Registered nurses' thinking strategies on malnutrition and pressure ulcers in nursing homes: a scenario-based think-aloud study

Aim. The aim of this study was to explore the thinking strategies and clinical reasoning processes registered nurses use during simulated care planning for malnutrition and pressure ulcers in nursing home care. Background. Clinical reasoning is an essential component of nursing practice. Registered nurses' thinking strategies and clinical reasoning have received limited attention in nursing science. Further research is needed to understand registered nurses' clinical reasoning, especially for prevention of malnutrition and pressure ulcers as they are important quality indicators of resident care in nursing homes. Design. A qualitative explorative design was used with a think-aloud interview technique. Methods. The transcribed verbalisations were analysed with qualitative deductive content analysis. Data were collected during six months in 2007-2008 from 30 registered nurses at nine nursing homes in Norway. Results. The registered nurses used a variety of thinking strategies, but there were differences in the frequency of use of the different strategies. The three most commonly used thinking strategies were 'making choices', 'forming relationships' and 'drawing conclusions'. None of the nurses performed a structured risk assessment of malnutrition or pressure ulcers. Registered nurses started with assessing data from the scenarios, but after a short and elementary assessment they moved directly to planning. Conclusion. Many different thinking strategies were used in registered nurses' clinical reasoning for prevention of malnutrition and pressure ulcers. The thinking strategy 'making choices' was most commonly used and registered nurses' main focus in their reasoning was on planning nursing interventions. Relevance to clinical practice. This study showed that most of the registered nurses go directly to planning when reasoning clinically about residents in nursing homes. A lack of systematic risk assessments was identified. The insight gained from this study can be used to recommend improvements in tools designed for nursing homes to support the registered nurses.