Reasoning in a Specialty Area

C O N C E P T A N A L Y S I S

Clinical reasoning: concept analysis

Barbara Simmons

Accepted for publication 4 December 2009

Correspondence to B. Simmons:

e-mail: [email protected]

Barbara Simmons PhD RN

Clinical Assistant Professor

Department of Biobehavioral Health Science,

University of Illinois at Chicago, USA

S I M M O N S B . ( 2 0 1 0 )S I M M O N S B . ( 2 0 1 0 ) Clinical reasoning: concept analysis. Journal of Advanced

Nursing 66(5), 1151–1158.

doi: 10.1111/j.1365-2648.2010.05262.x

Abstract Title. Clinical reasoning: concept analysis.

Aim. This paper is a report of a concept analysis of clinical reasoning in nursing.

Background. Clinical reasoning is an ambiguous term that is often used synony-

mously with decision-making and clinical judgment. Clinical reasoning has not been

clearly defined in the literature. Healthcare settings are increasingly filled with

uncertainty, risk and complexity due to increased patient acuity, multiple

comorbidities, and enhanced use of technology, all of which require clinical reasoning.

Data sources. Literature for this concept analysis was retrieved from several data-

bases, including CINAHL, PubMed, PsycINFO, ERIC and OvidMEDLINE, for the

years 1980 to 2008.

Review methods. Rodgers’s evolutionary method of concept analysis was used be-

cause of its applicability to concepts that are still evolving.

Results. Multiple terms have been used synonymously to describe the thinking skills

that nurses use. Research in the past 20 years has elucidated differences among these

terms and identified the cognitive processes that precede judgment and decision-

making. Our concept analysis defines one of these terms, ‘clinical reasoning,’ as a

complex process that uses cognition, metacognition, and discipline-specific

knowledge to gather and analyse patient information, evaluate its significance, and

weigh alternative actions.

Conclusion. This concept analysis provides a middle-range descriptive theory of

clinical reasoning in nursing that helps clarify meaning and gives direction for future

research. Appropriate instruments to operationalize the concept need to be developed.

Research is needed to identify additional variables that have an impact on clinical

reasoning and what are the consequences of clinical reasoning in specific situations.

Keywords: clinical reasoning, concept analysis, decision-making, diagnostic

reasoning, clinical judgment, nursing, problem-solving

Introduction

Clinical reasoning guides nurses in assessing, assimilating,

retrieving, and/or discarding components of information that

affect patient care. It is considered a characteristic that

separates professional nurses from ancillary healthcare

providers. Worldwide, nurses are increasingly more autono-

mous, responsible, and accountable for patient care.

� 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd 1151

J A N JOURNAL OF ADVANCED NURSING

Shortened hospital stays, patient acuity (nursing care

intensity level), and advances in technology require nurses

to think quickly to resolve problems. Decision-making under

conditions of uncertainty, risk and complexity has become

the norm of professional practice (Ebright et al. 2003, 2006).

It is clinical reasoning that enables nurses to make these

decisions, often without collaboration. However, little is

known about the reasoning processes that nurses use to make

clinical decisions, or how clinical reasoning differs from other

commonly used terms (Norman 2005, Tanner 2006, Banning

2008). The term ‘heuristics’ has been used to explain

decision-making by some authors (Cioffi 1997, Greenwood

et al. 2000) and ‘clinical reasoning’ by others (Fonteyn 1998,

Ferrario 2004). Greater understanding of this concept will

enhance nursing education, improve nursing practice, and

offer direction for further research.

Background

Multiple concepts have been used synonymously in the

literature: decision-making, problem-solving, clinical ju-

dgment, diagnostic reasoning and clinical reasoning. While

these concepts all include elements of both process and

outcome, the concepts diagnostic reasoning and clinical

reasoning focus on the thinking strategies that a nurse uses

to make a judgment or decision and solve problems (Murphy

2004, Kautz et al. 2005, Su et al. 2005). Clinical reasoning is

the precursor to a decision and action. Although authors

provide conceptual and operational definitions for the terms

they use, these definitions may only apply to that individual

study or review paper. The same term may be redefined in

subsequent work. Therefore, a concept analysis of clinical

reasoning is necessary to clarify the meaning of this term and

distinguish its attributes from those of other concepts.

Rodgers’s method of evolutionary concept analysis was

chosen as the method for this inquiry because of its rigorous

inductive approach and its relevance to concepts that continue

to evolve or change. It also focuses on current application of the

concept and its relationship or ‘interconnectedness’ with

multiple factors (Rodgers 2000). Rodgers suggests a technique

of concept analysis that begins with a literature search using

key words, titles, or abstracts that include the concept of

interest. Table 1 lists the eight steps used in Rodgers’s

evolutionary method of concept analysis.

Data sources

Multiple databases and search strategies were used to review

the literature, including the term clinical reasoning and the

surrogate terms diagnostic reasoning, decision-making and

problem-solving. Of these three, the term decision-making

gave access to the most literature. This was the initial step in

Rodgers’s evolutionary method of concept analysis.

The EBSCOHost online search platform and CINAHL

(Cumulative Index of Nursing and Allied Health Literature)

databases were used with Boolean operators and an advanced

search process. A thematic approach was employed to

determine the relevance of citations, and all papers with the

words ‘decision-making,’ ‘clinical reasoning,’ ‘problem-

solving’ or ‘judgment’ in the title were retrieved, yielding a

Table 1 Applying Rodgers’s method of concept analysis to clinical reasoning

Rodgers’s evolutionary method Concept analysis of clinical reasoning

Rodgers’s steps in concept analysis

1. Identify the concept of interest and

associated expressions/terminology

1. Concept: clinical reasoning

2. Identify and select an appropriate

discipline and period of time for data collection

2. Disciplines: philosophy, psychology, education,

medicine, nursing; Databases: FirstSearch,

Philosopher’s Index, PsychINFO, ERIC, Medline,

CINAHL; Time period: 1980–2008

3. Collect data regarding the attributes

of the concept, including surrogate terms,

antecedents, consequences, and references

3. Surrogate terms: diagnostic reasoning Antecedents:

cues, cognitive perception, knowledge, experience,

education, memory Consequences: judgment, decision,

action, choice, inference, evaluation. References:

nursing practice

4. Identify related concepts 4. Related concepts: problem-solving, decision-making,

clinical judgment

5. Analyse data regarding the above characteristics 5. Identification of major themes: cognitive processes

6. Conduct interdisciplinary comparisons 6. Clinical reasoning in medicine

7. Identify a model case of the concept, if appropriate 7. Not identified

8. Identify hypotheses and implications for further development 8. Attributes: analysis, deliberation, heuristics, inference,

metacognition, logic, cognition, information processing, intuition

B. Simmons

1152 � 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd

total of 5966 publications. Due to the volume of data

retrieved, additional limits of source type (periodicals), major

heading (decision-making, clinical) and years (1980–2008)

were placed. This yielded 1014 publications. Rodgers suggests

that 20% of the retrieved literature be included in the sample,

which further reduced the volume to 200 with adjustments for

double entries (Rodgers 2000) (Table 2). This sample was

drawn by assigning a number to each article and using a

random number table to determine which publications would

be included in the sample. Papers that included decisi-

on-making by physicians, advanced practice nurses, physical

therapists or patients, and those that addressed ethical

decision-making, were eliminated. This search completed

the second step in Rodgers’s method of concept analysis.

The literature was analysed for antecedents and con-

sequences, surrogate terms, related concepts and attributes of

clinical reasoning. Antecedents and consequences are defined

as those events that either precede or follow the concept

under analysis. Multiple conditions, behaviours or attitudes

that occur prior to the concept are considered antecedents.

Similarly, events or phenomena that occur afterwards suggest

an action, outcome or response. Identification of surrogate

terms and related concepts differentiates words that are

synonymous and interchangeable with the concept under

analysis. Finally, attributes that comprise the definition of the

concept are listed. These activities represent multiple steps in

the evolutionary method of concept analysis and can be

carried out simultaneously (Rodgers 2000).

Results

Literature review

Psychology is credited with the two major theoretical

frameworks which explain cognitive processes: subjective

expected utility theory (SEUT) and information processing

theory (Von Neumann & Morgenstern 1944, Newell &

Simon 1972). Research methods developed and implemented

in numerous studies have increased the scientific knowledge

base of the discipline and stimulated research that followed

later as these theories were applied to medicine and nursing.

SEUT explains how decisions ‘ought’ to be made by

expressing the best choice as a mathematical estimate of

highest probability. Using this theory, a decision is made by

assigning values, or utilities, to expected outcomes and by

assigning probabilities, or decision weights, to uncertain

outcomes (Von Neumann & Morgenstern 1944, Lopes 1987,

Goldstein & Hogarth 1997). It has been suggested that

judgment quality and decision accuracy may be better

predicted by using SEUT, in which normative criterion

measures indicate the best outcome (Dowding & Thompson

2003). Application of SEUT to nursing is apparent in basic

life support (BLS) and advanced cardiac life support (ACLS)

algorithms, emergency room triaging, and pain management.

Although certain outcomes can be achieved by taking

prescribed steps, not all situations can be standardized.

As interest in psychology increased, a new theory was

needed to describe the process of decision-making in

behavioural terms. Information processing theory (IPT)

explained decision-making as a process of gathering inform-

ation, weighing alternative options, and then making a final

judgment (Newell & Simon 1972). Bounded rationality is an

assumption of this theory. It states that only a limited number

of bits of information (seven plus or minus two pieces) can be

stored and easily retrieved from short-term memory. All other

information is stored in long-term memory, which is harder

to access (Miller 1956). Information processing theory is

descriptive and focuses on how decisions are made rather

than how decisions ought to be made, the basis of SEUT.

Contrary to the linear algorithms of decision analysis, IPT

represents decision-making as a multidimensional, cyclical,

recursive process that easily adds or subtracts pieces of

information for consideration.

The concept of clinical reasoning evolved from the

application of decision-making to the healthcare professions.

The goal of clinical reasoning in medicine is the accurate

diagnosis of disease (Elstein 1995). Decision analysis has

been the preferred normative and prescriptive model of

decision-making in medicine, where a final ‘best’ outcome is

depicted through an algorithm or decision tree (Cohen 1996,

Eeckhoudt 1996). Elstein et al. (1978) proposed a medical

descriptive model of decision-making based on information

processing to guide clinicians in hypothesis generation and

testing: the hypothetico-deductive method. Elstein used

the terms clinical reasoning, clinical decision-making,

Table 2 Search strategies for nursing literature

1. EBSCOHost online research platform

2. CINAHL (Cumulative Index of Nursing & Allied Health

Literature) database

3. Advanced string search – Boolean/Phrase

4. Clinical reasoning in title (or)

5. Decision-making in title (or)

6. Problem-solving in title (or)

7. Judgment in title (and)

8. Nursing practice (5966)

9. Narrow results by Source type: periodicals (5545)

10. Narrow results by Subject: Major Heading – Decision-making,

Clinical (1051)

11. Narrow results by year 1980–2008 (1014)

12. Access 20% of literature as sample for concept analysis

JAN: CONCEPT ANALYSIS Clinical reasoning

� 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd 1153

problem-solving and diagnostic reasoning interchangeably in

his work. Clinical judgment is yet another term that has been

used in medical research, which adds to the conceptual

confusion (Feinstein 1994).

The concept of clinical reasoning fits well within the

context of Benner’s Model of Skill Acquisition in Nursing. In

their seminal work, Dreyfus and Dreyfus (1980) developed a

model of skill acquisition that ranked a person’s performance

according to five levels of proficiency. In 1984, Benner

adapted this model to nursing skills at different levels of

practice, ranging from limited cue recognition and analytic

thinking (novice) to comprehensive understanding and

intuition (expert). Conceptual reasoning was considered a

requirement of problem-solving (Benner 1984). While the

terms decision-making and problem-solving were used in her

early research, the term clinical judgment was later preferred

to describe the way a nurse understands problems, issues and

concerns of patients (Benner 1984, Benner & Tanner 1987,

Benner et al. 1992).

The term clinical reasoning was introduced into nursing

literature in the 1980s to refer to the cognitive processes used

by healthcare providers to think about patient issues (Jones

1988). It has been described as a ‘forward chaining process’

that moves sequentially through a series of logical inferences

to a final decision. A representative model of clinical

reasoning depicts it as an upward and outward spiral, which

begins with an initial patient encounter and moves forward

through data interpretation until a final outcome is reached

(Higgs & Jones 1995). This model, which is congruent with

information processing theory, integrates multiple key

elements: cognition (thinking), metacognition (reflective

thinking), knowledge, and contextual parameters of the

patient and the environment.

Attributes of clinical reasoning have been identified in

studies using information processing as the dominant

theoretical framework and think-aloud approach with

protocol analysis as the methodology (Greenwood et al.

2000, Simmons et al. 2003, O’Neill et al. 2005, Andersson

et al. 2006, Funkesson et al. 2007, Banning 2008, Goransson

et al. 2008). Beginning distinctions were made among terms

that had previously been used indistinctly: decision-making,

problem-solving and clinical reasoning (Norman 2005,

Tanner 2006, Banning 2008). Simmons et al. (2003) propose

that the terms decision-making and problem-solving imply an

outcome or result of thinking, while clinical reasoning is the

cognitive process of thinking about healthcare information.

Recent publications have emphasized the impact of theor-

etical and procedural knowledge on thinking strategies used

when making clinical decisions (Ferrario 2004, Murphy

2004, Su et al. 2005).

Findings from the selected nursing research indicated

several attributes of clinical reasoning. These attributes

differ according to nursing experience and domain-specific

knowledge. Novice nurses identify fewer patient cues, are

limited in their ability to cluster these cues, have difficulty

identifying complex diagnoses, and do not reevaluate data

as often as more experienced nurses (Benner et al. 1992,

Greenwood & King 1995, O’Neill et al. 2005). While

novices readily retrieve patient data, important cues are

often overlooked as the degree of uncertainty or decision

complexity increases (O’Neill et al. 2005, Andersson et al.

2006). In addition, experiential, formal and informal

knowledge are all components of the reasoning process,

but higher level of education is not always consistent with

improved reasoning skills (Kuiper & Pesut 2004, Murphy

2004).

With increasing clinical experience, expert nurses employ

heuristics (informal thinking strategies or cognitive shortcuts)

to reason about complex issues. Heuristics enable nurses to

review extensive patient information quickly by using

numerous mental techniques (Cioffi 1997, Fonteyn 1998,

Ferrario 2004, Judd 2005). Such heuristics can enable quick

decision-making, but may result in erroneous conclusions due

to ‘thumbnail’ views (O’Neill 1995, Cioffi 1997, Buckingham

2000). Nursing studies have identified several components of

clinical reasoning: discipline-specific knowledge, experience,

and both formal and informal thinking strategies (Bynes &

West 2000, Funkesson et al. 2007, Banning 2008). Multiple

informal thinking strategies have been identified, several of

which include pattern recognition, generating hypotheses,

setting priorities and making generalizations (Cioffi 1997,

Fonteyn 1998, Buckingham & Adams 2000). While these

techniques speed the thinking process, they may lead to

erroneous conclusions when data are overlooked or

discarded.

Surrogate/related terms

The term clinical reasoning is often used interchangeably

with other concepts. The term reasoning is defined as a

cognitive process directed toward forming conclusions,

judgments or inferences from facts or premises (Webster’s

Dictionary 1989). Critical thinking is related to clinical

reasoning. However, it is a broader concept that involves

particular dispositions, skills and mental habits (Gordon

2000, Scheffer & Rubenfeld 2000, Hicks 2001). The terms

decision-making, problem-solving and clinical judgment

suggest an endpoint to the thinking process, while the terms

diagnostic reasoning and clinical reasoning emphasize the

cognitive processes involved prior to the endpoint.

B. Simmons

1154 � 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd

Antecedents/consequences

Antecedents are events that occur prior to clinical reasoning,

and consequences are events that occur as a result of it

(Table 3). The review of literature elucidated distinctions

among terms. Multiple events or circumstances may precede

clinical reasoning and account for the skill with which this

process is used. Variables that are difficult to measure may also

be involved, including risk taking, maturity, formal and

informal education, and experience. Similarly, events or

phenomena that follow clinical reasoning indicate the outcome

or the product of the concept. Choices may be correct or

incorrect, appropriate or inappropriate. Every choice has

implications and responsibilities associated with it. The

consequences make the concept purposeful, directive, and

dynamic. Clinical reasoning in nursing is as concerned with the

process (cognition) as it is with the product (choice, decision,

or resolution). If more strategies and models of clinical

reasoning are proposed, the process will facilitate improved

patient outcomes. Consequences from previous reasoning may

become the antecedents to the next process, making it cyclical

and recursive. Identification of surrogate and related terms, as

well as antecedents and consequences of the concept, is an

essential step in Rodgers’s evolutionary method.

Attributes constitute the real definition of the concept

under analysis and emerge as essences of meaning. Defining

attributes of clinical reasoning are: data analysis (interpreting

information), deliberation (rumination), heuristics (informal

thinking strategies), inference (speculation), metacognition

(reflective thinking), logic (argument), cognition (perception

or awareness), information processing (organizing data) and

intuition (insight independent of reasoning) (Figure 1).

Definition

Based on this concept analysis, clinical reasoning in nursing

can be defined as a complex cognitive process that uses

formal and informal thinking strategies to gather and analyse

patient information, evaluate the significance of this inform-

ation and weigh alternative actions. Core essences of this

concept include cognition, metacognition and discipline-

specific knowledge. Formal and informal thinking strategies

blend decision analysis, information processing and intuition

to evaluate the value of patient data. Information that is

initially discarded as non-essential may be retrieved later in

the process. Possible nursing actions are simultaneously

proposed and evaluated for relevance. Clinical reasoning is

dynamic, expansive and recursive, as information, interv-

entions and alternative actions are considered or discarded at

multiple cognitive entrance points.

Whether inductive or deductive reasoning is used, multiple

variables affect this process in nursing, including cognitive

ability, life experience, maturity and skill level within

practice. The amount of information that is available, degree

of risk involved and level of uncertainty also affect outcome.

Clinical reasoning is context-dependent and domain-specific,

incorporating knowledge unique to nursing within a specific

practice setting. Each practice setting has its own standards of

care, degrees of independence and interdependence with

other healthcare professionals, risks involved and reper-

cussions related to implied decisions. The use of formal

strategies (decision analysis or information processing) or

informal strategies (heuristics) depends on the situation and

the experience of the nurse. The recursive nature of the

process allows the nurse to move forward or backward

CLINICAL REASONING

Analysis Deliberation

Heuristics Inference

Intuition

Information Processing

Cognition Logic

Metacognition

Figure 1 Attributes of clinical reasoning.

Table 3 Antecedents and consequences of reasoning

Antecedents Consequences

Cognitive perception Choice

Tacit or explicit knowledge Cognitive awareness

of additional cues

Evaluation of alternatives

Cues Decision

Perceived need for action Implied action

Discipline-specific knowledge

Experience

Short- and long-term memory

Formal/informal education Judgment

Inference

JAN: CONCEPT ANALYSIS Clinical reasoning

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cognitively as information is added, deleted or re-evaluated.

Cognitive flexibility enables a person simultaneously to assess

cues, determine relevance, apply knowledge and experience,

and weigh the value of data and possible interventions.

Discussion

The purpose of this analysis was to define the concept

‘clinical reasoning’ through literature retrieval from key

disciplines. However, there were limitations. The inclusion

of additional disciplines, research prior to 1980, and

languages other than English would have broadened the

analysis. This concept analysis is a contribution toward the

development of a middle-range descriptive theory of clinical

reasoning in nursing. However, it has limitations in separa-

ting the term from similar ones identified in the literature

search. Formal and informal thinking strategies, discipline-

specific knowledge, and experience in practice intertwine to

enable nurses to evaluate data in the context of a clinical

situation. The clinical reasoning concept is also well-situated

within Benner’s model of skill acquisition in nursing.

Essential concepts in her model are experience, knowledge,

skills, and caring (Benner 1984, Benner et al. 1992, 1996,

Johnson & Webber 2005). In the present analysis, Rodgers’s

evolutionary method was used to investigate a concept that is

dynamic and still evolving within the practice of nursing. The

use of other methods of concept analysis, such as Wilson’s

approach, might produce different outcomes (Wilson 1963).

Multiple additional variables may affect the outcome of

clinical reasoning, including the complexity of the task,

uncertainty of outcome, time, practice setting and risk

involved. In addition, each nurse has a unique set of personal

traits that influence the process. Recent research has

identified what teaching strategies promote clinical reasoning

and how various technologies assist nurses at the point of

care (Murphy 2004, Kautz et al. 2005, Kuiper et al. 2008).

However, research is still needed to determine what cognitive

skills improve reasoning speed and accuracy, if English as a

second language or gender of the nurse affects the process,

and how increased risk and shortened deliberation time have

a negative impact on outcome.

Conclusion

This concept analysis will yield better understanding of the

term in nursing practice, theory development and research.

Correlations between clinical reasoning and various

attributes, antecedents and consequences are areas for future

research, as are gender differences, English as a second

language, area of practice and educational preparation.

Other questions might include what effect technology has

on the reasoning process, how the nursing shortage and

patient acuity affect clinical reasoning, what resources can be

developed or better implemented to assist nurses as they

reason about clinical situations, and how novice nurses can

learn the cognitive shortcuts and thinking strategies that

expert nurses use.

Acknowledgement

I would like to thank Kevin Grandfield, Publications

Manager, for editorial assistance.

What is already known about this topic

• Clinical reasoning is an ambiguous term that is often used synonymously with decision-making and clinical

judgment.

• Clinical reasoning has not been clearly defined in the literature.

• Healthcare settings are increasingly filled with un- certainty, risk and complexity due to increased patient

acuity, multiple comorbidities, and enhanced use of

technology, all of which require clinical reasoning.

What this paper adds

• An analysis of the concept using Rodger’s evolutionary method distinguished clinical reasoning from problem-

solving and decision-making.

• Clinical reasoning in nursing is defined as a complex cognitive process that uses formal and informal thinking

strategies to gather and analyse patient information,

evaluate the significance of this information, and

determine the value of alternative actions.

• Clinical reasoning in nursing is recursive and uses both inductive and deductive cognitive skills.

Implications for practice and/or policy

• This concept analysis provides a middle-range descriptive theory of clinical reasoning in nursing that

helps clarify meaning and gives direction for future

research.

• Appropriate instruments to operationalize the concept need to be developed.

• Research is needed to identify additional variables that have an impact on clinical reasoning and the

consequences of clinical reasoning in specific situations.

B. Simmons

1156 � 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd

Funding

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the authors.

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