What this article is about
In brief
A think-aloud study built a five-stage cognitive learning model of how nurses develop clinical reasoning from novice to expert.
For nursing students
Study summary
Modern nursing care is increasingly complex, and safe practice depends on a high level of clinical reasoning, the thinking process nurses use to gather information, make sense of a patient's situation, and decide what to do. Yet teaching clinical reasoning has long been a challenge for nursing educators. Part of the problem is that, before this study, researchers had not clearly mapped how clinical reasoning develops over time. Its developmental stages and the key turning points along the way had not been uncovered, so educators lacked a cognitive learning model, a description of how people actually learn and develop a specific competency, to guide their teaching. This 2014 study, published in Quality Advancement in Nursing Education, set out to build exactly that.
The researchers aimed to develop a cognitive learning model of clinical reasoning in nursing that stretched from the very beginning of a nurse's education all the way to the development of expertise, and that highlighted the critical milestones matching each stage. To do this they used a descriptive design built on the think aloud method. In a think aloud study, participants say their thoughts out loud as they work through a problem, giving researchers a window into reasoning that is normally invisible. The study took place in one university and two associated hospitals. It included 45 undergraduate nursing students and 21 registered nurses, so it captured reasoning across a wide range of experience, from novice learners to practicing professionals. Participants were asked to think aloud while working through five clinical scenarios that had been validated in a previous study. Their interviews were transcribed word for word and analyzed using protocol analysis, the method recommended for think aloud research.
From this analysis, the researchers identified five developmental stages of clinical reasoning, each with its own critical milestone, and used them to build their cognitive learning model. The first stage is the internalization of the idea that nursing is a scientific profession. This is a foundational shift in mindset: the learner comes to see nursing as grounded in science rather than only in tasks or routines. The second stage is learning to read and use scientific literature in care planning and nursing interventions, so that evidence informs decisions. The third stage is learning to move from data collection to hypothesis generation to nursing interventions, which captures the heart of clinical reasoning, gathering information, forming ideas about what might be going on, and acting on them. The fourth stage is integrating the ward's routines and protocols, blending individual reasoning with the established practices of a real clinical setting.
The fifth stage is notable because it branches in two directions. A nurse may move toward professional expertise, continuing to grow in sophisticated, evidence-based reasoning, or toward task-oriented practice, focusing narrowly on completing tasks rather than reasoning deeply. This fork is an important insight, because it suggests that development does not automatically end in expertise; the environment and the nurse's ongoing learning may steer them one way or the other.
Based on these stages, the authors offer recommendations for teaching and learning clinical reasoning during both initial education and continuing education. The model gives educators a shared language for where a learner is and what milestone comes next, which can make an abstract skill easier to teach and assess.
For students and nurses, this study is valuable in several ways. It reframes clinical reasoning as something that develops in identifiable stages rather than appearing all at once, which can be reassuring to learners who feel they are not yet experts. It emphasizes that seeing nursing as a scientific, evidence-using profession is foundational, not optional. And the fork at the final stage is a gentle warning: without continued reflection and learning, even experienced nurses can drift toward task-focused routines rather than rich reasoning. As with any single study, the model should be read thoughtfully. It was developed with 66 participants in one university and its associated hospitals, using simulated scenarios rather than live patient care, so the stages are a well-grounded framework rather than a proven law that fits every nurse. Even so, it offers a clear, practical map that educators and learners can use to strengthen the clinical judgment that safe, high-quality nursing care depends on.
Original publication
Source abstract and study details
Read the source abstract
Background. The current context of increasingly complex nursing care requires a high level of clinical reasoning in nursing practice. Still, teaching clinical reasoning in nursing remains a challenge for educators in the field. Although several studies have been conducted to try to understand clinical reasoning in nursing, neither its developmental stages nor the corresponding critical milestones have been uncovered. Therefore, nursing educators cannot rely on a cognitive learning model (a description of how people learn and develop a specific competency) to facilitate the learning of this crucial competency. Objectives. This study was conducted to develop a cognitive learning model of clinical reasoning in nursing, from the beginning of education to the development of expertise, highlighting the critical milestones corresponding to each stage. Design. A descriptive design based on the think aloud method was used. Settings and participants. The study was held in one university and two associated hospitals. Individual interviews were conducted with 45 undergraduate nursing students and 21 registered nurses (RNs). Participants were asked to think aloud, using five clinical scenarios that were validated in a previous study. Analysis. Interviews were transcribed verbatim and subsequently analyzed using the protocol analysis method recommended for think aloud studies. Results. Five developmental stages and their related critical milestones were identified and used in the elaboration of a cognitive learning model for clinical reasoning in nursing: (1) internalization of the idea that nursing is a scientific profession; (2) learning to read and use scientific literature in care planning and nursing interventions; (3) learning to move from data collection to hypothesis generation to nursing interventions; (4) integrating wards’ routines and protocols; (5a) towards professional expertise or (5b) towards task-oriented practice. Conclusion. Recommendations for teaching and learning clinical reasoning in nursing during initial and continuing education in nursing are suggested.
Reviewed findings
Main findings
- The study identified five developmental stages of clinical reasoning, each with a related critical milestone, and used them to build a cognitive learning model spanning from the start of education to expertise.
- Stage one is internalizing the idea that nursing is a scientific profession, and stage two is learning to read and use scientific literature in care planning and nursing interventions.
- Stage three is learning to move from data collection to hypothesis generation to nursing interventions, capturing the core of clinical reasoning.
- Stage four is integrating the ward's routines and protocols into one's reasoning within a real clinical setting.
- Stage five branches in two directions: toward professional expertise or toward task-oriented practice, showing that development does not automatically end in expertise.
For teaching and learning
Education implications
- Educators can use the five-stage model as a shared map to identify where a learner is and to target the next milestone in developing clinical reasoning.
- Framing clinical reasoning as developmental rather than innate may reassure students and help them see progress toward expertise as achievable.
- Because the final stage can branch toward task-oriented practice, continuing education and reflective, evidence-based habits are important throughout a career, not just during training.
- Emphasizing early that nursing is a science-based profession that uses scientific literature may lay a stronger foundation for later reasoning skills.
- As a model built from think aloud data and simulated scenarios in one setting, it should guide teaching design and further validation rather than be applied rigidly as a fixed rule for every nurse.
For educators
Teaching and appraisal notes
This study is directly useful for nurse educators because it delivers a stage-based cognitive learning model of clinical reasoning that can structure teaching and assessment. Use it to explain the think aloud method and protocol analysis: participants (45 undergraduate students and 21 registered nurses) verbalized their reasoning through five previously validated clinical scenarios, giving visible access to normally hidden thinking. The five stages provide a ready teaching scaffold: (1) internalizing that nursing is a scientific profession; (2) learning to read and use scientific literature in care planning; (3) moving from data collection to hypothesis generation to interventions; (4) integrating wards' routines and protocols; and (5) branching toward either professional expertise or task-oriented practice. Ask students to place themselves on this map and name their next milestone; this makes an abstract competency concrete and reduces anxiety by framing reasoning as developmental rather than innate. The branching fifth stage is a strong discussion prompt about how workplace culture and continuing education can push nurses toward deep reasoning or narrow task completion. Methodologically, use the study to teach the value and limits of think aloud data and simulated scenarios versus live practice, and to discuss transferability of a model built in one university and two associated hospitals. Pair it with the authors' recommendations for initial and continuing education to design curriculum activities and formative assessments targeted at specific milestones.
Critical appraisal
Limitations
- The model was developed with 66 participants (45 students and 21 registered nurses) in a single university and two associated hospitals, which may limit how broadly it transfers.
- Reasoning was studied using five simulated clinical scenarios rather than live patient care, which may differ from real-time bedside decision-making.
- The think aloud method depends on participants being able and willing to verbalize their thinking, and some reasoning may go unspoken.
Classroom use
Discussion Questions
- What is clinical reasoning, and why is it so important in increasingly complex nursing care?
- What is a cognitive learning model, and how could one help nurse educators?
- How does the think aloud method reveal reasoning that is usually invisible?
- Why might it matter that stage one is internalizing the idea that nursing is a scientific profession?
- Walk through stage three: how do nurses move from data collection to hypothesis generation to interventions?
- Why is integrating a ward's routines and protocols treated as its own developmental stage?
Knowledge check
Quiz
1. How many developmental stages of clinical reasoning did the study identify?
- Five
- Three
- Seven
- Ten
Show answer and rationale
Rationale: The study identified five developmental stages, each with a related critical milestone.
2. Which research method was used to make reasoning visible?
- The think aloud method
- A randomized controlled trial
- The Maslach Burnout Inventory
- A cross-sectional survey
Show answer and rationale
Rationale: The study used a descriptive design based on the think aloud method.
3. Who were the participants?
- 45 undergraduate nursing students and 21 registered nurses
- 52 nurses across Canada
- Five nursing and four pharmacy students
- 8,412 nurses in British Columbia
Show answer and rationale
Rationale: The study included 45 undergraduate nursing students and 21 registered nurses.
4. What is stage one of the model?
- Internalizing that nursing is a scientific profession
- Integrating ward routines and protocols
- Generating hypotheses from data
- Moving toward task-oriented practice
Show answer and rationale
Rationale: Stage one is the internalization of the idea that nursing is a scientific profession.
5. What does stage three involve?
- Moving from data collection to hypothesis generation to nursing interventions
- Reading scientific literature for the first time
- Choosing task-oriented practice
- Learning ward protocols
Show answer and rationale
Rationale: Stage three is learning to move from data collection to hypothesis generation to nursing interventions.