Variation in clinical judgment about client needs: A think-aloud study among home care nurses

Background This study aims to determine whether home care nurses adhere to the nursing process when assessing clients’ needs. It examines their clinical reasoning skills and the time dedicated to each skill and phase involved in making clinical judgments regarding the amount, type, and duration of home care. Additionally, it investigates the factors that influence their clinical judgments. Design A qualitative exploratory design was employed using the think-aloud interview method. Method Twelve home care nurses from nine Dutch organisations were invited to assess clients’ needs while expressing their thoughts. The case was presented through a video featuring an actress depicting a client with Parkinson’s disease, based on a real scenario. Nurses were asked to apply clinical reasoning to determine the amount, type, and duration of care needed. Interview transcripts were coded deductively using a scheme based on a conceptual framework that includes three components: the five phases of the nursing process, 17 clinical reasoning skills, and factors influencing clinical judgment. Results After conducting 12 interviews, saturation was reached. All but one home care nurse mentioned the five phases of the nursing process (i.e., assessment, diagnosis, goal-setting, intervention, and evaluation). Not all nurses utilised all 17 skills. Promoting health and identifying patterns were used the least, while intervention planning was the most frequently employed skill. The recommended duration for needed home care varied from three weeks to an indefinite period. The suggested hours ranged from one hour to over nine hours weekly for the same client. Home care nurses primarily focused on planning interventions and paid less attention to the diagnosing and goal-setting phases when applying clinical reasoning skills in the nursing process. They highly valued clients’ wishes and preferences in their clinical judgments. Conclusion Clinical judgments made by home care nurses varied, possibly due to inadequate clinical reasoning within the nursing process.