Diagnostic reasoning in the RN-to-NP transition: An interpretive description study

To explore how nurse practitioner (NP) students understand, experience, and develop diagnostic reasoning (DR) during their NP education, and to examine how prior nursing experience and clinical learning environments shape this development.

DR is a core competency for NP practice and represents a significant shift in responsibility during the transition from registered nurse (RN) to NP. While existing literature has focused primarily on teaching strategies, limited research has examined DR from the learner perspective.

This qualitative study employed Interpretive Description. Twenty-four NP students in their final semester from two Canadian universities participated in semi-structured interviews. Data were analyzed using a five-phase qualitative analytic process. Themes were developed through iterative coding and constant comparison.

Four themes emerged: (1) structured sense-making and professional identity transformation (2) prior RN experience as a double-edged influence (3) developing DR under conditions of complexity and constraint, and (4) scaffolded and iterative pathways to diagnostic development. Participants described DR as the "biggest leap" in the RN-to-NP transition, representing not only systematic hypothesis refinement but also diagnostic accountability as the most responsible provider. DR was experienced as inherently relational and co-constructed within the clinical encounter. Prior RN experience provided experiential foundations that supported pattern recognition, while at times narrowing diagnostic breadth due to specialization and habituated practice patterns. Developing DR in primary care was experienced as intellectually taxing, shaped by cognitive load, uncertainty, and contextual fragmentation. Students actively strengthened their DR through self-regulated strategies, while simulation, engaged preceptors, and iterative reassessment functioned as scaffolded supports for DR development.

NP students experience DR as a cognitive, relational, and identity-forming process that extends beyond technical skill acquisition to encompass diagnostic accountability. Educational approaches that explicitly address role transition, relational competencies, and structured reasoning may better prepare learners to assume diagnostic responsibility and navigate clinical uncertainty in NP practice.