et al., 2003 ).
Moving from data collection to diagnosis is difficult for novice APRNs.
As with all nurses, APRNs move from using domain- general knowledge to domain- specific knowledge in clinical decision making (Pretz & Folse, 2011 ). Novices will rely more on analytic process with common situations and rely more on intuition with novel problems (Price, Zulkosky, White,
& Pretz, 2016). For the inexperienced APRN, every judgment or decision has some degree of uncertainty, which is the probability that specific signs and symptoms are associated with particular conditions (Thompson,
Aitken, Brown, & Dowding, 2013). Ways to foster and support clinical de- cision making in the novice APRNs can be found in using clinical practice guidelines to reduce the uncertainty and mentoring.
Experience in the role of an RN is an important variable in examining factors that influence level of decision making. In a study of 70 entry- level nurse practitioners, Sands ( 2001 ) found that entry- level nurse practitioners with at least 5 years of RN experience demonstrated stronger scores on the test of diagnostic reasoning. Participants with less than 2 years of RN expe- rience were at increased risk for inadequate reasoning through the clinical problem.
APRN Practice Focus
One factor that can be used to distinguish clinical decision making in ad- vanced practice nursing from other autonomous healthcare providers is the focus of APRN practice. Smith ( 1995 ) identified the core of advanced prac- tice nursing as lying within nursing’s disciplinary perspectives on health, healing, person– environment interactions, and nurse– patient relationships.
Huch ( 1995 ) echoes this in identifying the need to use nursing theory as the basis for advanced nursing practice.
APRNs focus their clinical decision making on health promotion, health protection, disease prevention, and management of health concerns (National Association of Clinical Nurse Specialists [ NACNS ], 2017;
National Organization of Nurse Practitioner Faculties [NONPF], 2017). As outlined by nurse practitioner and clinical nurse specialist organizations, health promotion activities include lifestyle concerns, principles of lifestyle change, and behavioral change. Health protection includes knowledge of health risks, use of epidemiologic principles, and community/population- level measures to protect health. Disease prevention includes primary and secondary prevention measures addressing major chronic illness, disa- bility, and communicable disease. Management of health concerns focuses on assessing, diagnosing, monitoring, and coordinating the care of indi- viduals and populations (NACNS, 2017; NONPF, 2017). Depending on the APRN’s role and specialty preparation, the practice focuses include both disease- and non- disease– based etiologies that affect health, wellness, and quality of life. For nurse practitioners, the focus is generally on providing direct patient care. For clinical nurse specialists, the focus tends to be on influencing the outcomes of care more widely within an area of popula- tion focus, at individual patient, population, and health system levels. With the advent of the doctorate of nursing practice (DNP), practice doctorate APRNs are educated to practice with increased emphasis on the health- care system and population healthcare outcomes (American Association of Colleges of Nursing [AACN], 2004; NONPF, 2017).
APRN Practice Frameworks
Advanced practice nursing is holistic, patient- centered, theory- driven, population- and evidence- based practice that incorporates professional
autonomy, application of knowledge, critical analysis, and synthesis of data in decision making. Some of these characteristics are built into nationally recommended educational guidelines for advanced practice educational programs (AACN, 2006; NACNS, 2017; NONPF, 2017). For example, the core competencies for nurse practitioner and clinical nurse specialist clinical deci- sion making incorporate the following expectations for practice: critical anal- ysis of data (NONPF, 2017) and synthesis of data, knowledge, and expertise (NACNS, 2017). Like NONPF and NACNS, the American College of Nurse- Midwives (ACNM) core competencies include evaluation and application of clinical knowledge in management of patients (ACNM, 2014). AACN’s (2006) The Essentials of Doctoral Education for Advanced Practice Nursing outlines advanced clinical decision making as part of the core of APRN work: “Demonstrate sound critical thinking and clinical decision making” (p. 23).
An important feature of clinical decision making in advanced practice nursing is that the nursing focus continues to be evident in daily prac- tice. This can be done, for example, by making an effort to understand the meanings that patients attribute to their health situation; by learning about the patients’ lived social world, support systems, and role responsi- bilities; and by working with patients to identify personal and social health obstacles or facilitators. Several additional approaches for incorporating basic nursing perspectives into APRN care are listed in Exhibit 8.1 .
In addition to the specialty knowledge required for health and illness management, these patient- centered, holistic dimensions of clinical deci- sion making are necessary to maintain the quality of APRN care and the ability to distinguish advanced practice nursing from other forms of auton- omous health practice.
Exhibit 8.1 APPROACHES FOR INCORPORATING CORE NURSING PERSPECTIVES INTO APRN CARE
• Make an effort to understand meanings that patients attribute to their health situation.
• Learn about patients’ lived social world, support systems, and role responsibilities.
• Work with patients to identify their personal and social health obstacles or facilitators.
• Determine patients’ preferences for and abilities to participate in healthcare decision making and self- health management.
• Jointly determine appropriate healthcare goals and priorities.
• Work with patients as they struggle through personal crises, losses, or transitions.
• Learn about patients’ spiritual points of view and how they view the relationship between their health status and spirituality.