What is the historic evolution of the nursing process?
The nursing process in its various forms has always been the foundation for patient problem
management since Florence Nightingale (1859/1946) first described it. When considering the
evolution of the nursing process over time, one has to appreciate the evolving nature of
professional identity; developments in informatics; knowledge representation and classification
systems; and concurrent insights and developments related to critical, creative, systems and
complexity-thinking processes. The major phases in the nursing process and associated clinical-
thinking strategies have been described in the literature, which spans six decades of change and
can be classified into several generations.
DEVELOPMENTAL GENERATIONS OF NURSING PROCESS
Before the 1950s, there was not much attention paid to the thinking skills nurses needed to
practice. Once nursing education moved from hospitals into university settings, the need
developed for an academic discipline to discern the unique thinking strategies and skills nurses
used to reason about patient care challenges. The first-generation (1950–1970) nursing process
proposed was based on a problemsolving model and consisted of the following steps: assess,
plan, implement, and evaluate (APIE). This structured, stepwise logic model was taught and
learned as a linear process that focused on problems and pieces of a patient story, medical
conditions, and associated nursing care responses. Evaluation was linked with problem
identification and goal achievement. Over time, nurses realized that the problem–solutions they
identified in practice were redundant and could be classified and categorized according to the
evolving nature and scope of nursing practice.
Nursing informatics as a specialty influenced the development of and quest for ways to represent
nursing knowledge. Nursing diagnoses were developed and assimilated into the traditional APIE
nursing process model. Nursing process evolved from a four-step process (APIE) to a five-step
model: assess, diagnose, plan, implement, and evaluate (ADPIE). This development had
profound implications on how nurses began to teach, learn, think, and reason about nursing care
situations. With the advent of nursing knowledge representation systems and the beginning use
of standardized nursing language, it was clear that nursing knowledge could be captured,
analyzed, and evaluated and could yield insights into nursing patterns of care. Data could be
transformed into information. Information could be transformed into knowledge. Knowledge
could influence the way nurses think and reason and establish a repository of nursing knowledge
that could be tested, evaluated, and support the development of nursing science. As nurses
gained experience with the process, nursing knowledge classification models emerged and were
based on nurses creating and naming phenomena of concern. Grand nursing theories gave way to
more middle-range challenges in terms of specifying human responses to actual or potential
health problems, which became the purview and definition of nursing. The North American
Nursing Diagnosis Association (NANDA, 1994, 1996) assumed a leadership role in the creation
and vetting of nursing diagnoses. Given the nursing diagnosis development work, the second
generation of nursing process focused on the nature of diagnostic reasoning using the evolving
diagnostic labels.
The second generation of nursing process (1970–1990) focused on developing insights and
understanding regarding the nature of diagnosis and reasoning in nursing. Research in the area of
diagnostic reasoning led to discoveries and insights about the advantages and disadvantages of
the nursing process as a model and a method. Diagnosis of nursing problems shifted the nursing
process model from one of problem identification and solution finding to thinking and reasoning
about hypotheses and diagnoses. Diagnostic reasoning involved the recognition and clustering of
cues and analysis of data given specific clinical situations. The shift from problem identification
and solving to diagnostic reasoning was a revolution in thinking that continues to have ripple
effects in contemporary nursing practice.
Studies on diagnostic reasoning and the critical thinking involved in nursing practice emerged
(Facione & Facione, 1996; Jones & Brown, 1993; Kintgen-Andrews, 1991; Miller & Malcolm,
1990). Nursing Diagnosis: Process and Application by Marjory Gordon (1994) and Diagnostic
Reasoning in Nursing by Carnevali, Mitchell, Woods, and Tanner (1984) described a way of
thinking that offered an enhancement of the nursing process and was proposed to help nurses
manage information and make decisions. They defined diagnostic reasoning as a pattern of steps
beginning with pre-encounter data; entry into the data search field; shaping direction of data
gathering, cue clustering, determining diagnostic hypotheses, focused cue search, and testing
hypotheses for “goodness of fit” in order to derive a diagnosis. The nature and type of terms
linked at that time with thinking in nursing changed from problem identification to hypothesis
formulation and testing. Critical and creative thinking skills were essential to the development of
nursing diagnoses and nursing knowledge. Continued evolution and development of nursing
knowledge classification systems as well as continued research into the dynamics of clinical
reasoning set the stage for another transformation of the nursing process. Table 3.1 outlines the
American Nurses Association (ANA)-approved nursing languages and the classification systems
or approved terminologies most often used by advanced practice providers (American Nurses
Association [ANA], 2012).
The third generation of nursing process emerged (1990–2020) and highlighted a nursing process
model that emphasized reflection, outcome specification, and testing given a patient’s story. The
OPT clinical reasoning model (Pesut & Herman, 1999), built on the heritage of the nursing
process, was more responsive and relevant to contemporary nursing practice needs. Definitions
and distinctions among the terms clinical reasoning, clinical decision making, and clinical
judgment were made (Pesut & Herman, 1999).
Concurrently, Dr. Patricia Benner (1988) and her colleagues (Benner, Tanner, & Chesla, 1997)
were studying nurses, thinking and discovered that novice nurses were not as sophisticated in
their thinking skills as expert nurses. Based on her research, Benner (1988) reframed and
renamed many of the daily activities in which nurses were involved. Her studies indicated that
expert nurses did not necessarily use the nursing process, but relied on experience and intuition
and a combination of practical and academic intelligence. Exemplars illustrated how nurses
coupled thinking with caring and ethics. The role of intuition and the person as the focus in
reasoning about care needs was highlighted. Rather than retrofit new knowledge into an old,
linear, problem-solving process model, there was a need for an expanded model of reasoning. It
was becoming clear that clinical reasoning included more than critical thinking and involved
elements of creative thinking, systems thinking, ethical reasoning, and outcome specification.
The development of the OPT clinical reasoning model accommodated the changes in nursing
process over time. In this model, clinical reasoning is defined as the critical, reflective,
concurrent, and creative thinking embedded in nursing practice that results in the juxtaposition of
problems and outcomes that are subject to interventions and clinical judgments (Kuiper, 2002;
Pesut & Herman, 1999).
The OPT clinical reasoning model provides a structure, a process, and strategies for thinking
about multiple competing patient care needs in the context of the patient’s story. As the nurse or
clinicians reflect on and analyze how each of these needs or issues impacts and influences all the
other needs, patterns emerge that reveal leverage points of intervention that can accelerate the
specification of outcomes and provide foci for effective and efficient interventions. The OPT
model supports contemporary definitions of the nursing process, which include assessment,
diagnosis, outcome identification, planning, implementation, coordination of care, health
teaching and promotion, and evaluation (ANA, 2015). The OPT clinical reasoning model differs
considerably from the earlier generations of the nursing process. Its strengths include the
following: the model builds on a foundation of reflective judgment and is derived from empirical
data, the model honors the holistic nature of nursing, the model approaches patient situations in
terms of outcomes, the model identifies the thinking skills and strategies involved in making
clinical decisions and judgments, and the model can be used with interprofessional taxonomies
that provide the content for clinical reasoning.
The OPT clinical reasoning model (Figure 3.1) uses the patient’s story, diagnostic cluster cue
and web logic, keystone priority, present to outcome states to determine tests, and interventions
for health and illness management, all of which support the development and acquisition of skills
in clinical reasoning and judgment.
MASTERING THE OPT MODEL OF CLINICAL REASONING
Patient-centered clinical reasoning is the first phase of care coordination and is used to determine
the priorities between and among comorbidities the patient is dealing with. The OPT model
provides a structure, a process, and a method that support patient-centered clinical reasoning.
The major difference between the OPT clinical reasoning model and previous models is the
OPT’s emphasis on filters, framing, and focusing a situation and the gaps that exist between the
problems identified and the outcomes desired. The gaps are based on the story of the patient,
which is determined by an examination and history. The explicit focus on the patient’s story is a
way to frame relationships among contexts, present states, and desired outcomes. The OPT
clinical reasoning model underscores the fact that reasoning is concurrent and iterative as side-
by-side comparisons of outcomes with present-state information from the patient story create
gaps that can be analyzed and evaluated as test conditions about which judgments and
conclusions are made given decisions and actions that fill the gaps. The OPT clinical reasoning
model relies on higher order critical thinking skills, such as analysis, synthesis, evaluation,
creativity, and judgment.
The OPT clinical reasoning model is a way to help identify what is important in a patient case
and what outcomes you are trying to achieve for health and wellness. Based on the facts of the
situation, providers make choices to get to the most acceptable outcomes from the patient-and-
family story. The OPT clinical reasoning model is more likely than other models to be able to
accommodate present and future knowledge development activities in nursing and other
disciplines.
The first level of perspective challenge of patient-centered clinical reasoning is to represent all
the issues and needs that patients’ reveal. The second challenge is to consider how all these
issues are related to one another. The third challenge is to find the keystone or priority issue that
organizes the focus of care based on the story. Once the keystone issue is identified, other
diagnostic concerns may resolve through activities surrounding the keystone issue. The OPT
clinical reasoning web worksheet helps the advanced practice clinician define relationships
among issues and highlights potential keystone issues. Developing a clinical reasoning web helps
illustrate the art and science of clinical reasoning. The OPT clinical reasoning model is circular
and fluid, and allows for visualization of several problems and the “big picture” at the same time.
Delineating each problem and how it is related to all the others, and then developing a picture of
the whole dynamic interaction, helps the nurse focus on the what, why, and how of a patient
scenario once an outcome is specified to act to fill the gaps between problems and outcomes and
promote transitions from present to desired states.
PATIENT-CENTERED REASONING: ACTIVATING SYSTEMS-THINKING SKILLS
THROUGH THE USE OF CLINICAL REASONING WEBS
Patient stories are complex but with a little analysis and synthesis, complex stories can be
simplified into key issues. An OPT clinical reasoning web is a useful method and tool used to
illustrate the functional relationships between and among diagnoses, conditions, and diagnostic
hypotheses derived from critical thinking that can result in divergent and convergent
identification of central issues that necessitate nursing care.
Advanced practice clinicians could begin with a medical diagnosis or a nursing diagnosis in
mind when they begin planning of care. Whichever is primarily in the forefront, there are
medical and nursing consequences to be considered for each. The reasoning challenge begins
with a description and understanding of the patient’s story. Framing the story and discerning the
issues that need attention are crucial. Thinking about one’s thinking helps one evaluate, discover
flaws in thinking, and adjust and develop one’s clinical reasoning skills. One of the essential
parts of the OPT clinical reasoning is reflection. Some of the components of self-regulatory
reflection are self-monitoring, self-evaluation, and self-correction. This process is referred to as
metacognition. For example, one way to begin patient-centered reasoning is to spin and weave a
web of relationships among identified nursing diagnoses associated with medical conditions.
Spinning and weaving a web is the process of using thinking strategies to analyze and synthesize
functional relationships between and among diagnostic hypotheses associated with a patient’s
health status. The steps to the creation of an OPT clinical reasoning web using the worksheet are
as follows:
1.Place a general description of the patient in the respective middle circle.
2.Place the major medical diagnoses in the respective middle circle.
3.Place the major nursing diagnoses in the respective middle circle.
4.Choose the nursing domain for which each medical nursing diagnosis is appropriate.
5.Generate all the International Classification of Diseases (ICD)-10 codes that would result from
the particular patient-and-family story that coincide with the nursing domains (World Health
Organization, 2015).
6.Reflect on the total picture on the worksheet and begin to draw lines of relationship,
connection, or association among the diagnoses. As you draw the lines, try to justify and explain
your reasons for connecting these diagnoses.
7.Determine which pattern has the highest priority for care coordination and most efficiently and
effectively represents the keystone nursing care needs of the patient.
8.Look once again at the sets of relationships and determine the theme that summarizes the
patient-in-context or the patient’s story.
The OPT clinical reasoning web worksheet seen in Figure 3.2 shows a template with the patient
health care situation, medical diagnoses, and nursing diagnoses in the center. Around the outer
edges of the web are nursing domains with ICD-10 codes derived from history and physical
assessment associated with the patient story. The multidirectional arrows that create the web
effect are functional relationships between and among the diagnostic possibilities. Through the
use of self-talk and if–then thinking, clinicians can challenge themselves to explain the explicit
relationships between and among the competing issues. How does one condition affect the other?
What are the relationships, consequences, and/or impact and outcome of the concurrent
conditions? As one can see, the domains and ICD-10 codes with more arrows converging on one
of the circles display the priority problem or keystone, in this case, activity and rest. Keystone
issues are one or more central supporting elements of the patient’s story that guide reasoning and
care coordination based on an analysis and synthesis of diagnostic possibilities as represented in
the web.
THE OPT CLINICAL REASONING MODEL
After considering the whole picture using the clinical reasoning web worksheet, the next step is
to use the OPT clinical reasoning model worksheet to structure the provider’s reasoning about
relationships between and among problems, outcomes, interventions, decision making, and
judgments. As the provider thinks about the patient, he or she will concurrently consider the
frame, the outcome state, and the present state. Each aspect of the OPT clinical reasoning model
contributes to the other. The OPT clinical reasoning model worksheet is a map of the structure,
which is designed to provide a representation and guide thinking about relationships between and
among competing issues, problems, outcomes, interventions, and judgments.
By writing each element on the worksheet, it is easy to see how parts of the model relate to each
other. For example, as seen in Figure 3.1, on the far right-hand side, there is space to write the
patient’s story. This space is called the patient-in-context. It is a place for the provider to make
notes and jot down relevant facts of the story. Moving to the left, there are places to write down
inferences and conclusions that result from the provider’s logic and analysis of the facts between
and among the diagnoses and relationships. Remember diagnostic cluster cue web logic is
supported by the use of inductive and deductive thinking.
At the center and background of the worksheet are places to indicate the frame or theme that best
represents the background issues regarding thinking about the patient story. The frame is the
theme that often emerges after the creation of an OPT clinical reasoning web. The frame helps
organize the present state and the outcome state, and illustrates the gap and provides insights
about what tests or interventions are needed to fill the gap. Frames depend on the advanced
practice clinician’s filters and on distinctions being made about salient features of the case and
story. Decision making and reflection surround the framing as the advanced practice clinician
thinks of all the patient-centered elements concurrently. Reflective thinking is used to monitor
thinking and self-regulate thinking.
At the center of the worksheet are spaces to place the present state and outcome state side by
side. Putting the two states together in this way creates a gap analysis that naturally shows where
and what the goals are in terms of the patient’s care. The gap between where the patient is and
where you want the patient to be is one way to create a test. Tests are really gap analyses.
Clinical decisions are choices made about interventions that will help the patient transition from
present state to a desired outcome state. One is constantly updating and “testing” the degree to
which outcomes are being achieved or are not based on the results of the interventions. Testing is
concurrent and iterative as one gets closer and closer in successive increments toward goal
achievement.
The “reflection on clinical reasoning” box at the top of Figure 3.1 is a reminder of the thinking
strategies used for the patient situation. These strategies also help make explicit many of the
relationships among ideas and issues associated with the patient’s problems. Finally, the
judgment space on the far left-hand side of the figure is the place to write in the results of the
conclusions drawn from a test. Based on the degree of gap or comparison of where the patient is
and where the provider wants the patient to be, there may or may not be an evidence gap. Once
the provider gets evidence that fills that gap, he or she has to attribute meaning to the data.
Making judgments about clinical issues is all about the meaning the provider attributes to the
evidence derived from the test or gap analysis of the present to the desired state.
Once a provider has experience coordinating care for patients, the cases become part of a clinical
reasoning learning history. These schema experiences inform future thinking with patients who
are similar to those with whom the provider has had experiences. These schemata and experience
build on each other over time and result in the development of pattern recognition for future
clinical reasoning applications. If the scenario results in a negative judgment, or progress is not
being made to transition patients from present to desired states, the provider may have to reframe
the situation and reconsider the problem to be solved, the outcome to be achieved, or the framing
of the situation.
CLINICAL REASONING: FRAMING AND PERSPECTIVES
A patient’s story provides important information about the context and major issues for clinical
reasoning. Listening to patients, connecting with them in meaningful ways, attributing meaning
to their stories, and getting the facts of their situation constitute the art of nursing. Stories are a
key element of clinical reasoning. How you “frame” a story has implications for how you reason.
For example, consider the following case: George Appleton is a 99-year-old gentleman in a long-
term care facility with a diagnosis of end-stage renal disease. If you “frame” this situation as the
need to keep George comfortable and maintain a urinary output to excrete metabolic waste
products, how does such a frame guide and direct your thinking and doing? Would your thinking
and doing be different if the “frame” or lens you used to view this situation involved “promoting
a peaceful death?” How would your thinking and actions be different given these two different
perspectives?
We constantly frame situations. Frames are mental models or perceptual positions we have about
issues, events, and meanings. Peter Senge (1990) discusses mental models in his book The Fifth
Discipline. Mental models determine how we make sense of the world and take action. Senge
writes:
Mental models can be simple generalizations such as “people are untrustworthy” or they can be
complex theories, such as assumptions about why members of my family interact as they do. But
what is most important to grasp is that mental models are active—they shape how we act. If we
believe people are untrustworthy, we act differently from the way we would if we believed they
were trustworthy. If I believe that my son lacks self-confidence and my daughter is highly
aggressive, I will continually intervene in their exchanges to prevent her from damaging his ego.
(1990, p. 175)
