Registered nurses' clinical reasoning in home-based care: a retrospective think-aloud design - the DECIDE project

Clinical reasoning in nursing is described as complex, context-dependent, and difficult to articulate. Despite its recognised importance, it is often examined through narrative accounts or inferred from decision outcomes, offering limited insight into how reasoning is articulated and organised in practice. This has limited our understanding of the structure of reasoning, particularly in complex and dynamic settings, and underscores the need for approaches that make this structure explicit and open to systematic analysis.

To explore and describe how registered nurses retrospectively explain and structure their clinical reasoning in relation to observed care situations in home-based care.

A retrospective think-aloud design was used. Nineteen transcripts from registered nurses were analysed using a rule-based modified clinical protocol analysis, with AI-assisted procedures to identify clinical domains, operator configurations, and cross-case structures.

Clinical reasoning was consistently organised around recurring patterns of observation and evaluation, often extended into planning in more complex or risk-oriented situations. Reasoning was characterised by non-linear structures combining diagnostic and procedural orientations. Different clinical domains were associated with distinct reasoning structures, including verification-based processes in procedural care and evaluation-planning processes in autonomy- and support-focused situations.

Registered nurses' clinical reasoning in home-based care can be described as structured, multi-layered, and contextually adaptive, rather than strictly linear. The findings suggest that reasoning can be systematically described across cases, making reasoning structures visible and comparable.

This study offers a basis for describing and discussing clinical reasoning more systematically in nursing education, supervision, and future research.