Introduction: Rural acute care nursing requires an extensive breadth and depth of knowledge as well as the ability to quickly reason through problems in order to make sound clinical decisions. This reasoning often occurs within an environment that has minimal medical or ancillary support. Registered nurses (RN) new to rural nursing, and employers, have raised concerns about patient safety while new nurses make the transition into rural practice. In addition, feeling unprepared for the rigors of rural hospital nursing practice is a central issue influencing RN recruitment and retention. Understanding how rural RNs reason is a key element for identifying professional development needs and may support recruitment and retention of skilled rural nurses. The purpose of this study was to explore how rural RNs reason through clinical problems as well as to assess the quality of such reasoning. Methods: This study used a non-traditional approach for data collection. Fifteen rural acute care nurses with varying years of experience working in southern Alberta, Canada, were observed while they provided care to patients of varying acuity within a simulated rural setting. Following the simulation, semi-structured interviews were conducted using a substantive approach to critical thinking. Results: Findings revealed that the ability to engage in deep clinical reasoning varied considerably among participants despite being given the same information under the same circumstances. Furthermore, the number of years of experience did not seem to be directly linked to the ability to engage in sound clinical reasoning. Novice nurses, however, did rely heavily on others in their decision making in order to ensure they were making the right decision. Hence, their relationships with other staff members influenced their ability to engage in clinical reasoning and decision making. In situations where the patient's condition was deteriorating quickly, regardless of years of experience, all of the participants depended on their colleagues when making decisions and reasoning throughout the simulation. Conclusions: Deep clinical reasoning and decision making is a function of reflection and self-correction that requires a critical selfawareness and is more about how nurses think than what they think. The degree of sophistication in reasoning of experts and novices © MG Sedgwick, L Grigg, S Dersch, 2014. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au 2 is at times equivalent in that the reasoning of experts and novices can be somewhat limited and focused primarily on human physicality and less on conceptual knowledge. To become proficient in clinical reasoning, practice is necessary. The study supports the accumulating evidence that using clinical simulation and reflective interviewing that emphasize how clinical decisions are made enhances reasoning skills and confidence.

While the use of simulation is gaining popularity as an educational and training method, little is known about its utility in supporting field research activities. To address this gap, the physical, psychological, and conceptual dimensions of a full-scale simulated multi-bed rural nursing unit that became the 'field' for a rural nursing practice study is presented. The advantages of using simulation in this manner are that it: 1) allows processes to unfold in a controlled but natural fashion; 2) supports the exploration of complex phenomena; 3) and provides comparable data sets for analysis. Items to consider prior to using a simulation environment are also discussed.

Background and objective: Engaging in clinical reasoning frequently occurs in busy, high pressured, stressful settings with competing demands. Patient outcomes are affected in part by RNs' clinical reasoning ability. This study aims to explore the extent to which the clinical context influences clinical reasoning among urban and rural registered nurses. Methods: In this exploratory study using a mixed method approach, 11 rural hospital RNs and 7 RNs practicing in urban medical or surgical units completed a survey and a semi-structured individual qualitative interview. Data were generated over a two month period in 2015. Descriptive statistics and Mann-Whitney U was used to test for differences among groups. Qualitative data analysis procedures were used to help identify two major themes. Results: The perceived lack of time influenced the participants' ability to engage in clinical reasoning. The findings also suggest that rule following hampered the participants' ability to confidently share their clinical reasoning. Conclusions: To deepen RNs clinical reasoning an examination of the clinical environment's structure and processes that support or impede engagement in clinical reasoning is required. Specific strategies that enhance clinical reasoning need to be unit specific and driven by RNs.