Detecting acute confusion in older adults: Comparing clinical reasoning of nurses working in acute, long-term, and community health care environments

In an article on a previous study involving hospitalized older adults (McCarthy, 2003), it was argued that the theory of situated clinical reasoning explains why nurses often fail to recognize acute confusion. Further, the theory illuminates how nurses' perspectives toward health in aging affect the ways they regard and ultimately deal with older people in this particular clinical situation. The purpose of the current study was to challenge and refine the theory by exploring the influence of different care environments on clinical reasoning related to acute confusion. Following a period of participant observation, a purposive sample of 30 nurses, 10 each from a teaching hospital, a long-term facility, and a home care agency, participated in semistructured interviews. Dimensional analysis provided the methodological framework for data collection and interpretation. The results reinforce prior findings that the ability of nurses to recognize acute confusion and to distinguish it from dementia can be attributed to their personal philosophies about aging. Care environment was identified as a factor that influenced clinical reasoning in limited ways under certain conditions and within certain contexts.