Clinical Reasoning in Nursing: Developing an Achievement-Based Framework

Clinical Reasoning in Nursing: Developing an Achievement-Based Framework

Clinical reasoning incorporates the use of critical thinking, discipline-specific knowledge, and experiential understanding in a non-linear process. Registered nurses use clinical reasoning to understand situations, identify issues, and make professional judgements and decisions involving nursing practice; however, concerns surrounding the preparedness of graduate registered nurses to use clinical reasoning are evident in research (del Bueno, 2005; Gillespie & Peterson, 2009; Levett-Jones et al., 2010; Purling & King, 2012). Underdeveloped clinical reasoning has been linked with adverse events and failure-to-rescue scenarios, with research now examining the capability of tertiary institutions to develop the clinical reasoning of registered nurses to a safe level prior to completion of their studies (Kavanagh & Szweda, 2017; Liao et al., 2016; Missen et al., 2016). Currently, there are no discipline-specific tools to assess the clinical reasoning of undergraduate registered nurses throughout their Bachelor of Nursing program and only sparse research on what clinical reasoning looks like and how it is demonstrated in undergraduate registered nurses.

To determine the standard of clinical reasoning required by undergraduate registered nurses upon completion of their preregistration studies, the clinical reasoning of registered nurses working in clinical practice was examined. This information formed the groundwork for the development of a professionally contextualised assessment framework for use in undergraduate registered nursing programs. A multi-phase study featuring a scoping review, benchmarking against practice standards, a literature review and a modified Delphi study was used to develop the Clinical Reasoning Achievement-Based (CRAB) framework. A further confirmation study was undertaken to test the useability, reliability, and validity of the developed framework.

In the scoping review, registered nurses were found to employ numerous interrelated characteristics and processes of clinical reasoning while working in practice with a multitude of factors influencing their clinical reasoning. The majority of the identified characteristics and processes aligned with the Nursing and Midwifery Board of Australia's Registered Nurse Standards for Practice (2016). The expert panel from the modified Delphi study determined which characteristics and processes of clinical reasoning should be included in the framework, as well as the level at which undergraduate registered nurses should be demonstrating these. The expert panel also agreed a clinical case scenario was the most appropriate method to assess the clinical reasoning of undergraduate registered nurses with the CRAB framework eventually comprising three components: a CRAB Assessment Tool, CRAB Explanatory Notes and CRAB Clinical Case Scenario requirements.

The CRAB framework was found to assess clinical reasoning, with the format of the CRAB Assessment Tool identified by the assessor as easy to use; however, further testing is required. The CRAB Clinical Case Scenario requirements were found to strengthen the development of clinical case scenarios, which supported the CRAB Assessment Tool.

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