Acquisition of clinical reasoning skills by undergraduate nursing students in Malawi; towards the development of a middle-range theory: a qualitative study

Abstract

Introduction

Acquiring clinical reasoning skills is essential for patient safety in nursing, and a lack of clinical reasoning skills can harm patients. However, teaching and learning clinical reasoning skills is not easy due to its complexity. Without a model, clinical reasoning is taught intuitively. Therefore, this study aimed to investigate how undergraduate nursing students acquire clinical reasoning skills towards the development of a middle-range theory.

Methods

This study employed the grounded theory of systematic design underpinned by a social constructivism paradigm. Forty-eight (48) undergraduate nursing students were purposive, and 12 nurse educators were theoretically sampled. Nurse educators were full-time lecturers with two or more years of teaching experience who were willing to share their knowledge to promote clinical reasoning skills. Students in their third and fourth years were selected because of their completion of the three- to four-year educational process and their acquisition of essential knowledge and competencies. Twelve individual in-depth interviews and six focus group discussions were conducted with nurse educators and undergraduate nursing students, respectively. Two qualitative data analysis frameworks were employed to analyse the data: thematic analysis and grounded theory analysis. Ethical principles of respect for human dignity, beneficence and justice were observed.

Results

Undergraduate nursing students reported that their clinical reasoning skills were acquired through automation while they utilized the nursing process. Through the themes, a new theory called ‘a middle-range theory for the acquisition of clinical reasoning skills’ was generated in the present study. The associated concepts were the environmental setting, type of curriculum, anchors and expected outcomes, which included individual and health care system indicators.

Conclusion

Teaching undergraduate nursing students how to reason clinically will help nurses adjust and solve problems in changing patients’ situations. On the basis of the findings of this study, it is recommended that nursing students be equipped with adequate clinical reasoning skills before they graduate. Therefore, implementing the new model called ‘a middle range theory for the acquisition of clinical reasoning skills’ could foster the development of clinical reasoning skills from the start of the nursing training program.

Background

Nurses who do not have clinical reasoning skills are dangerous to the nursing profession, as they fail to rescue patients who could have been saved. Clinical reasoning is crucial for nursing students, as it informs decision-making that affects patient care.

Clinical reasoning is a broad phrase that refers to the processes by which information is gathered and analysed to make essential conclusions for health care [1]. However, other terms are used interchangeably with clinical reasoning, such as clinical judgment, decision-making, or even critical thinking, which supports safe and effective care delivery [2, 3]. Although they share some characteristics, each has distinct features. The Tanner defines clinical judgement as an interpretation or conclusion regarding a patient’s wants, concerns, or health problems, as well as the decision to act (or not), apply or adjust established procedures, or create new procedures that are regarded as appropriate by the patient’s response [4]. Simmons defines clinical reasoning as a complicated cognitive process that employs formal and informal thinking processes to receive and analyse patient information, evaluate its importance, and weigh alternative options [2].

The clinical reasoning process involves acquiring cues and analysing them to identify clients who require attention [5, 6]. The nurse is prompted by these cues to take the necessary action at the appropriate time to assist these patients [5, 6]. To make informed professional judgments and face problems, the metacognitive process requires critical thought, exposure, and information [4, 7]. Critical thinking is an intellectual process requiring analysis, logic, and knowledge change and is influenced by mental habits such as confidence, determination, and creativity [8].

Nurse educators are tasked with providing educational experiences that produce safe, competent nurses who can reason in a clinical setting. However, published reports have highlighted a lack of clinical reasoning skills in practicing nurses and have called for the acquisition of these skills within nursing education [9, 10]. Nursing schools should provide learning opportunities to encourage students to critically assess complex issues rather than merely consuming information [11]. Nurse educators should include clinical reasoning processes in their curricula to instruct and engage students in this process. Even though clinical reasoning is required in both classroom and clinical settings, nurse educators confront obstacles in teaching it [10]. contend that clinical reasoning is sophisticated, invisible, and implicit, making it difficult for students to learn.

Registered nurses use clinical reasoning in dynamic healthcare scenarios, which is influenced by factors such as communication, education, critical thinking, the environment, experiences, and professionalism. Graduate nurses should have a solid foundation in clinical reasoning to join professional practice [12]. However, there is a paucity of evidence in the literature for the identification of the necessary nature of clinical reasoning skills, allowing for the acquisition of these skills, particularly in clinical nursing [13].

The term “clinical reasoning” first appeared in the nursing literature in the 1980s and refers to a sophisticated mental process used by healthcare providers to process patient information before planning [14]. In the nursing profession, the notion of clinical reasoning has been described by several writers, such as Tanner [4] and Dalton et al. [5], to demonstrate that it is an important concept for encouraging caring practices. In 2004, Murphy described clinical reasoning as health practitioners’ ability to make judgments about patient requirements and find solutions to problems in patients. Similarly, Dalton et al. [5] conceptualize clinical reasoning as a set of possible acts that nurses select from, as evidence, to arrive at a clinical conclusion on the basis of recognition and natural intuition.

In a 2010 concept analysis [2], Simmons described clinical reasoning as a multidimensional process that uses metacognition, cognition, and a discipline with specific expertise to assemble and analyse patient information, evaluate its meaning, and consider choices thoughtfully. Clinical reasoning in nursing is the process of forming professional judgments on the basis of the quality of available evidence to enhance how patients’ problems might be treated [15]. Clinical reasoning has also been recognized as a significant aspect of medicine. Clinical reasoning in medicine is also essential for achieving accurate clinical diagnosis [16]. For doctors, clinical reasoning includes not only holding a body of information but also gaining a level of experience that distinguishes an expert from a novice. According to Audetat et al. [17], most clinical reasoning errors are caused by the fragility of thinking in complex real-life settings rather than a lack of expertise or ineptitude. As a result, students must become familiar with the clinical reasoning process and learn how to gather evidence to make sound decisions. To learn how to work in complicated clinical scenarios, nursing students need to know the procedures used in clinical reasoning, a process that is based on obtaining patient cues to shape clinical decisions, which in turn can impact outcomes.

The clinical reasoning cycle consists of eight major phases: look, collect, process, decide, plan, act, evaluate, and reflect [18]. Because clinical reasoning is a nonlinear, dynamic process, these phases frequently mix in real-world settings, leaving no apparent distinctions. When a nurse makes a decision, phases might be mixed, or one phase can move back and forth through the processes to ensure that actions are completed and results are assessed. Clinical reasoning can be acquired via a variety of models, including pattern recognition or inductive reasoning (comparison); decision tree or decision analysis algorithm methods for organizing, which involve generating preliminary hypotheses and processing information via logic to reformulate, accept, or refute them; and the exhaustion method, which searches an individual’s clinical data and compares it to known standards to determine the current diagnosis [19].

Although teaching clinical reasoning skills is regarded as a difficult process, fields such as nursing have little choice but to teach these skills, as errors in clinical reasoning continue to cause high rates of morbidity and mortality [20]. Nurses with good clinical reasoning skills have a beneficial impact on patient outcomes. Conversely, individuals with poor clinical reasoning skills frequently fail to anticipate patient deterioration, resulting in a ‘failure to rescue’ [16]. Given the importance of clinical reasoning skills for caring professionals, both academic and clinical contexts should be used to develop these skills [21]. Nurse educators require a solid basis to encourage clinical reasoning (CR) in students and practice nurses. The educational process in nursing programs should include a program-specific curriculum to ensure that future nurses flourish. The curriculum design influences teaching strategies and learning activities for nurse educators and student nurses, promoting a student-centred approach that prioritizes patient safety and aims to produce safe, capable graduates in nursing education.

In Malawi, the landscape of clinical reasoning in nursing education is relatively understudied, with limited available research. However, the general recognition of the importance of this skill in healthcare practice is consistent with global trends. Efforts to strengthen clinical reasoning capabilities in Malawian nursing students may benefit from the insights and strategies employed in other contexts. Incorporating evidence-based teaching and learning methods, leveraging technology, and fostering a culture of ongoing professional development may prove valuable in enhancing the clinical reasoning skills of future Malawian nurses.

Malawi’s nursing education is consistent with the NMCN’s goal to provide clinical reasoning skills and acceptable attitudes for student nurses to attain the requisite practice [22]. This can be accomplished through classroom teaching and learning strategies used by nurse educators and students. Notably, clinical reasoning is an absolute need for undergraduate nursing students to contribute to positive results in the delivery of nursing care in Malawian institutions.

Ironically, new graduate nurses have not been effectively adapted, regardless of whether they are trained as registered nurses with a bachelor’s degree or as technicians with a nursing diploma. Records show that qualified nurses provide significantly inadequate patient care, have limited clinical thinking, and use appropriate judgments when dealing with complex patient situations [22]. This lack of critical thinking produces an imbalance in which nurses are expected to think in new ways to suit the changing health environment [22]. Furthermore, reports suggest that undergraduate student nurses do not make clinical judgments about client care in practice; instead, they rely on the clinician or doctor to determine what should be done for the patient. However, undergraduate nursing students are taught how to collect data, analyse them, and make judgments on the basis of the client’s circumstances in a classroom setting and during clinical practice. Nurses with poor clinical reasoning skills lead to errors in care delivery and failure to rescue patients from negative outcomes [23]. Saintsing et al. in Spain [9] reported that approximately 50% of new graduate nurses were responsible for medication errors, 20% were involved in incidences of falls, and 30% had incidences of failure to rescue within their first year of employment. With such incidences, it is known that it is expensive for the healthcare system to settle these issues due to a lack of clinical reasoning skills. The effect of underdeveloped clinical reasoning has been observed in healthcare settings through the inability of undergraduate and experienced registered nurses to link theory, identify deteriorating individuals promptly, and manage emergencies [24]. According to Delany [10], learning clinical reasoning skills in clinical settings is difficult for student nurses since qualified nurses who are expected to impart the skill do not do so. Failure to transmit skills could be related to teachers’ insufficient expertise in employing clinical reasoning skills in their practice [10]. Despite educational institutions teaching clinical reasoning skills, graduates in Malawi are often unprepared for the workforce and lack the necessary skills to provide high-quality nursing care to patients [25]. As such, when teaching in classroom settings, nurse educators must assist students in understanding the subject content as well as the importance of patients’ data. This can be accomplished if there is a theory to guide the teaching and learning of clinical reasoning skills. Clinical reasoning skills in classrooms and clinical settings are underutilized, and factors influencing them have received minimal attention in nursing education [26]. The findings of this study might act as a tool for use by nurse educators in the planning and implementation of strategies for promoting the acquisition of clinical reasoning skills. The findings would also contribute to the existing body of knowledge which might provide a useful guide for further studies in clinical nursing education in Malawi. The study findings would provide evidence-based data for curricula review to incorporate innovative teaching strategies, assessment and evaluation of students on clinical reasoning in the clinical area

Therefore, this study sought to investigate how undergraduate nursing students acquire clinical reasoning skills to develop a middle-range theory that could guide the teaching and learning process of this skill. The study was specifically led by the research questions listed below. (1) How do undergraduate nursing students learn clinical reasoning skills? (2) What theory can be developed to help undergraduate nursing students learn clinical reasoning skills more effectively?

Methods

Study design, paradigm and context

The current study employed a grounded theory approach [27, 28]. A grounded theory based on a social constructivism paradigm was utilized, also known as the constant comparative approach, which is an inductive systematic investigation of empirical observations and data to produce a theory [27, 28]. This approach was useful for developing a middle-range theory. The researcher conducted interviews with nurse educators and students to understand clinical reasoning skills acquisition and how educators promoted it, aiming to develop a middle-range theory on the basis of participant experiences. Researchers have utilized the Tanner Model of Clinical Judgment, a framework that emphasizes intuition and experiential factors in decision-making [4]. The model comprises four components: noticing, interpreting, responding, and reflecting. This structured approach helps nursing students improve their ability to make good judgments in patient care scenarios, as illustrated in Fig. 1 [4].

Fig. 1

Conceptual framework. Adopted clinical judgement model Tanner [4] to illustrate acquisition of clinical reasoning skills by undergraduate nursing students

The study was conducted at Kamuzu University of Health Sciences and Mzuzu University. Kuhes consists of five schools that train health professionals in a variety of subjects at the undergraduate and postgraduate levels around the country. The school has two campuses: Blantyre in the south and Lilongwe in the Centre. While Mzuzu University is one of two state universities in Malawi’s northern region, it offers nursing education at the bachelor’s and master’s levels through its nursing and midwifery faculty. The faculty of nursing and midwifery oversees training registered nurses to the bachelor’s degree level for four years.

Participants

The participants were nurse educators and undergraduate nursing students. Nurse educators were full-time lecturers with two or more years of teaching experience who were willing to share their knowledge to promote clinical reasoning skills. Nurse educators with fewer than two years of teaching experience, as well as those in upper management, were excluded because of their lack of teaching expertise. The nursing students were preregistered student nurses pursuing a bachelor’s degree in their third and fourth years of study. Students in their third and fourth years were chosen since they had completed the educational process for three to four years and were expected to have gained essential knowledge and competencies. Nursing students in the first and second years of the study were not recruited for the study because they did not have enough clinical experience.

Sampling and sample size

The researcher used both purposeful and theoretical sampling [29]. Glassier (1978), as cited in [30], defined theoretical sampling as a data collection process for generating a theory in which the analyst collects, codes, and analyses data together before deciding what to collect next and where to find participants to provide information to develop the theory as it emerges. The sample size comprised 6 focus group discussions with students who met three times each, with 8 participants from the two training institutions (8×3x2 = n 48), referred to as FGD 1–6 in the results section, and 12 individual in-depth interviews with nurse educators, referred to as B1–12 in the findings section. Hence, (48) forty-eight undergraduate nursing students and (12) twelve nurse educators were purposively sampled to explore the acquisition of clinical reasoning skills. The sample size was not fixed, and data were frequently reintroduced until saturation [30]. Guest et al. [31] argued that data saturation has “become the gold standard by which purposive sample sizes are determined in health science research” and proposed that data saturation can occur after 12 interviews.

Instrumentation and data collection

Instrument

A semi structured interview guide was ideal for the study since it offered a foundation for truth convergence while also allowing a researcher to explore the issues under investigation more deeply [27]. A semi structured interview guide was used for an in-depth interview. The instructions included six open-ended questions for nurse educators, several probes, and five open-ended questions for nursing students. The topics in these guides addressed various elements that were hypothesized to be associated with nursing students’ acquisition of clinical reasoning skills. A checklist was also utilized to review the curriculum’s clinical reasoning content. The two qualitative experts reviewed the interview guide to enhance its reliability and validity.

Data collection

The researcher collected the data over a period of six months from October 2022 to March 2023. Data were collected through semistructured interviews, focus group discussions, document reviews, and observations. In-depth interviews were conducted with nurse educators, and focus group discussions were held with undergraduate nursing students in English. The focus group discussions with the undergraduate nursing students were conducted in English, because it is a learning medium for nursing training institutions in Malawi. The nursing students were in six (6) groups comprising 8 students, for easy management. In this study the focus group discussions are referred to as (FGD 1–6). At the start of each focus group discussion, undergraduate nursing students were asked: in which year of study are you. How are clinical activities done here? These questions encouraged undergraduate nursing students to reflect on the challenges they face when nurse educators engage them in acquiring clinical reasoning skills.

After background details, the researcher asked open-ended questions and listened to the responses while using the audio tape recorder with the permission of the participants so that no data was missed. File notes were taken where necessary. The focus group discussion took approximately 60 min. The number of sessions depended on data saturation. In total 8 focus group discussions were conducted. The researcher conducted 12 in-depth interviews with nurse educators. The room in which the interviews were conducted was quiet and comfortable in the training institutions, with good lighting and good ventilation, all of which contributed to a relaxed and informal atmosphere. The researcher continued with the open-ended questions and listened to the responses while maintaining eye contact and nodding to encourage the participant to narrate. The researcher also probed where it was necessary to elicit more information that was thought to be relevant to the study. The audiotape recorder was used with the permission of the participants so that no data was missed. At the end of each interview, participants were asked if they wish to make any comments about the study topic. Following this, the researcher thanked each participant for his or her time and valuable contribution. The interview took approximately 45 min with each nurse educator. The interviews were conducted only with the researcher and participants [30].

Data analysis

Two qualitative data analysis frameworks were employed: thematic analysis and grounded theory analysis. Thematic analysis [32] was used to analyse data collected from semistructured interviews, focus group discussions with nurse educators, and undergraduate nursing students. It entailed categorizing data into themes derived from reoccurring codes that were similar or related to one another. The study consisted of five primary steps: familiarizing oneself with the data, generating initial codes, searching for themes, refining the themes, and identifying and labelling themes. The data analysis began with data gathering from the first focus group discussion with undergraduate nursing students and semistructured interviews with nurse educators. The data were analysed via the [33] ground theory technique.

Forty-eight (48) undergraduate nursing students from the two nursing training institutions were divided into six groups of eight each and took part in focus group discussions where they were asked to respond to questions from the interview guide (Additional file 1). The undergraduate nursing students discussed how they learned and acquired clinical reasoning skills, both in the classroom and in clinical settings. In total, six focus group discussions involving eight students were held, three per training institution. In this study, focus group discussions were used to gather retrospective data on past events about the acquisition of clinical reasoning skills in undergraduate nursing students, despite the limitations of focus group discussions regarding dominant voices [34]. Three questions were asked: 1. How do you see your educational preparation for practice? 2. How can teaching help you develop your reasoning skills? 3. What is your opinion of the nature of classroom instruction for the acquisition of clinical reasoning skills during this training?

The three questions allowed the undergraduate nursing students to explain how they came to learn and acquire their clinical reasoning skills. Themes related to the acquisition of clinical reasoning skills were identified from the three questions. Other questions provided additional information about the acquisition of clinical reasoning skills among undergraduate nursing students. With assistance from the dean’s office, the students in the first focus group discussion were purposefully chosen on the basis of their clinical practice performance. The other groups, which the students themselves formed, proceeded afterwards. Data were gathered from the remaining focus groups until saturation, or the absence of new information, occurred [35]. This method was proposed by [36], in which the data collection process for creating theory is jointly collected, coded, and evaluated, with the researcher deciding what data to collect next and where to discover the data to create the emerging theory. The interviews with nurse educators complemented the data on the acquisition of clinical reasoning skills.

Using grounded theory principles [28], data were analysed mostly by reading and rereading transcribed focus group discussions, one-to-one interviews and comparing transcribed verbatim interviews to audio recordings. The selected themes were compared, modified, and regrouped into key themes, which were then coded at various nodes via the NVivo version 10 qualitative data analysis program. Because data collection and analysis are integrated in GT [37], the data analysis processes occurred concurrently, as the researcher had to go backwards and forth between data analysis and collection. The researcher and supervisors discussed the categories to develop succinct and clear labels for each, allowing the core category of a proposed model to emerge. Finally, one (1) major theme was discovered, along with six (6) subthemes related to how undergraduate nursing students acquired clinical reasoning skills (Table 1). Through these themes, a proposed model called “a middle-range theory” for acquiring clinical reasoning skills emerged. The researcher then developed a model to explain how undergraduate nursing students learn clinical reasoning skills on the basis of themes found in the qualitative data and theoretical linkages most clearly demonstrated by the data (see Fig. 2).

Table 1 Summary of transcribed data

Fig. 2

A middle- range theory for acquisition of clinical reasoning skills to guide teaching and learning of undergraduate nursing students in Malawi by Mwale 2024

Trustworthiness of the study

Trustworthiness is a measure of how well researchers’ findings describe circumstances or entities. All research findings should be free of prejudice and inaccuracy (to the greatest extent possible) [29]. According to Lincoln and Guba 1985, as cited in [27], trustworthiness is related to the quality, authenticity, and reliability of qualitative research findings. To increase credibility and confirmability, we developed a positive relationship with the participants and triangulated the qualitative materials during transcription, analysis, and induction. To ensure the reliability of the study, we carefully constructed it and recruited two experts from outside the team to examine it. To determine transferability, the researchers ensured that enough information about the research procedure was available to duplicate this work. This includes information about the study paradigm, research design, location, recruiting and sampling strategies, data collection procedure, interview guide, and data analysis approach.

Findings

Demographic characteristics of the participants

This study recruited (n = 48) undergraduate nursing students and (n = 12) nurse educators. Tables 2 and 3. The demographic characteristics of the undergraduate nursing students are reported in terms of the following variables: age, sex, and level of study. The demographic characteristics of the nurse educators are reported on these variables, such as years of teaching experience, gender and qualifications.

Table 2 Demographic characteristics of the undergraduate nursing student

Table 3 Demographic characteristics of nurse educators

The majority of the undergraduate nursing students were females (n = 28) (58%), and (n = 20) (42%) were males. The undergraduate nursing students (n = 28) (58%) were in their third year, whereas 20 (42%) were in their fourth year.

The nurse educators had different work experiences. A total of (n = 4) (33%) had taught for 16–20 years, whereas (n = 5) (47%) had worked for 6–10 years. Two (8%) had worked for 21–25 years, whereas (n = 1) (2%) had worked for 0–5 years. All the nurse educators were registered nurses with different qualifications in nursing. Ten (n = 10) (83%) had a master’s degree in nursing, whereas (n = 2) (17%) held a PhD in nursing.

One major theme that emerged from the transcribed data is the classroom and clinical setting, with six subthemes: (1) attitudes of nurse educators, (2) lack of preparedness by nurse educators, (3) lack of modelling, (4) assessment and feedback, (5) improved nursing profession and (6) improved delivery care system. The undergraduate nursing students reported that clinical reasoning was acquired through automation while utilizing the nursing process.

Classroom and clinical setting

Under this theme, six subthemes emerged from the transcribed data.

Attitudes of nurse educators

When students are not well prepared to acquire clinical reasoning skills, it means they will not be ready to practice safely. In addition when nurse educators have negative attitudes towards students, students fail to acquire the skills. In this study, it was discovered that nurse educators’ attitudes influenced the undergraduate nursing students ability to learn clinical reasoning skills. It was alleged that some lecturers yelled at students and terrified them that their destiny was in the hands of nurse educators. As a result, students recoil. The participants echoed the statement, “Some lecturers shout at us. (FGD1).

Lack of preparedness by nurse educators

The current study revealed that nurse educators’ lack of preparation hindered the acquisition of clinical reasoning skills. It has been claimed that nurse educators arrive at class or in the clinical setting unprepared. In support of this, the participants stated, “They come to class unprepared, so how can they impart clinical reasoning skills?” (FGD3).

Lack of role modelling

The study also revealed that a lack of role modelling had a greater influence on the acquisition of clinical reasoning skills. The participants said, when you are in the ward, the qualified nurses fail to transfer the skill to us. Even when nurse educators come for supervision, they greet us only, and when they do not, they do so, they do not engage us. (FGD 5). However, the undergraduate nursing students believed that the acquisition of clinical reasoning skills would help transform the perception of the nursing profession and assist society as a whole if they were well prepared for it.

Nonetheless, undergraduate nursing students strongly suggested that if they were well equipped to gain clinical reasoning skills, the image of the nursing profession could change, and society would benefit.

Assessment and feedback

Under this subtheme, it was discovered that the Nurses and Midwives Council of Malawi assessment methods do not address the component of clinical reasoning skills, despite the regulatory body’s desire to maintain nursing standards. The participants stated, for example, “Let me be honest here; I do not believe I have ever been assessed on clinical reasoning because the assessment forms do not capture that.” We students must master the topic to pass the exam or evaluation. (FGD6, FGD5). ‘no timely feedback is given to us.’

Improved image of nursing professionals

The study also revealed that teaching clinical reasoning skills to undergraduate nursing students could influence their perceptions of the nursing profession. The participants stated that ‘if we have clinical reasoning skills, we will apply the knowledge/skills to address current trends and concerns’ (FGD1, FGD3). When an undergraduate nurse graduates are competent, it indicates that they are safe to practice. The participants also stated that ‘we feel that avoidable deaths of patients will be minimized’ (FGD4; FGD2).

Improved nursing care delivery system

The study findings also revealed that if undergraduate nursing students were well prepared with clinical reasoning skills, patients would receive better treatment. The participants commented as such. ‘If we acquire clinical reasoning skills, the quality of care will improve’ (FGD2, FGD6). It has also been reported that patients are satisfied with their care. The participants stated that ‘even the stakeholders’ complaints will be a thing of the past’ (FGD6).

One-on-one interviews with nurse educators revealed that the acquisition of clinical reasoning skills was dependent on specific anchors. These anchors included the curriculum type, qualified nurse educators, a conducive learning and teaching environment, access to functioning learning and teaching tools, a student-centered curriculum, and ongoing support. These are depicted in Table 4, which shows clinical reasoning anchors and excerpts from the nurse educators about the genesis of the suggested middle-range theory. Through the process of reduction and comparison, the basic category of clinical reasoning skill acquisition was identified. Several traits began to integrate, and the resulting middle-range theory emerged (Fig. 2).

Table 4 Clinical reasoning process anchors

Discussion

In this study, undergraduate nursing students stated that they were not well equipped to learn clinical reasoning skills. The students also explained that they learned clinical reasoning skills through automation as they applied the nursing process. This study significantly confirms the findings of [34], who noted that nurses provide the best care when it is administered within the nursing process framework. On the other hand [38], claimed that clinical reasoning and the nursing process are not equivalent. The nursing process is linear and does not capture more sophisticated clinical reasoning principles. While the nursing process is linear, clinical reasoning is required while planning treatment [4]. further argued that the nursing process does not allow for the more complex brain processes required for clinical reasoning, such as analysis, intuition, and narrative thinking. It appears that there is no relationship between [4] clinical judgment and the nursing process that undergraduate nursing students utilize to develop their clinical reasoning skills. This is far from the truth. The nursing process is the original and widely accepted model for how nurses think and make decisions. The nursing process includes assessment, analysis, planning, implementation, and evaluation [38]. emphasized that the assessment step contains Tanner’s noticing. Both need the nurse to analyse the patient and/or scenario, as well as notice/recognize indicators that indicate a problem. The analysis envelopes rank the hypotheses via cue analysis. Interpreting [4] includes not only these but also the planning and production of solutions. The reason for this is that interpretation requires the nurse to analyse the cues discovered during the assessment, prioritize what he or she believes is wrong, and then begin developing remedies to the problem. The next step in the nursing process is implementation. This means that the nurse acts on clinical judgement. Finally, evaluation occurs. According to Tanner [8], this is a phase of reflection in which a nurse assesses outcomes.

Another conclusion worth highlighting from this study was that nurse educators were unable to supervise students in the clinical setting, hence impeding the development of clinical reasoning skills. When students receive constant feedback, it is much easier to learn clinical reasoning skills because nurse educators can impart them. This study finding is consistent with the findings of [39], who similarly discovered that a lack of supervision of students in the clinical area severely impacted students’ learning.

The study also revealed that the clinical environment was not conducive to students learning clinical reasoning skills. Many qualified nurses shouted at students. This finding contradicts what was reported in [40], in which doctors were able to engage with students and provide guidance, facilitating the learning of clinical reasoning skills, which was not the case in this study.

This study revealed that undergraduate nursing students were unable to develop clinical reasoning skills due to a lack of modelling. When supervisors or qualified nurses actively demonstrate and explain the skills to students, the students learn clinical reasoning skills through observation and self-reflection. This is consistent with the assertions of [41], who revealed that role modelling occurs when a witness imitates an action or skill that has been exhibited. In this study, however, the students did not have any role models from which to observe their skills.

Clinical reasoning is a core competency that all practicing nurses must develop. The narratives of undergraduate nursing students regarding the acquisition of clinical reasoning skills were also linked to the assessment and feedback offered by nurse educators. One participant stated, “Let me be honest here: I do not believe I was assessed on clinical reasoning because the tool does not cover the clinical reasoning skill from the regulatory body.” The formative evaluation of a student’s thinking provides information into how and whether educational methods promote the development of clinical reasoning. Nurse educators use formative evaluation to assess the quality of thinking and provide specific feedback, directing skill acquisition and additional teaching to assist in the development of clinical judgment [42]. This was not the case in the current study.

The undergraduate nursing students in this study believed that if clinical reasoning skills were taught to them, the provision of care would improve, as would the image of the nursing profession. When new nursing graduates receive clinical reasoning training, they are safe to practice. This is consistent with the [43] Ministry of Health’s policies and Health Sector Strategic Plans III (2023–2030), which aim to reform universal health coverage. Health coverage can be attained when new graduate nurses graduate with strong clinical reasoning skills, allowing them to deliver high-quality care to hospitalized patients.

A middle-range theory for the acquisition of clinical reasoning skills

The six (6) primary subthemes that arose from the transcribed data gave rise to the key categories needed to create the suggested model. A middle-range theory for the acquisition of clinical reasoning skills was developed through reduction and comparison, with a focus on the key category of clinical reasoning skill acquisition. It was necessary to develop a middle-range theory that could support the teaching and learning of the acquisition of clinical reasoning skills because undergraduate nursing students lacked sufficient clinical reasoning skills, nurse educators faced difficulties in encouraging the development of these skills, and clinical reasoning skills were absent from the curriculum.

The assumptions of a middle-range theory for the acquisition of clinical reasoning skills generated in the current study are described in the paragraphs that follow. The assumptions are derived from the transcribed data.

Assumptions for a middle-range theory to promote the acquisition of clinical reasoning skills

Undergraduate nursing students’ ability to acquire clinical reasoning skills is based on specific anchoring

The anchors, as defined in the emerging theory, are frameworks that help undergraduate nursing students understand the process and acquire clinical reasoning skills more effectively. These are relevant and responsible curricula, collective methods between clinicians and academics, student-oriented learning, the availability of functional resources and a suitable clinical learning environment.

Clinical reasoning skills are developed through continuous reflection, self-assessment, and self-correction

According to [44], experiences are understood through apprehension or reflection. The undergraduate nursing student must participate in continuous self-reflection after encountering a case and perform a self-assessment of how the patient is managed. Further self-evaluations are carried out by examining weaknesses and strengths. In doing so, undergraduate nursing students develop critical thinking skills.

The mastery of clinical reasoning skills is built on repeated hands-on learning experiences with genuine scenarios

According to experiential learning theory [44], students must acquire clinical reasoning skills through repeated skills. If undergraduate nursing students want to acquire clinical reasoning skills, they must use concrete experience, introspective observation, abstract conceptualization, and active experiments.

Clinical reasoning skills are acquired through a cumulative process that progresses undergraduate nursing students from novice to expert levels on the basis of their experience

This implies that learning is individual, and Kolb felt that experiential learning is a continual process in which the learner brings their unique learning requirements and experiences to their learning environment and learning communities [44]. As a result [44], proposed that this will employ a ‘constructive’ approach to learning, implying that this method sees learning as a continual cycle rather than a permanent process. This suggests that knowledge is built on prior information, that learners are not a ‘clean slate’, and that knowledge cannot be taught without the learner making sense of it on the basis of his or her prior notions. As a result, learners learn best when they develop their understanding via experience and reflection.

Promoting clinical reasoning skills in undergraduate nursing students is a purposeful, intentional, and creative process

When teaching undergraduate nursing students, nurse educators are expected to develop lessons that are demonstration-based. This begins when nursing students enter the programme, where they are tested at each level and encouraged to adopt evidence-based interventions when providing care to patients in the clinical setting.

Description of the concepts from the model central to this research study

To have the same understanding between the researcher and the reader, the following concepts have been defined.

Types of curriculum

It refers to the curriculum that is used to promote the acquisition of clinical reasoning skills. The curriculum used is student-centred, pertinent and responsive.

Prototype competency-based curriculum

In this model, the prototype competency-based curriculum refers to a curriculum that emphasizes self-directed, learner-centred approaches to teaching and learning for the acquisition of competencies, which include transferable skills, problem-solving ability, communication and lifelong learning. In this curriculum, learning is taken as a change in behaviours that are observable or non-observable, where the undergraduate nursing student starts as a novice and later can demonstrate the ability to reason clinically by the end of the four-year programme. This curriculum uses learning and teaching methods that promote the acquisition of clinical reasoning skills through involving students in group discussions, problem-solving, case studies, problem-based learning, and reflection. These teaching methods allow undergraduate nursing students to create controversy and challenge students to think and reason through their intellectual capabilities. The assessment methods used in this curriculum also enhance the acquisition of clinical reasoning skills, which are performed in classroom assessments. These include multiple-choice questions, problem-based learning and case studies. These assessments give the nursing student a chance to reflect, hence fostering higher-order thinking skills and clinical reasoning.

Pertinent and responsive curriculum

It refers to the curriculum, which educates for a long-life process in which the current trends and issues that affect the health care system and society are addressed. This is in line with [45], which reformed universal health coverage.

Clinical reasoning skills acquisition process

This model defines “clinical reasoning process anchors” as the structures that facilitate undergraduate nursing students’ effective acquisition of clinical reasoning skills. This model starts with the nurse collecting assessment data and clustering it to determine a priority nursing diagnosis. On the basis of this diagnosis, a strategy is created, and nursing interventions are performed. After implementation, the client is evaluated again to determine how well the strategy meets the identified patient goals. Teaching nursing students to think in this manner is meant to turn unseen cognitive processes that direct care into visible patterns of thought [45]. The nursing process was found to be useful for beginning nurses but insufficient to guide experienced nursing practice, as it could not account for the intricacies of clinical judgement [42]. Teaching the nursing process is not the same as teaching critical thinking or clinical reasoning, and they should not be treated interchangeably [4]. The students stated that they were examining the patient scenario at hand and collecting subjective and objective data. After the obtained data were analysed to obtain nursing diagnoses, a plan was developed while the key problems were considered. The plan was implemented, and the interventions were delivered to patients who were assessed [4]. suggested that as students learn to think like nurses do, their processes progress from perceiving to interpreting, responding, and finally reflecting.

Anchors of the clinical reasoning process

In this model, the term “clinical reasoning process anchors” refers to the structures that hold the process together and support the effective acquisition of clinical reasoning skills by undergraduate nursing students. Table 4 illustrates the concepts that have emerged as clinical reasoning anchors.

Collective approaches between clinical staff and nurse educators

This refers to the established interaction between nurse educators and clinical staff, which improves nursing education. Both nurse educators and clinical personnel work together to ensure that undergraduate nursing students have appropriate support to develop clinical reasoning skills. This relationship provides an opportunity to expand personnel to teach students by sharing varied experiences on the basis of their field of specialty, thereby bridging the knowledge gap.

Student-centred learning

In this model, student-centred learning refers to teaching and learning that promotes autonomy and individuality in students, allowing them to study independently. Undergraduate nursing students are actively involved, allowing them to be creative while also comprehending and connecting topics through experience learning. These experiences actively immerse and reflectively engage the learner’s inner world as a whole person (including physical-bodily, intellectual, emotional, and spiritual) with the intricate “outer world” of the learning environment (including belonging and doing-in places, spaces, and social, cultural, and political contexts) to create memorable, rich, and effective learning experiences [44, 45].

Qualified nurse educator as a facilitator

In this model, along with the constructivist philosophy, a trained nurse educator is an educator who assists undergraduate nursing students in developing their knowledge and meaning rather than delivering preexisting meaning. This concept is based on the idea that as people reflect on their experiences, they create their perspective of the universe. Every person creates their own “mental models” and “rules” to make sense of their experiences [46]. As a result, trained nurse educators have emerged as critical in encouraging the learning of clinical reasoning skills. These nurse educators encourage knowledge development by helping undergraduate nursing students through the clinical reasoning process and requesting clarification when students make mistakes during the cognitive process.

Accessibility of functional teaching and learning resources

In this middle-range theory, the accessibility of functional teaching and learning resources refers to having resources that are sufficient, functional, and simple to utilize to assist and facilitate the acquisition of clinical reasoning skills. Nursing students currently face difficulty working in a complicated nursing healthcare milieu that requires them to be sensitive and relevant to society’s current needs. This will be accomplished by making available functional learning and teaching resources. These resources must be easily accessible in both the skills/clinical area and the classroom context.

Favourable clinical environment

In this model, a favourable clinical learning environment refers to a practical session that improves nursing students’ socialization with the nursing profession. This suitable clinical learning environment assists nursing students in considerably improving their skills through experiences in which patients, peers, clinical staff, and nurse educators mentor and provide enough support for the development of clinical reasoning skills.

Model indicators

In this study, indicators for the learning of clinical reasoning skills were composed of the following subconcepts: personal-related indicators and systems indicators (Fig. 2).

Personal-related indicators

The following subthemes emerged as personal indicators: (a) competent and safe nursing graduates, (b) ability to think critically, (c) ability to reflect and (d) innovation in care.

• (a) A competent and safe nursing graduate possesses the required knowledge, psychomotor skills, and emotional intelligence to offer evidence-based care. It is envisaged that these graduates would respond to the public’s priority health requirements, as defined by the Malawi Nurses and Midwives Council, but would also become lifelong learners who would be able to convey their skills to the next generation.

• (b) The ability to think critically is defined in this model as the nursing student’s ability to consider their thinking while providing patient care. Undergraduate nursing students can develop the ability to reflect on their cognitive processes while reasoning to achieve positive patient outcomes. This is accomplished by inheriting the ability to recognize and repair errors during the reasoning process [47].

• (c) The ability to reflect allows students to evaluate their learning experience. It is envisaged that the graduates produced will become independent and competent in analysing clinical practice for higher-quality patient care through reflection on action, reflection in action, or evaluation [47].

• (d) Innovative care refers to nursing graduates who can positively impact health care services. The graduate will be able to construct evidence-based interventions to improve patient outcomes. These graduates changed people’s opinions about nursing, particularly in Malawi’s private and public institutions.

Systems related indicators

The following subthemes emerged as system-related concepts: (a) providing appropriate clinical education, (b) improving nursing outcomes, and (c) providing a strong professional image of nursing.

• (a) Providing appropriate clinical education. This refers to nursing clinical education that aligns with public healthcare and student needs, as well as the government’s strategic health plans and programs. It is envisaged that supporting the development of clinical reasoning skills among undergraduate nursing students will be vital and responsive to nursing clinical education. This will prepare graduates for work.

• (b) Improved nursing outcomes. As illustrated by this model, the acquisition of clinical reasoning skills among undergraduate nursing graduates ensures that healthcare institutions in Malawi and elsewhere have a highly qualified nursing labour workforce to offer the necessary quality nursing care. In this model, it is hoped that a nurse with clinical reasoning skills in the health care delivery system will help sustain the Ministry of Health strategic health plan III of (2023–2030) [43], which is in line with sustainable development goal number 3, which advocates universal health care for all.

• (c) Strong image of nursing professionals. The term refers to the public’s and nurses’ improved perceptions of nursing as a profession. According to this paradigm, undergraduate nursing graduates who are learning clinical reasoning will help to protect the nursing profession.

It is believed that reforming nursing clinical education by adequately preparing nurses with higher-order thinking skills for clinical reasoning will increase nursing professional independence since nurses will be able to make decisions that reflect their professional status. Improving the image of the nursing profession influences stakeholders’ perceptions of the profession.

Relationships among the concepts in the proposed middle-range theory

The development of clinical reasoning skill in undergraduate nursing students is a multifaceted process, depending upon a complex interplay of elements that contribute to the formation of competent and confident nurses. This interconnectedness lies at the heart of the proposed middle-range theory offering a clear understanding of clinical reasoning acquisition. This model posits that the acquisition process centers on a dynamic interplay between five key concepts: the curriculum, the clinical reasoning skills acquisition process itself, the anchors supporting this process, and the resulting personal and system-level indicators of success. The curriculum serves as the base, laying the groundwork for the entire learning process. It provides the structured framework upon which the “clinical reasoning skills acquisition process” unfolds. This process, a central pillar of the model, is conceptualized as a dynamic cycle, guiding students through distinct yet interconnected steps: from considering patient conditions and gathering cues to evaluating outcomes and integrating reflections for future practice.

Significantly, this cyclical process does not exist in a vacuum. It is strengthened by a network of “anchors,” including well-designed learning environments, the expertise of qualified nurse educators, readily available resources, and a student-centered approach that fosters continuous support. These anchors provide the rich ground for clinical reasoning to take root and flourish.

As students actively engage in this dynamic process, supported by robust anchors, the model predicts observable changes on both personal and systemic levels. On an individual level, students develop into competent and safe practitioners, demonstrating sharpened critical thinking, reflective practice, and innovative approaches to care. This individual growth then spreads outward, impacting the larger system through improved nursing outcomes and enhanced professional image.

The “middle range theory” exceeds a linear view of clinical reasoning acquisition, instead enlightening a dynamic interplay of curriculum, process, supportive anchors, and the resulting individual and healthcare system transformations. Figure 3 illustrates how the process of acquiring clinical reasoning skills is based on specific anchors.

Fig. 3

Illustrative representation of summary of findings in line with Strauss and Corbin’s model

Limitations of the study

Since the study investigated how undergraduate nursing students acquire clinical reasoning at only two nursing training institutions, other training institutions also promote clinical reasoning skills differently. Therefore, transferability was limited, but as a first study in Malawi, the findings might have implications for influencing subsequent research and practice and informing the Nurses and Midwives Council of Malawi to find ways to improve clinical nursing education. Data on clinical reasoning acquisition was collected retrospectively, potentially introducing recall bias as third and fourth-year nursing students reflected on their experiences.

Conclusion

Despite the absence of explicit clinical reasoning instruction within the curriculum and the identified obstacles, a key discovery emerged: undergraduate nursing students demonstrated an ability to acquire clinical reasoning skills through their engagement with the nursing process. This finding underscores the importance of the nursing process as a foundational framework for developing clinical reasoning.

Significantly, analysis of the transcribed data revealed emergent themes that culminated in the development of a middle-range theory. This novel theory provides a framework for understanding the process by which undergraduate nursing students acquire clinical reasoning skills in Malawi.

The development of the a middle-range theory is a significant contribution to the field of nursing education. Even though clinical reasoning skills are difficult to learn, they are critical in clinical nursing education. When undergraduate nursing students are well prepared with clinical reasoning skills, the quality of care they provide to patients improves. Using the new model known as ‘a middle range theory for the acquisition of clinical reasoning skills’ may promote the development of clinical reasoning skills from the beginning of the nursing training program. Nurse educators should implement and thoroughly evaluate the newly developed middle-range theory for teaching and learning clinical reasoning in Malawian nursing schools for patient safety.