Clinical Reasoning and Clinical Learning Theories

Original Editor - Stacy Schiurring based on the course by Angela Patterson

Top Contributors - Stacy Schiurring and Jess Bell  

Introduction

"To do the right thing in the right way at the right time in clinical contexts, health professionals need clinical reasoning abilities. [Clinical reasoning] is thus an essential component of health professional's practice and includes knowledge and skills to gather and analyze patient data, arrive at diagnoses, and make management decisions in relation to patient needs, often under time pressure." - Elvén et al., 2023

Teaching and learning in clinical education require a careful balance of structured frameworks, tailored teaching strategies, and personalised support to aid student development and progress. By understanding and implementing various teaching models, recognising the different stages of student progression, and nurturing strong clinical reasoning skills, clinical instructors can create effective learning environments that prepare students for entry into professional practice. Whether working with high-performing students or those requiring additional support, the overarching goal remains the same: to develop competent, confident healthcare practitioners who can deliver excellent patient care and contribute to the advancement of their profession.

Situated Clinical Decision-Making Framework

The Situated Clinical Decision-Making Framework was designed to explain how healthcare professionals make decisions in clinical settings, taking into account the complexities of real-world practice. The framework emphasises that clinical decision-making is not a linear or isolated process but is shaped by the specific context in which the healthcare professional operates. It integrates various factors, such as the clinical environment, patient characteristics, and the practitioner's own experiences, in order to better understand how decisions are made in practice.

Thinking Steps

The Situated Clinical Decision-Making Framework outlines four key thinking steps that guide healthcare professionals in making informed and effective decisions in clinical practice. These steps help ensure that clinical decisions are based on a thorough understanding of the patient, context, and available knowledge. The four thinking steps are (1) noticing and gathering clues, (2) interpreting and making judgements, (3) responding to situations and making decisions, and (4) reflecting on and evaluating decisions.

Noticing and gathering clues: this is the first step in clinical decision-making, where the clinician notices and perceives the key aspects of the clinical situation. It involves recognising what is important about the patient's condition, environment, and any other relevant factors. Noticing requires the clinician to be alert and attentive to subtle changes or signs that may indicate potential problems. This step is critical for identifying issues that require immediate attention or further investigation.

Interpreting and making judgements: after noticing relevant details, clinicians must interpret the information - i.e. they must make sense of their observations made during step 1. The clinician draws on their theoretical and practical knowledge to understand the meaning of the information, integrating the patient's history, symptoms, and clinical context. Interpreting involves considering different possible diagnoses or outcomes and organising the information to form a clearer picture of the patient's condition.

Responding to situations and making decisions: in this step, the clinician decides how to respond to the situation based on their interpretation of the information. The clinician formulates a plan of action, which may include interventions, treatments, or further assessments. Responding requires the clinician to make decisions about the most appropriate course of action, considering factors like urgency, available resources, and the patient's preferences and needs.

Reflecting on and evaluating decisions: the final thinking step is reflecting on the decision-making process and its outcomes. After implementing the response, clinicians reflect on the effectiveness of their actions. They consider what went well, what could have been done differently, and whether the desired outcomes were achieved. Reflecting helps clinicians learn from their experiences, improving future clinical decision-making and fostering ongoing professional development.

These four thinking steps—noticing, interpreting, responding, and reflecting—form the core of the Situated Clinical Decision-Making Framework. Together, they guide healthcare professionals through a thoughtful, structured process of clinical reasoning that leads to more effective, patient-centred care.

Key Components of the Situated Clinical Decision-Making Framework

The Situated Clinical Decision-Making Framework identifies specific components that influence clinical decision-making.

The context of practice: clinical decision-making is always influenced by the context in which it occurs, such as the healthcare setting (e.g., hospital, clinic, home care) and available resources (e.g., equipment, time, staff). The context provides constraints and opportunities that impact the types of decisions healthcare professionals make. For example, a decision in an emergency department may differ from one made in a long-term care facility due to the time-sensitive nature of care or available technology.

The patient's situation: the patient's characteristics (e.g., their condition, history, preferences, and social context) are crucial in the decision-making process. Each patient is unique, and healthcare professionals must tailor their decisions to suit the specific needs and circumstances of the individual. Understanding the patient’s values, goals, and preferences is critical for making patient-centred decisions.

The clinician's experience and knowledge: the practitioner’s expertise, including their education, clinical experience, and professional judgement, plays a significant role in their decision-making process. More experienced clinicians may rely on intuitive decision-making, while less experienced practitioners might depend more heavily on protocols, guidelines, or supervisory input. The clinician’s ability to reflect on their own practice also influences the quality and appropriateness of their decisions. The Situated Clinical Decision-Making Framework identifies five key types of knowledge that are essential for building strong clinical reasoning skills in students. These types of knowledge help students process information, make informed decisions, and adapt to complex clinical situations. The five key types of knowledge are:

1. Personal knowledge or "knowing the self": personal knowledge refers to the self-awareness, values, and attitudes that students bring to their practice. It involves reflecting on personal experiences, biases, and emotional responses. This type of knowledge helps students develop a more empathetic, patient-centred approach and contributes to their growth as reflective practitioners.
2. Theoretical knowledge or "knowing the case": refers to the foundational understanding of health conditions, treatment methods, and clinical principles learned in the classroom. It provides the core knowledge that students use to understand and interpret clinical situations. Theoretical knowledge helps guide students in applying scientific evidence to practice.
3. Practical knowledge or "knowing the patient": practical knowledge is the hands-on, experiential knowledge that students acquire through direct clinical practice. It encompasses the skills, techniques, and procedural knowledge needed to perform tasks effectively in clinical settings. Practical knowledge allows students to develop competence in performing patient assessments, interventions, and other clinical procedures.
4. Contextual knowledge or "knowing the person": contextual knowledge involves understanding the clinical environment, including the physical, organisational, and cultural factors that shape patient care. This includes awareness of the available resources, the structure of healthcare teams, and the socio-cultural context in which healthcare is delivered. Contextual knowledge helps students adapt their clinical decision-making to the specific circumstances of each patient and setting.
5. Collaborative knowledge or "knowing the profession": collaborative knowledge emphasises the importance of interdisciplinary teamwork and communication. In clinical settings, students must work with other healthcare professionals, such as physicians, nurses, and therapists. Collaborative knowledge involves understanding how to share information, make joint decisions, and contribute to a cohesive care plan. It helps students appreciate the value of teamwork in providing comprehensive patient care.

The interaction between clinician and patient: communication and the therapeutic relationship between the clinician and the patient are central to decision-making. Effective communication ensures that the clinician understands the patient’s needs and that the patient is fully informed about their options. The decision-making process is interactive, with clinicians and patients working together to arrive at the most appropriate course of action.

Environmental and organisational factors: broader organisational and systemic factors also influence clinical decisions. These include hospital policies, protocols, or institutional constraints that may limit or guide clinical practice. External factors like time pressures, staffing levels, and interprofessional collaboration can shape decision-making in ways that go beyond the individual clinician and patient.

Ethical and legal considerations: ethical dilemmas and legal requirements often come into play during clinical decision-making. Clinicians must navigate complex situations involving patient autonomy, confidentiality, informed consent, and cultural sensitivities while adhering to professional codes of conduct and legal regulations.

Reflective practice: the Situated Clinical Decision-Making Framework stresses the importance of reflective practice—where clinicians analyse and evaluate their decisions post-action to improve future decision-making. This continuous process of reflection and learning is essential for refining clinical reasoning and improving patient outcomes over time.

Steps in Clinical Reasoning

In the Situated Clinical Decision-Making Framework, five key steps are outlined to guide clinical reasoning. These steps help healthcare professionals navigate complex clinical situations and make informed, patient-centred decisions. The five steps in clinical reasoning are (1) recognising and assessing the situation, (2) appraising and defining the problem, (3) formulating the action plan, (4) implementing the action plan, and (5) evaluating and reflecting.

Recognising and assessing the situation: the first step involves gathering and evaluating relevant patient information and context. This includes the patient's clinical history, current symptoms, and any environmental factors influencing their care. The clinician must identify the key aspects of the situation, including any urgent issues that need immediate attention. This step is about noticing what is important and ensuring a comprehensive understanding of the patient's condition.

Appraising and defining the problem: in this step, the clinician uses the information gathered to analyse and define the problem. This involves interpreting the signs and symptoms in the context of the patient's overall health and situation. The clinician may consider potential diagnoses, underlying causes, and the relationships between different aspects of the patient's condition. Defining the problem also includes setting clear goals for the patient’s care, based on the clinical data.

Formulating the action plan: once the problem is defined, clinicians move to planning and decision-making. This step involves formulating a treatment plan and intervention strategies or identifying further assessments needed to address the patient's condition. The clinician decides on the best course of action, considering the available resources, institutional policies, and patient preferences. Collaborative decision-making with the patient and other healthcare team members may also be part of this step.

Implementing the action plan: after creating a plan, the next step is to implement the interventions or actions outlined. This step involves putting the treatment plan into practice, such as administering medications, providing physical therapy, or coordinating with other healthcare professionals. Successful implementation relies on effective communication and teamwork with both the patient and the healthcare team.

Evaluating and reflecting: the final step involves evaluating the outcomes of the interventions and reflecting on the entire decision-making process. This includes assessing whether the patient’s condition improved as expected, if the goals were achieved, and identifying areas for improvement. Reflecting on the experience helps clinicians learn from both successes and challenges, fostering continuous development of their clinical reasoning skills for future practice.

Key Learning Theories in Clinical Education

"... clinical decision making in novice and student nurses is well documented as linear, based on limited knowledge and experience, and often focused on single tasks or problems. Thus, it is a professional imperative to improve patient safety by integrating practical tools for developing critical thinking and clinical reasoning in both undergraduate and post-licensure education and practice." - House-Kokan and Jetha, 2023

Understanding learning theories is crucial for clinical instructors because they form the foundation for developing effective teaching strategies and offer insight into how students gain knowledge and skills in clinical settings. These theories go beyond theoretical concepts; they directly influence how clinical experiences are structured and guide the way instructors engage with students in practice.

Table 1. Learning theories commonly utilised in clinical education

	Description	Use in clinical education	Examples of application by clinical instuctors
Behaviourism	Focuses on observable behaviours as the primary indicators of learning All behaviours are acquired through interactions with the environment and learning occurs when a response to a stimulus is reinforced Behaviourism suggests that reinforcement and punishment can shape and control human behaviour	Behaviourism forms the cornerstone of clinical skills teaching, where students develop competencies through repeated practice with feedback and reinforcement	Break down complex clinical skills into smaller, more manageable componenets Provide immediate, specific feedback during skill practice Create opportunities for repeated practice until mastery is achieved Use demonstration followed by guided practice
Constructivism	Emphasises the active role of learners in constructing their understanding and knowledge through experiences and reflection Rather than passively receiving information, learners actively build new knowledge by connecting it to their existing experiences, ideas, and understanding Constructivism sees learning as the process of adapting a person's mental model of the world based on interactions with their environment and peers	Constructivism emphasises how learners build new knowledge by connecting it to prior experiences and understanding	Begin teaching sessions with questions about relevant previous knowledge Encourage students to explain the reasoning process Create opportunities to discuss cases and share perspectives Help students connect theoretical knowledge to clinical situations
Active Learning Theory	Emphasises the active role of students in the learning process, encouraging them to engage directly with the material, think critically, and apply their knowledge through hands-on activities Involves students in activities that require them to actively process, discuss, and apply what they are learning in real-time	Active learning theory highlights the importance of student engagement in the learning process	Involve students in hands-on patient care activites Facilitate case-based discussions Encourage student participation in clinical decision-making Create opportunities for peer-to-peer learning
Experimental and Reflective Learning	Refers to two complementary approaches to learning that focus on the importance of experience and reflection in the learning process Learners actively engage with practical situations and then reflect on those experiences to improve their understanding and performance	Experimental and reflective learning play vital roles in clinical education as students develop expertise through direct experience and reflection	Guide students in reflecting on clinical encounters Help students analyse both successful and challenging experiences Encourage self-assessment Use debriefing sessions to enhance learning from experiences
Socio-cultural Learning Theory	Emphasises the importance of social interactions, cultural context, and the role of community in the learning process Suggests that cognitive development and learning are deeply influenced by social experiences and the cultural tools provided by society Asserts that learning is not just an individual process, but one that is inherently social and occurs through engagement with others and the surrounding environment	Socio-cultural learning theory recognises that learning occurs within a social and cultural context	Create a supportive learning environment Model professional behaviours and communication Integrate students into the healthcare team Help students understand the cultural aspects of healthcare delivery

In practical implementation, clinical instructors should combine various learning theories based on the learning objectives, the student’s experience level, the complexity of the skill or concept being taught, the clinical context, and available resources. By understanding and applying these theories intentionally, instructors can create more effective learning experiences and better support student development. The key is to move beyond theory and practical application by using frameworks to guide teaching strategies while remaining flexible and responsive to individual student needs and situations.

It is important to recognise that many other theories exist, from broad frameworks to specialised approaches. Clinical instructors should remain adaptable and familiar with the learning theories endorsed by their academic institutions and clinical sites. They can also draw from previous successful frameworks while staying open to new ones that may better meet student needs. The goal is not to strictly follow one theory but to thoughtfully select and adapt approaches based on the context, student needs, and learning objectives.

Resources

The following articles can help deepen your understanding of learning theories useful in clinical education, and provide insight into how to apply teaching frameworks to education in the fast-paced healthcare setting:

• Arja SB, Arja SB, Fatteh S. The hybrid model of clinical skills teaching and the learning theories behind it. Journal of Advances in Medical Education & Professionalism. 2019 Jul;7(3):111.
• House-Kokan M, Jetha F. Teaching to learn, learning to teach: Clinical thinking tools to support novice clinical educators, preceptors and students. Journal of Nursing Education and Practice. 2024;14(5).