CHAPTER 3

THE EVOLVING NATURE OF NURSING PROCESS AND CLINICAL REASONING

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.

LEARNING OUTCOMES

After completing this chapter, the reader should be able to:

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).

TABLE 3.1 Standardized Nursing Languages

ABC, Alternative Billing Concepts.

Source: American Nurses Association (2012).

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.

FIGURE 3.1 Outcome-Present State-Test clinical reasoning model.

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:

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.

FIGURE 3.2 Outcome-Present State-Test clinical reasoning web worksheet.

ICD-10, International Classification of Diseases, 10th edition.

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:

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