Exploring the Development of Diagnostic Reasoning Among Nurse Practitioner Students at Two Canadian Universities

Abstract

Background Diagnostic Reasoning (DR) is a core competency for entry-level nurse practitioner (NP) practice and is fundamental to safe and effective clinical decision-making. Although numerous educational strategies have been proposed to strengthen DR, limited research has explored how NP students experience and develop DR throughout their educational journey. Purpose The purpose of this dissertation was to explore how NP students develop DR during their educational programs at two Canadian universities. Methods This qualitative dissertation employed Interpretive Description and comprised three interconnected manuscripts derived from a larger study. Twenty-four NP students in the final semester of their programs at two Canadian universities participated in semi-structured interviews conducted between May and June 2025. Interview transcripts were analyzed inductively using iterative coding, constant comparison, and Bingham’s five-phase qualitative analysis framework to generate clinically relevant interpretations. Results Across three manuscripts, the findings demonstrate that DR development extends beyond acquiring diagnostic knowledge and technical skills. Rather, it is the developmental process involving professional identity transformation, metacognitive growth, and learning within complex educational and clinical environments. Participants described the transition from registered nurses to NP as a shift toward diagnostic accountability while simultaneously developing the ability to calibrate intuition and analytical reasoning, recognize and regulate cognitive biases, reflect on clinical decision-making, and tolerate diagnostic uncertainty. DR development was further shaped by curriculum design, simulation, clinical preceptors, peer learning, and opportunities for deliberate practice. Conclusion This dissertation contributes a learner-centered understanding of DR development and addresses an important gap in NP education literature. The findings support explicit, longitudinal, and practice-oriented approaches to teaching DR that integrate classroom, simulation, and clinical learning experiences. These insights have implications for NP education, preceptor development, curriculum design, and future research aimed at preparing graduates for safe and independent diagnostic practice.