Practice Rationale Care Model: The Art and Science of Clinical Reasoning, Decision Making and Judgment in the Nursing Process ()
1. Introduction
Many of our nurses are confused on the differences between critical thinking, clinical reasoning and clinical judgment, and how it affects clinical decision making; they are related to each other but not comparable. The ultimate goal of this initiative is to help and guide the nurses to understand dissimilarity of these important components in the process of nursing care and use it an appropriate manner based on different situations they encounter in every day routine at their workplace in different clinical areas and capacities. Based on the study conducted, most of the nurses responded that clinical reasoning is only incorporated during assessment [1] . The findings of the research study were used to develop a model to guide every nurse that in every action taken in the process of nursing care, it has a valid rationalization, importance and benefits to the recipient of care. Nurses must be enlightened that clinical reasoning, clinical decision making, and clinical judgement must be incorporated and applied in the whole course of the nursing process.
Reasoning is a skill that a real nurse must understand and apply to deliver a safe nursing practice. This is skill is not acquired accidentally; thus, it is learnt in process. Clinical reasoning is thought-provoking and interesting to know; it requires simultaneous methodologies in learning nursing procedures that is essential in the delivery of safe patient care. This is an important aspect in order to come up with a constructive clinical decision making. A real nurse must recognize that dealing with patients under their care is not only based on what they see superficially but centered on in-depth analysis and reasoning about the patient condition. Most of the studies about critical thinking and clinical reasoning competence focus on nursing students. Nonetheless, in this exploration the focus is to know and understand the disposition of staff nurses practicing in the clinical arena about their clinical reasoning competency at different levels of their responsibility. It is imperative to recognize and appreciate the process and steps of clinical reasoning. According to the American Nurses Association, the nursing process such as assessment, nursing diagnosis, planning, implementation and evaluation is a critical thinking model use to promote proficient level of nursing care. Critical thinking is comprehensive and broad; it is a process of revealing unseen problems, determining goals, investigating assumptions, identifying appropriate actions and evaluating proofs of evidences. It denotes the significance of recognizing queries, issues and concerns and finding correct action and solution. This encompasses reasoning in both outside and inside clinical arena.
Nurses play a pivotal role in the healthcare system and compose the prime number in the healthcare workforce. Approximately 50% of the healthcare workers account for nurses and midwives and out of 43.5 million workers around the world, 20.7 million comprises nurses and midwives. In reaching the goal on sustainable development, 9 million more nurses and midwives will be needed by 2030 [2] .
The guidance of nursing care is being instigated by Ida Jean Orlando in 1958 and is now being defined as a scientific method towards care utilizing the essential philosophies of clinical reasoning, patient-centered methodologies, evidence-based practice commendations, goal-oriented responsibilities, and nursing insights [3] . The five (5) chronological steps in the nursing process was identified: assessment which starts the steps involving the skills of critical thinking along with data collection and this can be subjective (verbal) and objective (measurable); diagnosis which formulates nursing diagnosis through utilizing clinical judgment; planning which formulates goals and outcomes that directly influence the care of patient as based from evidence-based practice for a positive outcome and these goals are specific, measurable, attainable, realistic and time-oriented; implementation which comprises action or executing nursing interventions bounded by care plan and this includes application of monitors, administration of medications, standard protocols of treatment, and evidence-based practice standards; and the last step is evaluation which evaluates or assesses to meet desired results [3] .
Evidence-based practice is driving current’s healthcare situation. Specifically, the practice of nursing, and the must-be structure for nurses in the frontline to start prevention, initial recognition, involvement and application of practices and platforms to address Global Health Issues. Lastly, the maintenance of leaders for execution of practice revolutions is essential in establishing a conservational belief that implements and values evidence-based practice [4] .
1.1. Nursing as an Art and Science: The Profession
Nursing as an art may be defined as the care, compassion, communication, comprehension, and love in patients care while nursing as a science refers to the physiological disease processes along with the methodologies acquired through learning and applied through patient care [5] . Nurses apply these skills using systematic knowledge earned from learning institutions while bonding with patients. In a study entitled, “Opinions of Nursing Students on the Art of Nursing: A Qualitative Study”, stated that to balance the art and science in nursing, education needs restructuring to intertwine the two in order to relate it both in nursing care. Hence, recommended working the same research in nurses in other culture [6] .
To drive the art and science of care, the compassionate care is related with improved well-being results, better concordance to prevention and management commendations, lesser medical errors, lesser expenses and improved patient-family health care experiences. These are being integrated in everyday practice; the scientific knowledge in caring and the art of making it, as killis important in nursing management. Whether nursing is an art or a science, it is a noble practice to instill health and help the ill or the sick. It is a profession of helping people back to their feet. Most of all, it is a career that entails all the right essentials to make the right management work [7] .
The nursing profession illuminates the nature of a combined science and art, both are indispensable in the process and delivery of nursing care. The science in nursing is made up of structured knowledge that deals with principles and the art of nursing is the creative application of knowledge learnt based on skills and expertise. The competency of nurses in the process of nursing care is imperative to promote patient safety, not just competency but caring with dedication and compassion. The art and science of nursing must be embedded with sound reasoning, appropriate decision making and precise judgement as the key elements in preventing iatrogenic harm to the recipient of care and achieving high level of wellness.
1.2. Nursing Practice: Readiness and Competency
Nurses assume a systematic role in patients with persistent condition needs and with the increasing incidence of chronic diseases and aging populace, the burden on prime care also increases [8] . Along with the involvement of nurses in the primary care, they need to use the extent of their training to its full prospective for the improvement of experience in health practice. Integrating fresh approaches in practice, nursing professionals can practice towards improving and refining occurrences of informal teaching to generate it effectively and productively while in making informed practice judgments, comprehensive data is accessed by nursing professionals and be able to interpret it right [9] [10] .
The “Global strategic directions for strengthening nursing and midwifery 2016-2020” and dissected the themes in guiding the influences of the nurse and midwife professionals in improving world health like: ensure education, competency and motivation in the workforce through efficacy and responsiveness among all levels and settings of health organizations; optimize program improvement, operative leadership, organization and authority; maximize their capabilities and potentialities by professional collaboration, learning/training, and continuing professional development (CPD); and mobilize political intention to build operative evidence-based development of workforce [2] .
2. Practice Rationale Care: The Model
The Practice Rational Care Model (Figure 1) illustrates that the center of nursing care in the health care settings are its patients. It is imperative that nurses must develop rapport by therapeutic communication and performing nursing skills and procedures competently. Clinical reasoning is a precise expression that refers to the nurses’ approach of thinking about patient concerns. The impact of patients’ positive outcomes relies on how nurses are effective in clinical reasoning and put it into action upon clinical decision making occurs. Thus, nurses with poor clinical reasoning skills frequently fail to see and notice patient worsening condition, thus misguided decision making arises that leads to ineffective patient care and adding patients suffering. Clinical judgment on the other hand denotes on the outcome after the cycle of clinical reasoning. Within this context, nurses apply reflection about their actions from the clinical decision making they made. The process of applying knowledge, skills and expertise in the clinical arena through clinical reasoning is the work of art in the nursing profession in promoting patient safety in the course of delivering routine nursing interventions. Nurses must be guided with their sound clinical reasoning to have an optimistic outcome and prevent iatrogenic harm to patients.
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Figure 1. The practice rational care model.
With the growing demands for nurses in the health care industry all over the world, every nurse is obliged and defied to meet the expectations of providing quality healthcare. Nurses must be equipped with knowledge, skills, attitude and values but most importantly prepared to face the bigger picture of responsibility to care for every patient in the clinical field. Dealing to patient issues and concerns is not easy and meeting the demands of care is challenging but with proper training and appropriate use of clinical reasoning, right and sound decision making, and positive clinical judgement will ease the burden of both nurses and patients and their significant others.
2.1. Elements of Care
The care that is patient-centered is an essential element in delivering healthcare. Empathy, compassion and rapport are the cornerstones of constructive experience in the clinical setting along with behavioral methodologies to enjoin optimistic relationship between the care provider and the patient [11] . These strategies include providing thorough explanation and numerous opportunities for all questions of the patients, being attentive to body language and creation of positive clinical setting, evading the use of jargons, and having an appropriate time management [11] . There are more discussions and by that, patients are enjoined to bring out their sentiments and perceptions. Human resources and role of nurses in supervising decisions as regions to improve for optimum health care and the nurse managers must be equipped with knowledge on working settings to improve significant dimensions in carrying out nursing process [12] .
Clinical reasoning is an in-depth analysis of a gathered data and information from the patient in the entire course of the nursing process to identify patient risk and existing problems including rationales of all nursing procedures and interventions rendered. Clinical decision making is a period where actions are chosen to perform after a comprehensive investigations and examinations and identifying appropriate management to address the patient condition; whereas clinical judgment is the outcome of every actions that takes place in clinical reasoning and clinical decision-making in the process of nursing care. These outcomes are accompanied by responsibility and accountability.
2.2. Clinical Reasoning
Clinical reasoning is a “cognitive processes and strategies that nurses use to understand the significance of patient data, to identify and diagnose actual or potential patient problems, to make clinical decisions to assist in problem resolution, and to achieve positive patient outcomes” [13] . Moreover, they see clinical reasoning as a manner of nurses observing the status of the patients, processing relevant data/records, comprehending the problem of the patients, planning and implementing involvements, evaluating results, reflecting from the results, and learning from the methods. Clinical reasoning happens every day in a hospital or home setting. The need to bring a rational standpoint will affect the outcome of the management, and the condition of the patient as well [14] .
The practice of nursing mandates skills of comprehensive judgment and decision making because of thinking critically and deciding clinically is important elements in the practice of nursing [15] . The employed records of nursing process in assessing the development of clinical reasoning before and after the exposure in a high-reliability post-operative model practice thus resulted to fostered quality patient care [16] . The barometers of clinical reasoning include control, recognition and response to significant information, specified symptoms, utilizing questions pointing to pathophysiological rationale, asking questions in chronological direction, focusing on pact with patients, making summary, and understanding body semantic [17] . Prior seeing the effects of clinical reasoning, it is important that it starts at the level of undergraduate activities for its development. It is a skill learned at the undergraduate level that needs involvement and willpower during practice and to acquire these skills, the need of students to improve the capability of critical thinking along with comprehension reaching multi-faceted healthcare settings through decisions and judgments [15] .
2.3. Clinical Decision Making
Clinical decision making is defined as “a contextual, continuous, and evolving process, where data are gathered, interpreted, and evaluated in order to select an evidence-based choice of action” [18] . Thus, refining healthcare compels refining clinical decisions and creating it even more rational. Selected normative philosophies point that choosing to be rational is a method of selecting and not of what is being selected: decisions can be good at first but it can also become bad afterwards or vice versa, but in the end, better decisions will also generate better outcomes [19] . There are factors that influence clinical decision-making. In a study entitled, “Analyzing the effectiveness of teaching and factors in clinical decision-making found that past experience, workload, and decision-making are essential factors that influence decision-making”. These factors are implemented with varieties of challenges and by identifying all of these; it will develop the process of nursing rightly [20] . The main challenges are insubstantial comprehension on the idea of nursing process, diverse views of the development, deficiency of understanding and consciousness among nursing professionals akin to implementation of nursing process, support of management methods, and problems that are related to records during the process [20] .
2.4. Clinical Judgment
The concept of clinical judgment is critical and complex to nursing professionals for it requires the practice of observation skills, identification of appropriate data, and recognition of associations among the elements by judgment and rationalization [15] . Therefore, the actions of nurses are their own responsibility and their judgment along with their inaction and action are their accountability [21] . This means that nurses must be focused on clinical judgment based on evidence-based practice. With everyday activity of keen observation and reasoning skills will bring a reliable and sound medical judgment. It is through nurses’ experience where their speed and capability in making comprehensive clinical judgment is affected [15] . Therefore, new nurses can find difficulty in this process while more experienced ones depend on their perception and then act at once. The categories for the development of clinical judgment include: striving for gaining professional autonomy for individual proficient identity; striving for integrating clinical judgment for utilization of varied skills in clinical judgment via condition and situation of the patient; scrambling to make educational interventions to incorporate judgment in the curriculum and education in nursing; and striving for professional and inter professional collaboration to include important members of the management team [22] .
The combination of Modified Early Warning Score (MEWS) an objective vital sign-based risk prediction scale and Patient Acuity Rating (PAR) a subjective 7-point Likert scale assessment is useful in identifying patient deteriorating condition. This means that judgment must be incorporated with objective and subjective data to generalize assessment during clinical deterioration [23] . Additionally, this will bring assistance in an on-time mobilization of funds in addressing the cause of clinical deterioration [23] . On the other hand, the intricacy of theory-practice incorporation, reflection, and clinical supplement as critical components in facilitating clinical judgment and the necessity of strategies to facilitate it in the nursing setting and recommends enhancement of experiences in learning to develop thinking skills, knowledge, and attributes of students through placement in the learning settings [24] .
3. Summary
The Practice Rationale Care Model is system of clinical reasoning and clinical decision yielded by clinical judgment. It commences during undergraduate course in nursing and improved tremendously in practice as a profession. It provides a multi-faceted method to integrate clinical reasoning, clinical decision-making, and clinical judgment essential in the process of nursing care to prevent iatrogenic harm. The Institute of Medicine (IOM) report on the Future of Nursing specified that nursing professionals should continue their education and participate in lifetime learning to advance the desired competencies and skills for practice.
The identified key points in the nursing process will help nurses to mold a well-rounded care plan. Clinical reasoning is an activity on a daily basis, and it comes along with clinical decision making and clinical judgment. To mold the nursing process with positive results for patient care, critical reasoning, clinical decision making, and clinical judgment are utilized even with a non-critical event to ensure the safety and well-being of every patient. Critical reasoning phases include observe, collect, process, decide, plan, act, evaluate, and reflect [16] . Some researchers used different methods to come up with effective reasoning like records of nursing process in assessing the development of clinical reasoning before and after exposure in a high-reliability post-operative model practice and questions for rationale [16] [17] .
Clinical decision-making refines healthcare. Factors that influence decision making are past experience, workload, and decision-making [20] . Challenges come along with these factors; therefore, it is important to identify these factors. Challenges are insubstantial comprehension on the idea of nursing process, diverse views of the development, deficiency of understanding and consciousness among nursing professionals akin to implementation of nursing process, support of management methods, and problems that relate to records during the process [20] . Clinical judgment needs practice of observation skills, identification of appropriate data, and recognition of the associations among the elements by judgment and rationalization because nurses take responsibility and accountability with their judgment in their action and inaction and this will be enacted using evidence-based practice, trainings, and learning [15] [21] . New nurses will need more time to hone their skills while the experienced nurses will use sensitivity and fast action.
There are categories in developing clinical judgment striving for gaining professional autonomy for individual proficient identity; striving for integrating clinical judgment for utilization of varied skills in clinical judgment via condition and situation of the patient; scrambling to make educational interventions to incorporate judgment in the curriculum and education in nursing; and striving for professional and inter professional collaboration to include important members of the management team [22] . The need of students to improve the capability of critical thinking along with comprehension reaching multi-faceted healthcare settings through decisions and judgements [15] .
This model will guide the nurses in the delivery of safe patient care and enhance the quality of healthcare services provided in the healthcare settings. With the aim to empower nursing skills and competency, every nurse must have the power of mind to comprehend and rationalized all actions performed in the process of patient care in order to come up with an excellent achievement of the goals of the nursing care plan and provide every patient a high quality of care any varieties of condition. The model is designed and presented to clearly understand the essentiality and vitality of clinical reasoning, clinical decision making, and clinical judgement in the whole course of the nursing process.