We know what we need to pay attention to in building our primary care system - and no population will put the performance of primary care more to the test over the next two decades than the rapidly growing number of people who will be living with complex chronic conditions like dementia. Recent literature around primary care and dementia shows promise in attending to some of the attributes of high-performing primary care, yet much more work is needed if we are to truly leverage the potential value of primary care in addressing the needs of these complex and numerous future patients.

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.