Factors Influencing Clinical Reasoning Among Clinical Nurses: An Integrative Review Using the Decision-Making Ecology...

Clinical reasoning (CR) is a complex, context-dependent process that is essential for safe nursing care. Existing reviews have primarily focused on nursing students rather than practicing clinical nurses. Rapid changes in patient acuity and the increasing integration of digital technologies into healthcare highlight the need for an updated synthesis that reflects contemporary clinical environments.

To identify and synthesize factors influencing CR among nurses in contemporary healthcare settings using the decision-making ecology (DME) model.

Integrative review.

The review followed the framework proposed by Whittemore and Knafl (2005). Literature searches were conducted in CINAHL, Cochrane Library, EMBASE, and PubMed for peer-reviewed studies published between January 2014 and June 2025. Data evaluation was performed using the Mixed Methods Appraisal Tool Version 2018.

A total of 25 studies were included, and 116 factors were initially extracted. After synthesis, 55 factors were identified and organized into 17 subdomains within four domains of the DME model: decision-maker, case, organizational, and external.

This review systematically identified multidimensional factors influencing nurses' CR using the DME model. CR competence should be understood not solely as an individual attribute but as a capability shaped by practice, organizational, and broader sociocultural environments. The findings highlight both established determinants and emerging technology-related influences on CR.

Nurse managers should provide opportunities for case-based learning, peer feedback, and reflective discussion tailored to nurses' levels of CR competence and clinical practice environments. Organizations should support the development of CR by ensuring adequate human and material resources, clear guidelines, and open organizational cultures that enable nurses to express and act on their clinical judgments. As technologies become more integrated into clinical practice, policymakers should promote their appropriate use to strengthen CR while minimizing technology-related barriers.