Exploring Clinical Reasoning and Judgement Processes among New Graduate Nurses

Dr. Ndolo Njie-Mokonya has over 20 years experience in the health care field. She has worked in acute and primary care settings and in the academia-nursing faculty as a registered nurse, clinical instructor and part-time faculty member, nurse educator, and more recently, nursing practice coordinator with the professional practice department at a metropolitan hospital in Ottawa. She is a published author in both academic and professional journals and book chapters and is very passionate about building health human resource practice capacity and support for professional development and learning among new grads, IENs and different learner groups. A mother to three lovely children she enjoys a good action-packed movie once in a while.

Exploring Clinical Reasoning and Judgement Processes among New Graduate Nurses

The notion of supporting clinical knowledge development and seeing the transformation in a novice nurse when they come into the workforce has been an area of interest and passion for me in my career. To observe and assist nurses as they mature in their practice performance is, for me, an area of high impact as a nurse colleague, educator and contributor to my community of practice. My journey in supporting learning started at the frontline as a preceptor to newly hired nurses. Next, as a part-time school of nursing faculty member, I taught clinical practicum, lab and a few theoretical courses. During this time I quickly noticed unique learning experiences and challenges among different groups of nursing students. The experiences varied with certain nursing students, particularly when they came from ethnic backgrounds that differed from that which dominated the work context. I noticed the same nuance with the newly hired nurses I was preceptoring into the workplace. My curiosity led me to begin graduate work that examined the experiences of internationally educated nurses as they integrated into the Canadian health care system, specifically into the workforce after obtaining their practice licenses. When I moved into my nurse educator role I continued to support clinical practice and learning among NGN and newly hired nurses.

As I progressed through my career, I realized the extent to which transition support for NGNs entering the workforce was required. In addition, noting that the landscape of the nursing workforce is increasingly diverse, I found workplaces to be increasingly complex and fast paced, characterized by high patient acuity levels. As a nurse educator, despite the practice support, programs and tools in place to support NGNs in the early months of practice, I could see that not all learners progressed at the same pace and not all met the requirements of competent clinical practice. Despite vast published work which described the challenges newly graduated nurses faced during their transition into the workplace, a complete understanding of factors that shape their ability to recognize and reason through clinical scenarios effectively was lacking. This practice gap marked the beginning of my doctoral research journey to examine NGNs clinical reasoning and judgement attributes and how the growth of this critical skill can be nurtured.

Clinical reasoning falls solidly within a nurses’ professional role (Hong et al., 2021), and it is critical that clinical leaders help novices create cognitive scaffolding processes that allow them to navigate the clinical decision-making and judgement required in a variety of clinical scenarios. Failure to fully understand the challenges to a NGNs clinical reasoning capability upon entering the workplace can potentially compromise patient safety.  

The use of mixed methodology allowed for a broad understanding of the clinical reasoning dynamics that influence NGNs within the workplace and guided my research questions: 1) what challenges do NGNs face at 3 months and at 12 months of transition into the clinical workplace? 2) what assists NGNs in recognizing patient change? 3) how do NGNs engage in clinical reasoning and decision-making? and 4) what factors contribute and impede NGNs clinical judgment abilities?

An intersection of four theoretical frameworks and conceptual models framed my inquiry. Duchscher’s (2008) stages of professional role transition described how NGNs evolve professionally during their initial 12 months in practice; Benner’s (1982) model of skill acquisition described nurses’ performance based on their cognitive reasoning and knowledge development abilities; Ebright’s (2012) human performance awareness model described the complexity of health care environments influencing the nurses’ ability to perceive changes in patient status; and Kramer and colleague’s (2013) complexity adaptive systems framework portrayed the clinical environment and patient conditions as complex, dynamic and interrelated systems.

Of the four main research themes unveiled, uncertainty was a recurrent attribute in both the quantitative and qualitative strand of data collection that influenced NGNs clinical reasoning and decision-making about different aspects of their practice at 3-months and at 12-months. In the earlier months of NGN practice, they were uncertain about practice competencies and patient care processes, while in the later months NGNs had developed clinical reasoning and decision-making processes based on practice experience, familiarity and prior exposure to different patient care scenarios. Clinical reasoning uncertainties at l1-12 months of practice were associated with complex patient conditions and/or patient-family responsibility as well as with leadership responsibilities required of their role for example, charge nurse duties involving complex patient discharges. Over the 12-months of practice, these NGNs experienced different aspects of transition shock and to varying extents, which influenced their decision-making and reasoning ability as well as their sense of vulnerability and willingness to stay on their units of work or in the nursing profession. The persistence of transition shock even at 12-months suggested NGNs come into the workforce with a lack of understanding about the extensive components of the professional nurse role. This knowledge is crucial for nurse administrators and educators who support NGN onboarding as it highlights the need for continual support well into the first 12 months; and supports not limiting expectations to skill performances and content accuracy only. Developing process accuracy with decision-making is important as both content and process accuracy are complementary components of clinical decision-making. Deciding on what is needed for safe patient discharge requiring feeding tube is an aspect of content accuracy, while process accuracy ensures that necessary disciplinary teams involved within hospital and community are in place to ensure a seamless transition process from hospital to community. A key takeaway is the need to recognize the effect of the transition experience and the stages through which a NGN will progress, their capacity to critically think, make sound clinical decisions and act on their practice judgements. The implications of the initial NGN transition experience are important for nurse administrators and educators alike to understand so that they can offer the needed support to smoothen the transition journey and facilitate long term retention of the newest members of our practice communities.