Clinical Reasoning Cycle (CRC) – Stages 5-8, Errors, Escalation, Case Study, and Learning points
Stage 1: Notice the person's current situation
Consider salient features about the person and their situation and anticipate emergent issues or concerns.
Stage 2: Collect cues/information
Review current information (e.g. handover reports, patient history, medical records, results of investigations and nursing/medical assessments previously undertaken).
When reviewing the person’s background, consider characteristics such as gender identity, sex assigned at birth, neurodivergence, ethnicity, etc.
Gather new information (e.g. subjective and objective assessment data and concerns of the person and their family and/or significant others as appropriate).
Recall knowledge (e.g. physiological, pharmacological, cultural, spiritual, environmental, ethical and legal factors).
Stage 3: Process information
Analyse cues and determine whether the person’s signs and symptoms are within expected ranges.
Discriminate: Differentiate relevant from irrelevant information; recognise inconsistencies; refine information to what is most important; recognise gaps in cues collected.
Relate: Discover new relationships or patterns; cluster cues together to identify relationships between them.
Infer: Form opinions by interpreting subjective and objective cues; consider alternatives and consequences.
Recognise the potential for one’s biases and preconceptions to influence opinions and thought processes.
Match current situation to previous situations.
Predict an outcome.
Stage 4: Synthesize facts and inferences to formulate a nursing diagnosis
Example: "Risk of impaired ventilation (concern) related to acute upper airway obstruction (related etiology) evidenced by swollen tongue and altered appearance (supporting evidence/cues)."
Stage 5: Describe desired outcomes and engage in shared decision making
Describe what you want to happen, a desired outcome and a time frame.
Engage in shared decision making with the person, their family and/or significant others as appropriate.
Stage 6: Prioritize actions
Prioritise action/s based on the different alternatives available.
This may include consultation with other members of the healthcare team and collaboration with the person, their family and/or significant others.
Stage 7: Escalating concerns (communication strategies)
Escalating concerns using graded assertiveness:
CUS: I’m Concerned, I’m Uncomfortable, this is not Safe.
PACE: Probe, Alert, Challenge, Emergency.
Example escalation framework (Summary):
Probe: Recognise and articulate the concern (e.g., signs of deterioration such as pain, hypotension, tachycardia, tachypnoea, oligoanuria).
Alert: Indicate you believe the patient may be sepsis and requires full assessment and escalation.
Challenge: Assert that the current plan is insufficient and that escalation is needed (e.g., involve consultant).
Emergency: If deterioration continues, call rapid response and contact the consultant.
Practical dialogue snapshot (from the scenario):
Probe: Nurse notes severe pain, hypotension, tachycardia, tachypnoea, mother’s concern.
Alert: Nurse flags possible sepsis and need for bloods and consultant evaluation; senior staff resists.
Challenge: Nurse asserts deterioration, red flag status, and necessity of consultant involvement.
Emergency: Nurse initiates rapid response and calls consultant (as needed).
Stage 8: Evaluate progress and outcomes
Evaluate progress and the effectiveness of actions.
Consider whether the person’s situation has improved from both a clinical perspective and the person’s perspective.
Evaluate Outcomes (after initiation of a rapid response and appropriate medical care):
ext{Urine output > 30}\,\text{mL/hr}
Reflection: Contemplate what you have learnt, what you could have done differently, and how this informs future practice.
The Clinical Reasoning Cycle: Errors, biases, and safeguarding practice
Common clinical reasoning errors and biases
Anchoring: Locking onto salient features early and failing to adjust with new information.
Ascertainment bias: Thinking shaped by prior assumptions/preconceptions (e.g., ageism, stigmatism, stereotyping).
Diagnostic momentum: Once a label is attached, it tends to persist and other possibilities are excluded.
Overconfidence bias: Belief that we know more than we do; acting on incomplete information or hunches.
Premature closure: Accepting a nursing diagnosis without sufficient evidence.
Skipping steps (risks)
Skipping steps undermines the CRC; reflect, evaluate, and ensure the cycle is followed from notice through to synthesis and evaluation.
Case study: Lewis (2 days post-surgery)
Presentation: Acute upper abdominal pain (possible constipation), diaphoresis, nausea, tachypnoea, tachycardia, hypotension, oliguria.
Working hypothesis: Signs consistent with hypovolaemic and/or septic shock.
Probable actions to take:
Reassess vitals and pain; obtain urgent investigations (bloods, cultures, imaging as indicated).
Administer fluids as indicated and reassess response.
Notify/consult surgery and pediatric specialists; prepare for rapid response if deterioration continues.
Monitor urine output, fluid balance, and hemodynamics closely; ensure airway and breathing support as needed.
Review analgesia and NSAID/narcotic use; consider opioid-sparing strategies if hemodynamically unstable.
Escalating concerns in practice: detailed example (Lewis case)
Probe: Identify severe pain, hypotension, tachycardia, tachypnoea, and oliguric status; acknowledge family concern.
Alert: Propose sepsis workup and consultant involvement; resistance from senior staff (perceived constipation).
Challenge: State deteriorating condition, red zone on the Between the Flags chart, need for consultant input.
Emergency: Initiate rapid response and contact consultant immediately if condition worsens or does not improve.
Evaluation of outcomes in the Lewis scenario
Key cues for improvement after rapid response and medical care: stabilization of vital signs, improved urine output, tolerance of fluids, reduced pain, and functional mobility improvements.
What you have learned and how it applies to practice
Reflect on what was learned from this scenario and how it will inform future nursing practice.
Consider how you would approach similar cases in the future and how to apply CRC stages to ensure patient safety and effective care.
What you should have learned to apply clinically
The 8 stages of the revised CRC and their practical application.
The eight types of clinical reasoning errors and how to avoid them.
Foundational understanding of hypovolaemic and septic shock: signs, causes, prevention, and management.
Post-operative pediatric care principles.
Fundamentals of pectus excavatum: what it is and management basics.
Family-centred care: concept and importance.
Pharmacology of NSAIDs and narcotics: actions, contraindications, nursing management.
The eight stages of the revised Clinical Reasoning Cycle (CRC)
Stage 1: Notice the person’s current situation
Stage 2: Collect cues/information
Stage 3: Process information
Stage 4: Synthesize facts and inferences to formulate a nursing diagnosis
Stage 5: Describe desired outcomes and engage in shared decision making
Stage 6: Prioritize action/s based on alternatives
Stage 7: Escalating concerns using graded assertiveness (CUS, PACE)
Stage 8: Evaluate progress and outcomes; reflect on learning and future practice
Final reflections and takeaways
Clinical reasoning matters: there is a direct link between nurses’ clinical reasoning skills and patient safety.
Your knowledge and skills as an undergraduate student have a direct and long-lasting impact on patient safety.
A substantial proportion of adverse events are preventable, estimated at .
Closing thought
"UNLESS someone like you cares a whole awful lot, nothing is going to get better. It’s not." — The Lorax (motivational reminder of responsibility in care)
The Clinical Reasoning Cycle (CRC) is an eight-stage process for nurses to ensure patient safety and effective care:
Notice: Identify the patient's current situation and potential issues.
Collect Cues: Gather information from existing records, new assessments, and relevant knowledge (e.g., physiological, pharmacological, cultural).
Process Information: Analyze cues, differentiate relevant from irrelevant, cluster information, infer conclusions, recognize biases, match situations, and predict outcomes.
Synthesize Diagnosis: Formulate a nursing diagnosis, e.g., Risk of impaired ventilation related to acute upper airway obstruction evidenced by swollen tongue and altered appearance
Desired Outcomes: Describe desired outcomes and engage in shared decision-making.
Prioritize Actions: Select and prioritize actions, often in consultation with the healthcare team.
Escalate Concerns: Communicate concerns using graded assertiveness (CUS: Concerned, Uncomfortable, Safe; PACE: Probe, Alert, Challenge, Emergency).
Example escalation: Probe (recognize deterioration), Alert (suggest condition like sepsis), Challenge (assert need for consultant), Emergency (initiate rapid response).
Evaluate & Reflect: Evaluate progress and outcomes (e.g., \text{BP, HR, and RR within normal ranges; Urine output > 30}\,\text{mL/hr; Pain \le 3/10}); reflect on learning.
Common Clinical Reasoning Errors:
Anchoring: Sticking to initial features without adjusting to new information.
Ascertainment bias: Opinions shaped by prior assumptions (e.g., ageism).
Diagnostic momentum: A diagnosis persists, excluding other possibilities.
Overconfidence bias: Acting on incomplete information.
Premature closure: Accepting a diagnosis without enough evidence.
Case Study: Lewis (2 days post-surgery)
Presentation: Acute upper abdominal pain, diaphoresis, nausea, tachypnoea, tachycardia, hypotension, oliguria.
Hypothesis: Hypovolaemic and/or septic shock.
Actions: Reassess vitals, obtain investigations, administer fluids, notify specialists, monitor vitals, review analgesia.
Escalation Example: Nurse probes severe pain, alerts to possible sepsis, challenges senior staff resistance, and initiates rapid response if needed.
Key Takeaways:
The CRC is crucial for patient safety, preventing an estimated 50−80%50−80% of adverse events.
Nurses' clinical reasoning skills directly impact patient outcomes.