Acquisition of clinical reasoning skills by undergraduate nursing students in Malawi; towards the development of a middle-range theory: a qualitative study.

Background: Acquiring clinical reasoning skills is essential for patient safety in nursing, and a lack of clinical reasoning skills can harm patients. However, teaching and learning clinical reasoning skills is not easy due to its complexity. Without a model, clinical reasoning is taught intuitively. Therefore, this study aimed to investigate how undergraduate nursing students acquire clinical reasoning skills towards the development of a middle-range theory.

Methods: This study employed the grounded theory of systematic design underpinned by a social constructivism paradigm. Forty-eight (48) undergraduate nursing students were purposive, and 12 nurse educators were theoretically sampled. Nurse educators were full-time lecturers with two or more years of teaching experience who were willing to share their knowledge to promote clinical reasoning skills. Students in their third and fourth years were selected because of their completion of the three- to four-year educational process and their acquisition of essential knowledge and competencies. Twelve individual in-depth interviews and six focus group discussions were conducted with nurse educators and undergraduate nursing students, respectively. Two qualitative data analysis frameworks were employed to analyse the data: thematic analysis and grounded theory analysis. Ethical principles of respect for human dignity, beneficence and justice were observed.

Results: Undergraduate nursing students reported that their clinical reasoning skills were acquired through automation while they utilized the nursing process. Through the themes, a new theory called 'a middle-range theory for the acquisition of clinical reasoning skills' was generated in the present study. The associated concepts were the environmental setting, type of curriculum, anchors and expected outcomes, which included individual and health care system indicators.

Conclusions: Teaching undergraduate nursing students how to reason clinically will help nurses adjust and solve problems in changing patients' situations. On the basis of the findings of this study, it is recommended that nursing students be equipped with adequate clinical reasoning skills before they graduate. Therefore, implementing the new model called 'a middle range theory for the acquisition of clinical reasoning skills' could foster the development of clinical reasoning skills from the start of the nursing training program.