Clinical Nursing Reasoning in Nursing Practice: A Cognitive Learning Model based on a Think Aloud Methodology

Abstract

Background. The current context of increasingly complex nursing care requires a high level of clinical reasoning in nursing practice. Still, teaching clinical reasoning in nursing remains a challenge for educators in the field. Although several studies have been conducted to try to understand clinical reasoning in nursing, neither its developmental stages nor the corresponding critical milestones have been uncovered. Therefore, nursing educators cannot rely on a cognitive learning model (a description of how people learn and develop a specific competency) to facilitate the learning of this crucial competency. Objectives. This study was conducted to develop a cognitive learning model of clinical reasoning in nursing, from the beginning of education to the development of expertise, highlighting the critical milestones corresponding to each stage. Design. A descriptive design based on the think aloud method was used. Settings and participants. The study was held in one university and two associated hospitals. Individual interviews were conducted with 45 undergraduate nursing students and 21 registered nurses (RN). Participants were asked to think aloud, using five clinical scenarios that were validated in a previous study. Analysis. Interviews were transcribed verbatim and subsequently analyzed using the protocol analysis method recommended for think aloud studies. Results. Five developmental stages and their related critical milestones were identified and used in the elaboration of a cognitive learning model for clinical reasoning in nursing: (1) internalization of the idea that nursing is a scientific profession; (2) learning to read and use scientific literature in care planning and nursing interventions; (3) learning to move from data collection to hypothesis generation to nursing interventions; (4) integrating wards’ routines and protocols; (5a) towards professional expertise or (5b) towards task-oriented practice. Conclusion. Recommendations for teaching and learning clinical reasoning in nursing during initial and continuing education in nursing are suggested.