what are the steps to critical thinking and clinical reasoning

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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Chapter 6 clinical reasoning, decisionmaking, and action: thinking critically and clinically.

Patricia Benner ; Ronda G. Hughes ; Molly Sutphen .

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This chapter examines multiple thinking strategies that are needed for high-quality clinical practice. Clinical reasoning and judgment are examined in relation to other modes of thinking used by clinical nurses in providing quality health care to patients that avoids adverse events and patient harm. The clinician’s ability to provide safe, high-quality care can be dependent upon their ability to reason, think, and judge, which can be limited by lack of experience. The expert performance of nurses is dependent upon continual learning and evaluation of performance.

• Critical Thinking

Nursing education has emphasized critical thinking as an essential nursing skill for more than 50 years. 1 The definitions of critical thinking have evolved over the years. There are several key definitions for critical thinking to consider. The American Philosophical Association (APA) defined critical thinking as purposeful, self-regulatory judgment that uses cognitive tools such as interpretation, analysis, evaluation, inference, and explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations on which judgment is based. 2 A more expansive general definition of critical thinking is

. . . in short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposes assent to rigorous standards of excellence and mindful command of their use. It entails effective communication and problem solving abilities and a commitment to overcome our native egocentrism and sociocentrism. Every clinician must develop rigorous habits of critical thinking, but they cannot escape completely the situatedness and structures of the clinical traditions and practices in which they must make decisions and act quickly in specific clinical situations. 3

There are three key definitions for nursing, which differ slightly. Bittner and Tobin defined critical thinking as being “influenced by knowledge and experience, using strategies such as reflective thinking as a part of learning to identify the issues and opportunities, and holistically synthesize the information in nursing practice” 4 (p. 268). Scheffer and Rubenfeld 5 expanded on the APA definition for nurses through a consensus process, resulting in the following definition:

Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, openmindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge 6 (Scheffer & Rubenfeld, p. 357).

The National League for Nursing Accreditation Commission (NLNAC) defined critical thinking as:

the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research 7 (p. 8).

These concepts are furthered by the American Association of Colleges of Nurses’ definition of critical thinking in their Essentials of Baccalaureate Nursing :

Critical thinking underlies independent and interdependent decision making. Critical thinking includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity 8 (p. 9).

Course work or ethical experiences should provide the graduate with the knowledge and skills to:

• Use nursing and other appropriate theories and models, and an appropriate ethical framework;
• Apply research-based knowledge from nursing and the sciences as the basis for practice;
• Use clinical judgment and decision-making skills;
• Engage in self-reflective and collegial dialogue about professional practice;
• Evaluate nursing care outcomes through the acquisition of data and the questioning of inconsistencies, allowing for the revision of actions and goals;
• Engage in creative problem solving 8 (p. 10).

Taken together, these definitions of critical thinking set forth the scope and key elements of thought processes involved in providing clinical care. Exactly how critical thinking is defined will influence how it is taught and to what standard of care nurses will be held accountable.

Professional and regulatory bodies in nursing education have required that critical thinking be central to all nursing curricula, but they have not adequately distinguished critical reflection from ethical, clinical, or even creative thinking for decisionmaking or actions required by the clinician. Other essential modes of thought such as clinical reasoning, evaluation of evidence, creative thinking, or the application of well-established standards of practice—all distinct from critical reflection—have been subsumed under the rubric of critical thinking. In the nursing education literature, clinical reasoning and judgment are often conflated with critical thinking. The accrediting bodies and nursing scholars have included decisionmaking and action-oriented, practical, ethical, and clinical reasoning in the rubric of critical reflection and thinking. One might say that this harmless semantic confusion is corrected by actual practices, except that students need to understand the distinctions between critical reflection and clinical reasoning, and they need to learn to discern when each is better suited, just as students need to also engage in applying standards, evidence-based practices, and creative thinking.

The growing body of research, patient acuity, and complexity of care demand higher-order thinking skills. Critical thinking involves the application of knowledge and experience to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. These skills can be cultivated by educators who display the virtues of critical thinking, including independence of thought, intellectual curiosity, courage, humility, empathy, integrity, perseverance, and fair-mindedness. 9

The process of critical thinking is stimulated by integrating the essential knowledge, experiences, and clinical reasoning that support professional practice. The emerging paradigm for clinical thinking and cognition is that it is social and dialogical rather than monological and individual. 10–12 Clinicians pool their wisdom and multiple perspectives, yet some clinical knowledge can be demonstrated only in the situation (e.g., how to suction an extremely fragile patient whose oxygen saturations sink too low). Early warnings of problematic situations are made possible by clinicians comparing their observations to that of other providers. Clinicians form practice communities that create styles of practice, including ways of doing things, communication styles and mechanisms, and shared expectations about performance and expertise of team members.

By holding up critical thinking as a large umbrella for different modes of thinking, students can easily misconstrue the logic and purposes of different modes of thinking. Clinicians and scientists alike need multiple thinking strategies, such as critical thinking, clinical judgment, diagnostic reasoning, deliberative rationality, scientific reasoning, dialogue, argument, creative thinking, and so on. In particular, clinicians need forethought and an ongoing grasp of a patient’s health status and care needs trajectory, which requires an assessment of their own clarity and understanding of the situation at hand, critical reflection, critical reasoning, and clinical judgment.

Critical Reflection, Critical Reasoning, and Judgment

Critical reflection requires that the thinker examine the underlying assumptions and radically question or doubt the validity of arguments, assertions, and even facts of the case. Critical reflective skills are essential for clinicians; however, these skills are not sufficient for the clinician who must decide how to act in particular situations and avoid patient injury. For example, in everyday practice, clinicians cannot afford to critically reflect on the well-established tenets of “normal” or “typical” human circulatory systems when trying to figure out a particular patient’s alterations from that typical, well-grounded understanding that has existed since Harvey’s work in 1628. 13 Yet critical reflection can generate new scientifically based ideas. For example, there is a lack of adequate research on the differences between women’s and men’s circulatory systems and the typical pathophysiology related to heart attacks. Available research is based upon multiple, taken-for-granted starting points about the general nature of the circulatory system. As such, critical reflection may not provide what is needed for a clinician to act in a situation. This idea can be considered reasonable since critical reflective thinking is not sufficient for good clinical reasoning and judgment. The clinician’s development of skillful critical reflection depends upon being taught what to pay attention to, and thus gaining a sense of salience that informs the powers of perceptual grasp. The powers of noticing or perceptual grasp depend upon noticing what is salient and the capacity to respond to the situation.

Critical reflection is a crucial professional skill, but it is not the only reasoning skill or logic clinicians require. The ability to think critically uses reflection, induction, deduction, analysis, challenging assumptions, and evaluation of data and information to guide decisionmaking. 9 , 14 , 15 Critical reasoning is a process whereby knowledge and experience are applied in considering multiple possibilities to achieve the desired goals, 16 while considering the patient’s situation. 14 It is a process where both inductive and deductive cognitive skills are used. 17 Sometimes clinical reasoning is presented as a form of evaluating scientific knowledge, sometimes even as a form of scientific reasoning. Critical thinking is inherent in making sound clinical reasoning. 18

An essential point of tension and confusion exists in practice traditions such as nursing and medicine when clinical reasoning and critical reflection become entangled, because the clinician must have some established bases that are not questioned when engaging in clinical decisions and actions, such as standing orders. The clinician must act in the particular situation and time with the best clinical and scientific knowledge available. The clinician cannot afford to indulge in either ritualistic unexamined knowledge or diagnostic or therapeutic nihilism caused by radical doubt, as in critical reflection, because they must find an intelligent and effective way to think and act in particular clinical situations. Critical reflection skills are essential to assist practitioners to rethink outmoded or even wrong-headed approaches to health care, health promotion, and prevention of illness and complications, especially when new evidence is available. Breakdowns in practice, high failure rates in particular therapies, new diseases, new scientific discoveries, and societal changes call for critical reflection about past assumptions and no-longer-tenable beliefs.

Clinical reasoning stands out as a situated, practice-based form of reasoning that requires a background of scientific and technological research-based knowledge about general cases, more so than any particular instance. It also requires practical ability to discern the relevance of the evidence behind general scientific and technical knowledge and how it applies to a particular patient. In dong so, the clinician considers the patient’s particular clinical trajectory, their concerns and preferences, and their particular vulnerabilities (e.g., having multiple comorbidities) and sensitivities to care interventions (e.g., known drug allergies, other conflicting comorbid conditions, incompatible therapies, and past responses to therapies) when forming clinical decisions or conclusions.

Situated in a practice setting, clinical reasoning occurs within social relationships or situations involving patient, family, community, and a team of health care providers. The expert clinician situates themselves within a nexus of relationships, with concerns that are bounded by the situation. Expert clinical reasoning is socially engaged with the relationships and concerns of those who are affected by the caregiving situation, and when certain circumstances are present, the adverse event. Halpern 19 has called excellent clinical ethical reasoning “emotional reasoning” in that the clinicians have emotional access to the patient/family concerns and their understanding of the particular care needs. Expert clinicians also seek an optimal perceptual grasp, one based on understanding and as undistorted as possible, based on an attuned emotional engagement and expert clinical knowledge. 19 , 20

Clergy educators 21 and nursing and medical educators have begun to recognize the wisdom of broadening their narrow vision of rationality beyond simple rational calculation (exemplified by cost-benefit analysis) to reconsider the need for character development—including emotional engagement, perception, habits of thought, and skill acquisition—as essential to the development of expert clinical reasoning, judgment, and action. 10 , 22–24 Practitioners of engineering, law, medicine, and nursing, like the clergy, have to develop a place to stand in their discipline’s tradition of knowledge and science in order to recognize and evaluate salient evidence in the moment. Diagnostic confusion and disciplinary nihilism are both threats to the clinician’s ability to act in particular situations. However, the practice and practitioners will not be self-improving and vital if they cannot engage in critical reflection on what is not of value, what is outmoded, and what does not work. As evidence evolves and expands, so too must clinical thought.

Clinical judgment requires clinical reasoning across time about the particular, and because of the relevance of this immediate historical unfolding, clinical reasoning can be very different from the scientific reasoning used to formulate, conduct, and assess clinical experiments. While scientific reasoning is also socially embedded in a nexus of social relationships and concerns, the goal of detached, critical objectivity used to conduct scientific experiments minimizes the interactive influence of the research on the experiment once it has begun. Scientific research in the natural and clinical sciences typically uses formal criteria to develop “yes” and “no” judgments at prespecified times. The scientist is always situated in past and immediate scientific history, preferring to evaluate static and predetermined points in time (e.g., snapshot reasoning), in contrast to a clinician who must always reason about transitions over time. 25 , 26

Techne and Phronesis

Distinctions between the mere scientific making of things and practice was first explored by Aristotle as distinctions between techne and phronesis. 27 Learning to be a good practitioner requires developing the requisite moral imagination for good practice. If, for example, patients exercise their rights and refuse treatments, practitioners are required to have the moral imagination to understand the probable basis for the patient’s refusal. For example, was the refusal based upon catastrophic thinking, unrealistic fears, misunderstanding, or even clinical depression?

Techne, as defined by Aristotle, encompasses the notion of formation of character and habitus 28 as embodied beings. In Aristotle’s terms, techne refers to the making of things or producing outcomes. 11 Joseph Dunne defines techne as “the activity of producing outcomes,” and it “is governed by a means-ends rationality where the maker or producer governs the thing or outcomes produced or made through gaining mastery over the means of producing the outcomes, to the point of being able to separate means and ends” 11 (p. 54). While some aspects of medical and nursing practice fall into the category of techne, much of nursing and medical practice falls outside means-ends rationality and must be governed by concern for doing good or what is best for the patient in particular circumstances, where being in a relationship and discerning particular human concerns at stake guide action.

Phronesis, in contrast to techne, includes reasoning about the particular, across time, through changes or transitions in the patient’s and/or the clinician’s understanding. As noted by Dunne, phronesis is “characterized at least as much by a perceptiveness with regard to concrete particulars as by a knowledge of universal principles” 11 (p. 273). This type of practical reasoning often takes the form of puzzle solving or the evaluation of immediate past “hot” history of the patient’s situation. Such a particular clinical situation is necessarily particular, even though many commonalities and similarities with other disease syndromes can be recognized through signs and symptoms and laboratory tests. 11 , 29 , 30 Pointing to knowledge embedded in a practice makes no claim for infallibility or “correctness.” Individual practitioners can be mistaken in their judgments because practices such as medicine and nursing are inherently underdetermined. 31

While phronetic knowledge must remain open to correction and improvement, real events, and consequences, it cannot consistently transcend the institutional setting’s capacities and supports for good practice. Phronesis is also dependent on ongoing experiential learning of the practitioner, where knowledge is refined, corrected, or refuted. The Western tradition, with the notable exception of Aristotle, valued knowledge that could be made universal and devalued practical know-how and experiential learning. Descartes codified this preference for formal logic and rational calculation.

Aristotle recognized that when knowledge is underdetermined, changeable, and particular, it cannot be turned into the universal or standardized. It must be perceived, discerned, and judged, all of which require experiential learning. In nursing and medicine, perceptual acuity in physical assessment and clinical judgment (i.e., reasoning across time about changes in the particular patient or the clinician’s understanding of the patient’s condition) fall into the Greek Aristotelian category of phronesis. Dewey 32 sought to rescue knowledge gained by practical activity in the world. He identified three flaws in the understanding of experience in Greek philosophy: (1) empirical knowing is the opposite of experience with science; (2) practice is reduced to techne or the application of rational thought or technique; and (3) action and skilled know-how are considered temporary and capricious as compared to reason, which the Greeks considered as ultimate reality.

In practice, nursing and medicine require both techne and phronesis. The clinician standardizes and routinizes what can be standardized and routinized, as exemplified by standardized blood pressure measurements, diagnoses, and even charting about the patient’s condition and treatment. 27 Procedural and scientific knowledge can often be formalized and standardized (e.g., practice guidelines), or at least made explicit and certain in practice, except for the necessary timing and adjustments made for particular patients. 11 , 22

Rational calculations available to techne—population trends and statistics, algorithms—are created as decision support structures and can improve accuracy when used as a stance of inquiry in making clinical judgments about particular patients. Aggregated evidence from clinical trials and ongoing working knowledge of pathophysiology, biochemistry, and genomics are essential. In addition, the skills of phronesis (clinical judgment that reasons across time, taking into account the transitions of the particular patient/family/community and transitions in the clinician’s understanding of the clinical situation) will be required for nursing, medicine, or any helping profession.

Thinking Critically

Being able to think critically enables nurses to meet the needs of patients within their context and considering their preferences; meet the needs of patients within the context of uncertainty; consider alternatives, resulting in higher-quality care; 33 and think reflectively, rather than simply accepting statements and performing tasks without significant understanding and evaluation. 34 Skillful practitioners can think critically because they have the following cognitive skills: information seeking, discriminating, analyzing, transforming knowledge, predicating, applying standards, and logical reasoning. 5 One’s ability to think critically can be affected by age, length of education (e.g., an associate vs. a baccalaureate decree in nursing), and completion of philosophy or logic subjects. 35–37 The skillful practitioner can think critically because of having the following characteristics: motivation, perseverance, fair-mindedness, and deliberate and careful attention to thinking. 5 , 9

Thinking critically implies that one has a knowledge base from which to reason and the ability to analyze and evaluate evidence. 38 Knowledge can be manifest by the logic and rational implications of decisionmaking. Clinical decisionmaking is particularly influenced by interpersonal relationships with colleagues, 39 patient conditions, availability of resources, 40 knowledge, and experience. 41 Of these, experience has been shown to enhance nurses’ abilities to make quick decisions 42 and fewer decision errors, 43 support the identification of salient cues, and foster the recognition and action on patterns of information. 44 , 45

Clinicians must develop the character and relational skills that enable them to perceive and understand their patient’s needs and concerns. This requires accurate interpretation of patient data that is relevant to the specific patient and situation. In nursing, this formation of moral agency focuses on learning to be responsible in particular ways demanded by the practice, and to pay attention and intelligently discern changes in patients’ concerns and/or clinical condition that require action on the part of the nurse or other health care workers to avert potential compromises to quality care.

Formation of the clinician’s character, skills, and habits are developed in schools and particular practice communities within a larger practice tradition. As Dunne notes,

A practice is not just a surface on which one can display instant virtuosity. It grounds one in a tradition that has been formed through an elaborate development and that exists at any juncture only in the dispositions (slowly and perhaps painfully acquired) of its recognized practitioners. The question may of course be asked whether there are any such practices in the contemporary world, whether the wholesale encroachment of Technique has not obliterated them—and whether this is not the whole point of MacIntyre’s recipe of withdrawal, as well as of the post-modern story of dispossession 11 (p. 378).

Clearly Dunne is engaging in critical reflection about the conditions for developing character, skills, and habits for skillful and ethical comportment of practitioners, as well as to act as moral agents for patients so that they and their families receive safe, effective, and compassionate care.

Professional socialization or professional values, while necessary, do not adequately address character and skill formation that transform the way the practitioner exists in his or her world, what the practitioner is capable of noticing and responding to, based upon well-established patterns of emotional responses, skills, dispositions to act, and the skills to respond, decide, and act. 46 The need for character and skill formation of the clinician is what makes a practice stand out from a mere technical, repetitious manufacturing process. 11 , 30 , 47

In nursing and medicine, many have questioned whether current health care institutions are designed to promote or hinder enlightened, compassionate practice, or whether they have deteriorated into commercial institutional models that focus primarily on efficiency and profit. MacIntyre points out the links between the ongoing development and improvement of practice traditions and the institutions that house them:

Lack of justice, lack of truthfulness, lack of courage, lack of the relevant intellectual virtues—these corrupt traditions, just as they do those institutions and practices which derive their life from the traditions of which they are the contemporary embodiments. To recognize this is of course also to recognize the existence of an additional virtue, one whose importance is perhaps most obvious when it is least present, the virtue of having an adequate sense of the traditions to which one belongs or which confront one. This virtue is not to be confused with any form of conservative antiquarianism; I am not praising those who choose the conventional conservative role of laudator temporis acti. It is rather the case that an adequate sense of tradition manifests itself in a grasp of those future possibilities which the past has made available to the present. Living traditions, just because they continue a not-yet-completed narrative, confront a future whose determinate and determinable character, so far as it possesses any, derives from the past 30 (p. 207).

It would be impossible to capture all the situated and distributed knowledge outside of actual practice situations and particular patients. Simulations are powerful as teaching tools to enable nurses’ ability to think critically because they give students the opportunity to practice in a simplified environment. However, students can be limited in their inability to convey underdetermined situations where much of the information is based on perceptions of many aspects of the patient and changes that have occurred over time. Simulations cannot have the sub-cultures formed in practice settings that set the social mood of trust, distrust, competency, limited resources, or other forms of situated possibilities.

One of the hallmark studies in nursing providing keen insight into understanding the influence of experience was a qualitative study of adult, pediatric, and neonatal intensive care unit (ICU) nurses, where the nurses were clustered into advanced beginner, intermediate, and expert level of practice categories. The advanced beginner (having up to 6 months of work experience) used procedures and protocols to determine which clinical actions were needed. When confronted with a complex patient situation, the advanced beginner felt their practice was unsafe because of a knowledge deficit or because of a knowledge application confusion. The transition from advanced beginners to competent practitioners began when they first had experience with actual clinical situations and could benefit from the knowledge gained from the mistakes of their colleagues. Competent nurses continuously questioned what they saw and heard, feeling an obligation to know more about clinical situations. In doing do, they moved from only using care plans and following the physicians’ orders to analyzing and interpreting patient situations. Beyond that, the proficient nurse acknowledged the changing relevance of clinical situations requiring action beyond what was planned or anticipated. The proficient nurse learned to acknowledge the changing needs of patient care and situation, and could organize interventions “by the situation as it unfolds rather than by preset goals 48 (p. 24). Both competent and proficient nurses (that is, intermediate level of practice) had at least two years of ICU experience. 48 Finally, the expert nurse had a more fully developed grasp of a clinical situation, a sense of confidence in what is known about the situation, and could differentiate the precise clinical problem in little time. 48

Expertise is acquired through professional experience and is indicative of a nurse who has moved beyond mere proficiency. As Gadamer 29 points out, experience involves a turning around of preconceived notions, preunderstandings, and extends or adds nuances to understanding. Dewey 49 notes that experience requires a prepared “creature” and an enriched environment. The opportunity to reflect and narrate one’s experiential learning can clarify, extend, or even refute experiential learning.

Experiential learning requires time and nurturing, but time alone does not ensure experiential learning. Aristotle linked experiential learning to the development of character and moral sensitivities of a person learning a practice. 50 New nurses/new graduates have limited work experience and must experience continuing learning until they have reached an acceptable level of performance. 51 After that, further improvements are not predictable, and years of experience are an inadequate predictor of expertise. 52

The most effective knower and developer of practical knowledge creates an ongoing dialogue and connection between lessons of the day and experiential learning over time. Gadamer, in a late life interview, highlighted the open-endedness and ongoing nature of experiential learning in the following interview response:

Being experienced does not mean that one now knows something once and for all and becomes rigid in this knowledge; rather, one becomes more open to new experiences. A person who is experienced is undogmatic. Experience has the effect of freeing one to be open to new experience … In our experience we bring nothing to a close; we are constantly learning new things from our experience … this I call the interminability of all experience 32 (p. 403).

Practical endeavor, supported by scientific knowledge, requires experiential learning, the development of skilled know-how, and perceptual acuity in order to make the scientific knowledge relevant to the situation. Clinical perceptual and skilled know-how helps the practitioner discern when particular scientific findings might be relevant. 53

Often experience and knowledge, confirmed by experimentation, are treated as oppositions, an either-or choice. However, in practice it is readily acknowledged that experiential knowledge fuels scientific investigation, and scientific investigation fuels further experiential learning. Experiential learning from particular clinical cases can help the clinician recognize future similar cases and fuel new scientific questions and study. For example, less experienced nurses—and it could be argued experienced as well—can use nursing diagnoses practice guidelines as part of their professional advancement. Guidelines are used to reflect their interpretation of patients’ needs, responses, and situation, 54 a process that requires critical thinking and decisionmaking. 55 , 56 Using guidelines also reflects one’s problem identification and problem-solving abilities. 56 Conversely, the ability to proficiently conduct a series of tasks without nursing diagnoses is the hallmark of expertise. 39 , 57

Experience precedes expertise. As expertise develops from experience and gaining knowledge and transitions to the proficiency stage, the nurses’ thinking moves from steps and procedures (i.e., task-oriented care) toward “chunks” or patterns 39 (i.e., patient-specific care). In doing so, the nurse thinks reflectively, rather than merely accepting statements and performing procedures without significant understanding and evaluation. 34 Expert nurses do not rely on rules and logical thought processes in problem-solving and decisionmaking. 39 Instead, they use abstract principles, can see the situation as a complex whole, perceive situations comprehensively, and can be fully involved in the situation. 48 Expert nurses can perform high-level care without conscious awareness of the knowledge they are using, 39 , 58 and they are able to provide that care with flexibility and speed. Through a combination of knowledge and skills gained from a range of theoretical and experiential sources, expert nurses also provide holistic care. 39 Thus, the best care comes from the combination of theoretical, tacit, and experiential knowledge. 59 , 60

Experts are thought to eventually develop the ability to intuitively know what to do and to quickly recognize critical aspects of the situation. 22 Some have proposed that expert nurses provide high-quality patient care, 61 , 62 but that is not consistently documented—particularly in consideration of patient outcomes—and a full understanding between the differential impact of care rendered by an “expert” nurse is not fully understood. In fact, several studies have found that length of professional experience is often unrelated and even negatively related to performance measures and outcomes. 63 , 64

In a review of the literature on expertise in nursing, Ericsson and colleagues 65 found that focusing on challenging, less-frequent situations would reveal individual performance differences on tasks that require speed and flexibility, such as that experienced during a code or an adverse event. Superior performance was associated with extensive training and immediate feedback about outcomes, which can be obtained through continual training, simulation, and processes such as root-cause analysis following an adverse event. Therefore, efforts to improve performance benefited from continual monitoring, planning, and retrospective evaluation. Even then, the nurse’s ability to perform as an expert is dependent upon their ability to use intuition or insights gained through interactions with patients. 39

Intuition and Perception

Intuition is the instant understanding of knowledge without evidence of sensible thought. 66 According to Young, 67 intuition in clinical practice is a process whereby the nurse recognizes something about a patient that is difficult to verbalize. Intuition is characterized by factual knowledge, “immediate possession of knowledge, and knowledge independent of the linear reasoning process” 68 (p. 23). When intuition is used, one filters information initially triggered by the imagination, leading to the integration of all knowledge and information to problem solve. 69 Clinicians use their interactions with patients and intuition, drawing on tacit or experiential knowledge, 70 , 71 to apply the correct knowledge to make the correct decisions to address patient needs. Yet there is a “conflated belief in the nurses’ ability to know what is best for the patient” 72 (p. 251) because the nurses’ and patients’ identification of the patients’ needs can vary. 73

A review of research and rhetoric involving intuition by King and Appleton 62 found that all nurses, including students, used intuition (i.e., gut feelings). They found evidence, predominately in critical care units, that intuition was triggered in response to knowledge and as a trigger for action and/or reflection with a direct bearing on the analytical process involved in patient care. The challenge for nurses was that rigid adherence to checklists, guidelines, and standardized documentation, 62 ignored the benefits of intuition. This view was furthered by Rew and Barrow 68 , 74 in their reviews of the literature, where they found that intuition was imperative to complex decisionmaking, 68 difficult to measure and assess in a quantitative manner, and was not linked to physiologic measures. 74

Intuition is a way of explaining professional expertise. 75 Expert nurses rely on their intuitive judgment that has been developed over time. 39 , 76 Intuition is an informal, nonanalytically based, unstructured, deliberate calculation that facilitates problem solving, 77 a process of arriving at salient conclusions based on relatively small amounts of knowledge and/or information. 78 Experts can have rapid insight into a situation by using intuition to recognize patterns and similarities, achieve commonsense understanding, and sense the salient information combined with deliberative rationality. 10 Intuitive recognition of similarities and commonalities between patients are often the first diagnostic clue or early warning, which must then be followed up with critical evaluation of evidence among the competing conditions. This situation calls for intuitive judgment that can distinguish “expert human judgment from the decisions” made by a novice 79 (p. 23).

Shaw 80 equates intuition with direct perception. Direct perception is dependent upon being able to detect complex patterns and relationships that one has learned through experience are important. Recognizing these patterns and relationships generally occurs rapidly and is complex, making it difficult to articulate or describe. Perceptual skills, like those of the expert nurse, are essential to recognizing current and changing clinical conditions. Perception requires attentiveness and the development of a sense of what is salient. Often in nursing and medicine, means and ends are fused, as is the case for a “good enough” birth experience and a peaceful death.

• Applying Practice Evidence

Research continues to find that using evidence-based guidelines in practice, informed through research evidence, improves patients’ outcomes. 81–83 Research-based guidelines are intended to provide guidance for specific areas of health care delivery. 84 The clinician—both the novice and expert—is expected to use the best available evidence for the most efficacious therapies and interventions in particular instances, to ensure the highest-quality care, especially when deviations from the evidence-based norm may heighten risks to patient safety. Otherwise, if nursing and medicine were exact sciences, or consisted only of techne, then a 1:1 relationship could be established between results of aggregated evidence-based research and the best path for all patients.

Evaluating Evidence

Before research should be used in practice, it must be evaluated. There are many complexities and nuances in evaluating the research evidence for clinical practice. Evaluation of research behind evidence-based medicine requires critical thinking and good clinical judgment. Sometimes the research findings are mixed or even conflicting. As such, the validity, reliability, and generalizability of available research are fundamental to evaluating whether evidence can be applied in practice. To do so, clinicians must select the best scientific evidence relevant to particular patients—a complex process that involves intuition to apply the evidence. Critical thinking is required for evaluating the best available scientific evidence for the treatment and care of a particular patient.

Good clinical judgment is required to select the most relevant research evidence. The best clinical judgment, that is, reasoning across time about the particular patient through changes in the patient’s concerns and condition and/or the clinician’s understanding, are also required. This type of judgment requires clinicians to make careful observations and evaluations of the patient over time, as well as know the patient’s concerns and social circumstances. To evolve to this level of judgment, additional education beyond clinical preparation if often required.

Sources of Evidence

Evidence that can be used in clinical practice has different sources and can be derived from research, patient’s preferences, and work-related experience. 85 , 86 Nurses have been found to obtain evidence from experienced colleagues believed to have clinical expertise and research-based knowledge 87 as well as other sources.

For many years now, randomized controlled trials (RCTs) have often been considered the best standard for evaluating clinical practice. Yet, unless the common threats to the validity (e.g., representativeness of the study population) and reliability (e.g., consistency in interventions and responses of study participants) of RCTs are addressed, the meaningfulness and generalizability of the study outcomes are very limited. Relevant patient populations may be excluded, such as women, children, minorities, the elderly, and patients with multiple chronic illnesses. The dropout rate of the trial may confound the results. And it is easier to get positive results published than it is to get negative results published. Thus, RCTs are generalizable (i.e., applicable) only to the population studied—which may not reflect the needs of the patient under the clinicians care. In instances such as these, clinicians need to also consider applied research using prospective or retrospective populations with case control to guide decisionmaking, yet this too requires critical thinking and good clinical judgment.

Another source of available evidence may come from the gold standard of aggregated systematic evaluation of clinical trial outcomes for the therapy and clinical condition in question, be generated by basic and clinical science relevant to the patient’s particular pathophysiology or care need situation, or stem from personal clinical experience. The clinician then takes all of the available evidence and considers the particular patient’s known clinical responses to past therapies, their clinical condition and history, the progression or stages of the patient’s illness and recovery, and available resources.

In clinical practice, the particular is examined in relation to the established generalizations of science. With readily available summaries of scientific evidence (e.g., systematic reviews and practice guidelines) available to nurses and physicians, one might wonder whether deep background understanding is still advantageous. Might it not be expendable, since it is likely to be out of date given the current scientific evidence? But this assumption is a false opposition and false choice because without a deep background understanding, the clinician does not know how to best find and evaluate scientific evidence for the particular case in hand. The clinician’s sense of salience in any given situation depends on past clinical experience and current scientific evidence.

Evidence-Based Practice

The concept of evidence-based practice is dependent upon synthesizing evidence from the variety of sources and applying it appropriately to the care needs of populations and individuals. This implies that evidence-based practice, indicative of expertise in practice, appropriately applies evidence to the specific situations and unique needs of patients. 88 , 89 Unfortunately, even though providing evidence-based care is an essential component of health care quality, it is well known that evidence-based practices are not used consistently.

Conceptually, evidence used in practice advances clinical knowledge, and that knowledge supports independent clinical decisions in the best interest of the patient. 90 , 91 Decisions must prudently consider the factors not necessarily addressed in the guideline, such as the patient’s lifestyle, drug sensitivities and allergies, and comorbidities. Nurses who want to improve the quality and safety of care can do so though improving the consistency of data and information interpretation inherent in evidence-based practice.

Initially, before evidence-based practice can begin, there needs to be an accurate clinical judgment of patient responses and needs. In the course of providing care, with careful consideration of patient safety and quality care, clinicians must give attention to the patient’s condition, their responses to health care interventions, and potential adverse reactions or events that could harm the patient. Nonetheless, there is wide variation in the ability of nurses to accurately interpret patient responses 92 and their risks. 93 Even though variance in interpretation is expected, nurses are obligated to continually improve their skills to ensure that patients receive quality care safely. 94 Patients are vulnerable to the actions and experience of their clinicians, which are inextricably linked to the quality of care patients have access to and subsequently receive.

The judgment of the patient’s condition determines subsequent interventions and patient outcomes. Attaining accurate and consistent interpretations of patient data and information is difficult because each piece can have different meanings, and interpretations are influenced by previous experiences. 95 Nurses use knowledge from clinical experience 96 , 97 and—although infrequently—research. 98–100

Once a problem has been identified, using a process that utilizes critical thinking to recognize the problem, the clinician then searches for and evaluates the research evidence 101 and evaluates potential discrepancies. The process of using evidence in practice involves “a problem-solving approach that incorporates the best available scientific evidence, clinicians’ expertise, and patient’s preferences and values” 102 (p. 28). Yet many nurses do not perceive that they have the education, tools, or resources to use evidence appropriately in practice. 103

Reported barriers to using research in practice have included difficulty in understanding the applicability and the complexity of research findings, failure of researchers to put findings into the clinical context, lack of skills in how to use research in practice, 104 , 105 amount of time required to access information and determine practice implications, 105–107 lack of organizational support to make changes and/or use in practice, 104 , 97 , 105 , 107 and lack of confidence in one’s ability to critically evaluate clinical evidence. 108

When Evidence Is Missing

In many clinical situations, there may be no clear guidelines and few or even no relevant clinical trials to guide decisionmaking. In these cases, the latest basic science about cellular and genomic functioning may be the most relevant science, or by default, guestimation. Consequently, good patient care requires more than a straightforward, unequivocal application of scientific evidence. The clinician must be able to draw on a good understanding of basic sciences, as well as guidelines derived from aggregated data and information from research investigations.

Practical knowledge is shaped by one’s practice discipline and the science and technology relevant to the situation at hand. But scientific, formal, discipline-specific knowledge are not sufficient for good clinical practice, whether the discipline be law, medicine, nursing, teaching, or social work. Practitioners still have to learn how to discern generalizable scientific knowledge, know how to use scientific knowledge in practical situations, discern what scientific evidence/knowledge is relevant, assess how the particular patient’s situation differs from the general scientific understanding, and recognize the complexity of care delivery—a process that is complex, ongoing, and changing, as new evidence can overturn old.

Practice communities like individual practitioners may also be mistaken, as is illustrated by variability in practice styles and practice outcomes across hospitals and regions in the United States. This variability in practice is why practitioners must learn to critically evaluate their practice and continually improve their practice over time. The goal is to create a living self-improving tradition.

Within health care, students, scientists, and practitioners are challenged to learn and use different modes of thinking when they are conflated under one term or rubric, using the best-suited thinking strategies for taking into consideration the purposes and the ends of the reasoning. Learning to be an effective, safe nurse or physician requires not only technical expertise, but also the ability to form helping relationships and engage in practical ethical and clinical reasoning. 50 Good ethical comportment requires that both the clinician and the scientist take into account the notions of good inherent in clinical and scientific practices. The notions of good clinical practice must include the relevant significance and the human concerns involved in decisionmaking in particular situations, centered on clinical grasp and clinical forethought.

The Three Apprenticeships of Professional Education

We have much to learn in comparing the pedagogies of formation across the professions, such as is being done currently by the Carnegie Foundation for the Advancement of Teaching. The Carnegie Foundation’s broad research program on the educational preparation of the profession focuses on three essential apprenticeships:

To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: (1) intellectual training to learn the academic knowledge base and the capacity to think in ways important to the profession; (2) a skill-based apprenticeship of practice; and (3) an apprenticeship to the ethical standards, social roles, and responsibilities of the profession, through which the novice is introduced to the meaning of an integrated practice of all dimensions of the profession, grounded in the profession’s fundamental purposes. 109

This framework has allowed the investigators to describe tensions and shortfalls as well as strengths of widespread teaching practices, especially at articulation points among these dimensions of professional training.

Research has demonstrated that these three apprenticeships are taught best when they are integrated so that the intellectual training includes skilled know-how, clinical judgment, and ethical comportment. In the study of nursing, exemplary classroom and clinical teachers were found who do integrate the three apprenticeships in all of their teaching, as exemplified by the following anonymous student’s comments:

With that as well, I enjoyed the class just because I do have clinical experience in my background and I enjoyed it because it took those practical applications and the knowledge from pathophysiology and pharmacology, and all the other classes, and it tied it into the actual aspects of like what is going to happen at work. For example, I work in the emergency room and question: Why am I doing this procedure for this particular patient? Beforehand, when I was just a tech and I wasn’t going to school, I’d be doing it because I was told to be doing it—or I’d be doing CPR because, you know, the doc said, start CPR. I really enjoy the Care and Illness because now I know the process, the pathophysiological process of why I’m doing it and the clinical reasons of why they’re making the decisions, and the prioritization that goes on behind it. I think that’s the biggest point. Clinical experience is good, but not everybody has it. Yet when these students transition from school and clinicals to their job as a nurse, they will understand what’s going on and why.

The three apprenticeships are equally relevant and intertwined. In the Carnegie National Study of Nursing Education and the companion study on medical education as well as in cross-professional comparisons, teaching that gives an integrated access to professional practice is being examined. Once the three apprenticeships are separated, it is difficult to reintegrate them. The investigators are encouraged by teaching strategies that integrate the latest scientific knowledge and relevant clinical evidence with clinical reasoning about particular patients in unfolding rather than static cases, while keeping the patient and family experience and concerns relevant to clinical concerns and reasoning.

Clinical judgment or phronesis is required to evaluate and integrate techne and scientific evidence.

Within nursing, professional practice is wise and effective usually to the extent that the professional creates relational and communication contexts where clients/patients can be open and trusting. Effectiveness depends upon mutual influence between patient and practitioner, student and learner. This is another way in which clinical knowledge is dialogical and socially distributed. The following articulation of practical reasoning in nursing illustrates the social, dialogical nature of clinical reasoning and addresses the centrality of perception and understanding to good clinical reasoning, judgment and intervention.

Clinical Grasp *

Clinical grasp describes clinical inquiry in action. Clinical grasp begins with perception and includes problem identification and clinical judgment across time about the particular transitions of particular patients. Garrett Chan 20 described the clinician’s attempt at finding an “optimal grasp” or vantage point of understanding. Four aspects of clinical grasp, which are described in the following paragraphs, include (1) making qualitative distinctions, (2) engaging in detective work, (3) recognizing changing relevance, and (4) developing clinical knowledge in specific patient populations.

Making Qualitative Distinctions

Qualitative distinctions refer to those distinctions that can be made only in a particular contextual or historical situation. The context and sequence of events are essential for making qualitative distinctions; therefore, the clinician must pay attention to transitions in the situation and judgment. Many qualitative distinctions can be made only by observing differences through touch, sound, or sight, such as the qualities of a wound, skin turgor, color, capillary refill, or the engagement and energy level of the patient. Another example is assessing whether the patient was more fatigued after ambulating to the bathroom or from lack of sleep. Likewise the quality of the clinician’s touch is distinct as in offering reassurance, putting pressure on a bleeding wound, and so on. 110

Engaging in Detective Work, Modus Operandi Thinking, and Clinical Puzzle Solving

Clinical situations are open ended and underdetermined. Modus operandi thinking keeps track of the particular patient, the way the illness unfolds, the meanings of the patient’s responses as they have occurred in the particular time sequence. Modus operandi thinking requires keeping track of what has been tried and what has or has not worked with the patient. In this kind of reasoning-in-transition, gains and losses of understanding are noticed and adjustments in the problem approach are made.

We found that teachers in a medical surgical unit at the University of Washington deliberately teach their students to engage in “detective work.” Students are given the daily clinical assignment of “sleuthing” for undetected drug incompatibilities, questionable drug dosages, and unnoticed signs and symptoms. For example, one student noted that an unusual dosage of a heart medication was being given to a patient who did not have heart disease. The student first asked her teacher about the unusually high dosage. The teacher, in turn, asked the student whether she had asked the nurse or the patient about the dosage. Upon the student’s questioning, the nurse did not know why the patient was receiving the high dosage and assumed the drug was for heart disease. The patient’s staff nurse had not questioned the order. When the student asked the patient, the student found that the medication was being given for tremors and that the patient and the doctor had titrated the dosage for control of the tremors. This deliberate approach to teaching detective work, or modus operandi thinking, has characteristics of “critical reflection,” but stays situated and engaged, ferreting out the immediate history and unfolding of events.

Recognizing Changing Clinical Relevance

The meanings of signs and symptoms are changed by sequencing and history. The patient’s mental status, color, or pain level may continue to deteriorate or get better. The direction, implication, and consequences for the changes alter the relevance of the particular facts in the situation. The changing relevance entailed in a patient transitioning from primarily curative care to primarily palliative care is a dramatic example, where symptoms literally take on new meanings and require new treatments.

Developing Clinical Knowledge in Specific Patient Populations

Extensive experience with a specific patient population or patients with particular injuries or diseases allows the clinician to develop comparisons, distinctions, and nuanced differences within the population. The comparisons between many specific patients create a matrix of comparisons for clinicians, as well as a tacit, background set of expectations that create population- and patient-specific detective work if a patient does not meet the usual, predictable transitions in recovery. What is in the background and foreground of the clinician’s attention shifts as predictable changes in the patient’s condition occurs, such as is seen in recovering from heart surgery or progressing through the predictable stages of labor and delivery. Over time, the clinician develops a deep background understanding that allows for expert diagnostic and interventions skills.

Clinical Forethought

Clinical forethought is intertwined with clinical grasp, but it is much more deliberate and even routinized than clinical grasp. Clinical forethought is a pervasive habit of thought and action in nursing practice, and also in medicine, as clinicians think about disease and recovery trajectories and the implications of these changes for treatment. Clinical forethought plays a role in clinical grasp because it structures the practical logic of clinicians. At least four habits of thought and action are evident in what we are calling clinical forethought: (1) future think, (2) clinical forethought about specific patient populations, (3) anticipation of risks for particular patients, and (4) seeing the unexpected.

Future think

Future think is the broadest category of this logic of practice. Anticipating likely immediate futures helps the clinician make good plans and decisions about preparing the environment so that responding rapidly to changes in the patient is possible. Without a sense of salience about anticipated signs and symptoms and preparing the environment, essential clinical judgments and timely interventions would be impossible in the typically fast pace of acute and intensive patient care. Future think governs the style and content of the nurse’s attentiveness to the patient. Whether in a fast-paced care environment or a slower-paced rehabilitation setting, thinking and acting with anticipated futures guide clinical thinking and judgment. Future think captures the way judgment is suspended in a predictive net of anticipation and preparing oneself and the environment for a range of potential events.

Clinical forethought about specific diagnoses and injuries

This habit of thought and action is so second nature to the experienced nurse that the new or inexperienced nurse may have difficulty finding out about what seems to other colleagues as “obvious” preparation for particular patients and situations. Clinical forethought involves much local specific knowledge about who is a good resource and how to marshal support services and equipment for particular patients.

Examples of preparing for specific patient populations are pervasive, such as anticipating the need for a pacemaker during surgery and having the equipment assembled ready for use to save essential time. Another example includes forecasting an accident victim’s potential injuries, and recognizing that intubation might be needed.

Anticipation of crises, risks, and vulnerabilities for particular patients

This aspect of clinical forethought is central to knowing the particular patient, family, or community. Nurses situate the patient’s problems almost like a topography of possibilities. This vital clinical knowledge needs to be communicated to other caregivers and across care borders. Clinical teaching could be improved by enriching curricula with narrative examples from actual practice, and by helping students recognize commonly occurring clinical situations in the simulation and clinical setting. For example, if a patient is hemodynamically unstable, then managing life-sustaining physiologic functions will be a main orienting goal. If the patient is agitated and uncomfortable, then attending to comfort needs in relation to hemodynamics will be a priority. Providing comfort measures turns out to be a central background practice for making clinical judgments and contains within it much judgment and experiential learning.

When clinical teaching is too removed from typical contingencies and strong clinical situations in practice, students will lack practice in active thinking-in-action in ambiguous clinical situations. In the following example, an anonymous student recounted her experiences of meeting a patient:

I was used to different equipment and didn’t know how things went, didn’t know their routine, really. You can explain all you want in class, this is how it’s going to be, but when you get there … . Kim was my first instructor and my patient that she assigned me to—I walked into the room and he had every tube imaginable. And so I was a little overwhelmed. It’s not necessarily even that he was that critical … . She asked what tubes here have you seen? Well, I know peripheral lines. You taught me PICC [peripherally inserted central catheter] lines, and we just had that, but I don’t really feel comfortable doing it by myself, without you watching to make sure that I’m flushing it right and how to assess it. He had a chest tube and I had seen chest tubes, but never really knew the depth of what you had to assess and how you make sure that it’s all kosher and whatever. So she went through the chest tube and explained, it’s just bubbling a little bit and that’s okay. The site, check the site. The site looked okay and that she’d say if it wasn’t okay, this is what it might look like … . He had a feeding tube. I had done feeding tubes but that was like a long time ago in my LPN experiences schooling. So I hadn’t really done too much with the feeding stuff either … . He had a [nasogastric] tube, and knew pretty much about that and I think at the time it was clamped. So there were no issues with the suction or whatever. He had a Foley catheter. He had a feeding tube, a chest tube. I can’t even remember but there were a lot.

As noted earlier, a central characteristic of a practice discipline is that a self-improving practice requires ongoing experiential learning. One way nurse educators can enhance clinical inquiry is by increasing pedagogies of experiential learning. Current pedagogies for experiential learning in nursing include extensive preclinical study, care planning, and shared postclinical debriefings where students share their experiential learning with their classmates. Experiential learning requires open learning climates where students can discuss and examine transitions in understanding, including their false starts, or their misconceptions in actual clinical situations. Nursing educators typically develop open and interactive clinical learning communities, so that students seem committed to helping their classmates learn from their experiences that may have been difficult or even unsafe. One anonymous nurse educator described how students extend their experiential learning to their classmates during a postclinical conference:

So for example, the patient had difficulty breathing and the student wanted to give the meds instead of addressing the difficulty of breathing. Well, while we were sharing information about their patients, what they did that day, I didn’t tell the student to say this, but she said, ‘I just want to tell you what I did today in clinical so you don’t do the same thing, and here’s what happened.’ Everybody’s listening very attentively and they were asking her some questions. But she shared that. She didn’t have to. I didn’t tell her, you must share that in postconference or anything like that, but she just went ahead and shared that, I guess, to reinforce what she had learned that day but also to benefit her fellow students in case that thing comes up with them.

The teacher’s response to this student’s honesty and generosity exemplifies her own approach to developing an open community of learning. Focusing only on performance and on “being correct” prevents learning from breakdown or error and can dampen students’ curiosity and courage to learn experientially.

Seeing the unexpected

One of the keys to becoming an expert practitioner lies in how the person holds past experiential learning and background habitual skills and practices. This is a skill of foregrounding attention accurately and effectively in response to the nature of situational demands. Bourdieu 29 calls the recognition of the situation central to practical reasoning. If nothing is routinized as a habitual response pattern, then practitioners will not function effectively in emergencies. Unexpected occurrences may be overlooked. However, if expectations are held rigidly, then subtle changes from the usual will be missed, and habitual, rote responses will inappropriately rule. The clinician must be flexible in shifting between what is in background and foreground. This is accomplished by staying curious and open. The clinical “certainty” associated with perceptual grasp is distinct from the kind of “certainty” achievable in scientific experiments and through measurements. Recognition of similar or paradigmatic clinical situations is similar to “face recognition” or recognition of “family resemblances.” This concept is subject to faulty memory, false associative memories, and mistaken identities; therefore, such perceptual grasp is the beginning of curiosity and inquiry and not the end. Assessment and validation are required. In rapidly moving clinical situations, perceptual grasp is the starting point for clarification, confirmation, and action. Having the clinician say out loud how he or she is understanding the situation gives an opportunity for confirmation and disconfirmation from other clinicians present. 111 The relationship between foreground and background of attention needs to be fluid, so that missed expectations allow the nurse to see the unexpected. For example, when the background rhythm of a cardiac monitor changes, the nurse notices, and what had been background tacit awareness becomes the foreground of attention. A hallmark of expertise is the ability to notice the unexpected. 20 Background expectations of usual patient trajectories form with experience. Tacit expectations for patient trajectories form that enable the nurse to notice subtle failed expectations and pay attention to early signs of unexpected changes in the patient's condition. Clinical expectations gained from caring for similar patient populations form a tacit clinical forethought that enable the experienced clinician to notice missed expectations. Alterations from implicit or explicit expectations set the stage for experiential learning, depending on the openness of the learner.

Learning to provide safe and quality health care requires technical expertise, the ability to think critically, experience, and clinical judgment. The high-performance expectation of nurses is dependent upon the nurses’ continual learning, professional accountability, independent and interdependent decisionmaking, and creative problem-solving abilities.

This section of the paper was condensed and paraphrased from Benner, Hooper-Kyriakidis, and Stannard. 23 Patricia Hooper-Kyriakidis wrote the section on clinical grasp, and Patricia Benner wrote the section on clinical forethought.

• Cite this Page Benner P, Hughes RG, Sutphen M. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 6.
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Advanced practice: critical thinking and clinical reasoning

Sadie Diamond-Fox

Senior Lecturer in Advanced Critical Care Practice, Northumbria University, Advanced Critical Care Practitioner, Newcastle upon Tyne Hospitals NHS Foundation Trust, and Co-Lead, Advanced Critical/Clinical Care Practitioners Academic Network (ACCPAN)

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Advanced Critical Care Practitioner, South Tees Hospitals NHS Foundation Trust

Clinical reasoning is a multi-faceted and complex construct, the understanding of which has emerged from multiple fields outside of healthcare literature, primarily the psychological and behavioural sciences. The application of clinical reasoning is central to the advanced non-medical practitioner (ANMP) role, as complex patient caseloads with undifferentiated and undiagnosed diseases are now a regular feature in healthcare practice. This article explores some of the key concepts and terminology that have evolved over the last four decades and have led to our modern day understanding of this topic. It also considers how clinical reasoning is vital for improving evidence-based diagnosis and subsequent effective care planning. A comprehensive guide to applying diagnostic reasoning on a body systems basis will be explored later in this series.

The Multi-professional Framework for Advanced Clinical Practice highlights clinical reasoning as one of the core clinical capabilities for advanced clinical practice in England ( Health Education England (HEE), 2017 ). This is also identified in other specialist core capability frameworks and training syllabuses for advanced clinical practitioner (ACP) roles ( Faculty of Intensive Care Medicine, 2018 ; Royal College of Emergency Medicine, 2019 ; HEE, 2020 ; HEE et al, 2020 ).

Rencic et al (2020) defined clinical reasoning as ‘a complex ability, requiring both declarative and procedural knowledge, such as physical examination and communication skills’. A plethora of literature exists surrounding this topic, with a recent systematic review identifying 625 papers, spanning 47 years, across the health professions ( Young et al, 2020 ). A diverse range of terms are used to refer to clinical reasoning within the healthcare literature ( Table 1 ), which can make defining their influence on their use within the clinical practice and educational arenas somewhat challenging.

The concept of clinical reasoning has changed dramatically over the past four decades. What was once thought to be a process-dependent task is now considered to present a more dynamic state of practice, which is affected by ‘complex, non-linear interactions between the clinician, patient, and the environment’ ( Rencic et al, 2020 ).

Cognitive and meta-cognitive processes

As detailed in the table, multiple themes surrounding the cognitive and meta-cognitive processes that underpin clinical reasoning have been identified. Central to these processes is the practice of critical thinking. Much like the definition of clinical reasoning, there is also diversity with regard to definitions and conceptualisation of critical thinking in the healthcare setting. Facione (2020) described critical thinking as ‘purposeful reflective judgement’ that consists of six discrete cognitive skills: analysis, inference, interpretation, explanation, synthesis and self–regulation. Ross et al (2016) identified that critical thinking positively correlates with academic success, professionalism, clinical decision-making, wider reasoning and problem-solving capabilities. Jacob et al (2017) also identified that patient outcomes and safety are directly linked to critical thinking skills.

Harasym et al (2008) listed nine discrete cognitive steps that may be applied to the process of critical thinking, which integrates both cognitive and meta-cognitive processes:

• Gather relevant information
• Formulate clearly defined questions and problems
• Evaluate relevant information
• Utilise and interpret abstract ideas effectively
• Infer well-reasoned conclusions and solutions
• Pilot outcomes against relevant criteria and standards
• Use alternative thought processes if needed
• Consider all assumptions, implications, and practical consequences
• Communicate effectively with others to solve complex problems.

There are a number of widely used strategies to develop critical thinking and evidence-based diagnosis. These include simulated problem-based learning platforms, high-fidelity simulation scenarios, case-based discussion forums, reflective journals as part of continuing professional development (CPD) portfolios and journal clubs.

Dual process theory and cognitive bias in diagnostic reasoning

A lack of understanding of the interrelationship between critical thinking and clinical reasoning can result in cognitive bias, which can in turn lead to diagnostic errors ( Hayes et al, 2017 ). Embedded within our understanding of how diagnostic errors occur is dual process theory—system 1 and system 2 thinking. The characteristics of these are described in Table 2 . Although much of the literature in this area regards dual process theory as a valid representation of clinical reasoning, the exact causes of diagnostic errors remain unclear and require further research ( Norman et al, 2017 ). The most effective way in which to teach critical thinking skills in healthcare education also remains unclear; however, Hayes et al (2017) proposed five strategies, based on well-known educational theory and principles, that they have found to be effective for teaching and learning critical thinking within the ‘high-octane’ and ‘high-stakes’ environment of the intensive care unit ( Table 3 ). This is arguably a setting that does not always present an ideal environment for learning given its fast pace and constant sensory stimulation. However, it may be argued that if a model has proven to be effective in this setting, it could be extrapolated to other busy clinical environments and may even provide a useful aide memoire for self-assessment and reflective practices.

Integrating the clinical reasoning process into the clinical consultation

Linn et al (2012) described the clinical consultation as ‘the practical embodiment of the clinical reasoning process by which data are gathered, considered, challenged and integrated to form a diagnosis that can lead to appropriate management’. The application of the previously mentioned psychological and behavioural science theories is intertwined throughout the clinical consultation via the following discrete processes:

• The clinical history generates an initial hypothesis regarding diagnosis, and said hypothesis is then tested through skilled and specific questioning
• The clinician formulates a primary diagnosis and differential diagnoses in order of likelihood
• Physical examination is carried out, aimed at gathering further data necessary to confirm or refute the hypotheses
• A selection of appropriate investigations, using an evidence-based approach, may be ordered to gather additional data
• The clinician (in partnership with the patient) then implements a targeted and rationalised management plan, based on best-available clinical evidence.

Linn et al (2012) also provided a very useful framework of how the above methods can be applied when teaching consultation with a focus on clinical reasoning (see Table 4 ). This framework may also prove useful to those new to the process of undertaking the clinical consultation process.

Evidence-based diagnosis and diagnostic accuracy

The principles of clinical reasoning are embedded within the practices of formulating an evidence-based diagnosis (EBD). According to Kohn (2014) EBD quantifies the probability of the presence of a disease through the use of diagnostic tests. He described three pertinent questions to consider in this respect:

• ‘How likely is the patient to have a particular disease?’
• ‘How good is this test for the disease in question?’
• ‘Is the test worth performing to guide treatment?’

EBD gives a statistical discriminatory weighting to update the probability of a disease to either support or refute the working and differential diagnoses, which can then determine the appropriate course of further diagnostic testing and treatments.

Diagnostic accuracy refers to how positive or negative findings change the probability of the presence of disease. In order to understand diagnostic accuracy, we must begin to understand the underlying principles and related statistical calculations concerning sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and likelihood ratios.

The construction of a two-by-two square (2 x 2) table ( Figure 1 ) allows the calculation of several statistical weightings for pertinent points of the history-taking exercise, a finding/sign on physical examination, or a test result. From this construct we can then determine the aforementioned statistical calculations as follows ( McGee, 2018 ):

• Sensitivity , the proportion of patients with the diagnosis who have the physical sign or a positive test result = A ÷ (A + C)
• Specificity , the proportion of patients without the diagnosis who lack the physical sign or have a negative test result = D ÷ (B + D)
• Positive predictive value , the proportion of patients with disease who have a physical sign divided by the proportion of patients without disease who also have the same sign = A ÷ (A + B)
• Negative predictive value , proportion of patients with disease lacking a physical sign divided by the proportion of patients without disease also lacking the sign = D ÷ (C + D)
• Likelihood ratio , a finding/sign/test results sensitivity divided by the false-positive rate. A test of no value has an LR of 1. Therefore the test would have no impact upon the patient's odds of disease
• Positive likelihood ratio = proportion of patients with disease who have a positive finding/sign/test, divided by proportion of patients without disease who have a positive finding/sign/test OR (A ÷ N1) ÷ (B÷ N2), or sensitivity ÷ (1 – specificity) The more positive an LR (the further above 1), the more the finding/sign/test result raises a patient's probability of disease. Thresholds of ≥ 4 are often considered to be significant when focusing a clinician's interest on the most pertinent positive findings, clinical signs or tests
• Negative likelihood ratio = proportion of patients with disease who have a negative finding/sign/test result, divided by the proportion of patients without disease who have a positive finding/sign/test OR (C ÷ N1) ÷ (D÷N1) or (1 – sensitivity) ÷ specificity The more negative an LR (the closer to 0), the more the finding/sign/test result lowers a patient's probability of disease. Thresholds <0.4 are often considered to be significant when focusing clinician's interest on the most pertinent negative findings, clinical signs or tests.

There are various online statistical calculators that can aid in the above calculations, such as the BMJ Best Practice statistical calculators, which may used as a guide (https://bestpractice.bmj.com/info/toolkit/ebm-toolbox/statistics-calculators/).

Clinical scoring systems

Evidence-based literature supports the practice of determining clinical pretest probability of certain diseases prior to proceeding with a diagnostic test. There are numerous validated pretest clinical scoring systems and clinical prediction tools that can be used in this context and accessed via various online platforms such as MDCalc (https://www.mdcalc.com/#all). Such clinical prediction tools include:

• 4Ts score for heparin-induced thrombocytopenia
• ABCD² score for transient ischaemic attack (TIA)
• CHADS₂ score for atrial fibrillation stroke risk
• Aortic Dissection Detection Risk Score (ADD-RS).

Conclusions

Critical thinking and clinical reasoning are fundamental skills of the advanced non-medical practitioner (ANMP) role. They are complex processes and require an array of underpinning knowledge of not only the clinical sciences, but also psychological and behavioural science theories. There are multiple constructs to guide these processes, not all of which will be suitable for the vast array of specialist areas in which ANMPs practice. There are multiple opportunities throughout the clinical consultation process in which ANMPs can employ the principles of critical thinking and clinical reasoning in order to improve patient outcomes. There are also multiple online toolkits that may be used to guide the ANMP in this complex process.

• Much like consultation and clinical assessment, the process of the application of clinical reasoning was once seen as solely the duty of a doctor, however the advanced non-medical practitioner (ANMP) role crosses those traditional boundaries
• Critical thinking and clinical reasoning are fundamental skills of the ANMP role
• The processes underlying clinical reasoning are complex and require an array of underpinning knowledge of not only the clinical sciences, but also psychological and behavioural science theories
• Through the use of the principles underlying critical thinking and clinical reasoning, there is potential to make a significant contribution to diagnostic accuracy, treatment options and overall patient outcomes

CPD reflective questions

• What assessment instruments exist for the measurement of cognitive bias?
• Think of an example of when cognitive bias may have impacted on your own clinical reasoning and decision making
• What resources exist to aid you in developing into the ‘advanced critical thinker’?
• What resources exist to aid you in understanding the statistical terminology surrounding evidence-based diagnosis?

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• Introduction to...

Introduction to clinical reasoning

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• Peer review
• Alison Round , consultant in public health medicine 1
• 1 North and East Devon Health Authority, Southernhay East, Exeter

How do doctors make decisions? Alison Round explains some of the thought processes that lead to a diagnosis

Doctors make decisions all the time - what the problem is, what the diagnosis is, whether to do anything, what to do. What facts do doctors take into account when they come to a decision, and what processes do they use to decide on a course of action? Where does intuition come from? These are the basics of clinical reasoning. When decisions are made in conjunction with the patient, doctors need to have an understanding of the “building blocks” of their thinking in order to explain this to the patient and to explore areas where differences in values and opinion may occur.

In all fields, not just medicine, experts make decisions in very different ways from students or beginners. Traditional bedside teaching guides students to take a history and perform an examination before constructing a differential diagnosis. In real life, however, experienced doctors do not work like this. They utilise a number of shortcuts (heuristics), based on knowledge and previous experience, which enable them to work much more quickly and, in general, more accurately than students. 1 There are many advantages to heuristics, such as very rapid processing and an ability to handle complex information without overload. There are, however, also a number of biases incorporated in the heuristics that may lead to poor decision making. 2 This article aims to discuss the processes and biases, using making a diagnosis as an example, and considers how improvements could be made.

Clinical reasoning in differential diagnosis

Experts use three main methods, or a combination of these, in making a diagnosis. Probably the most common is the hypothetico-deductive approach. An initial hypothesis or hypotheses are generated very early during the initial presentation of the problem, from existing knowledge, associations, and experience. Further questions or examination are oriented towards supporting or refuting these first ideas. If an hypoth- esis is discarded, an alternative one is considered and treated in the same way. Several hypotheses can be actively considered at any one time. Both awareness of probabilities (prevalence) of disease and knowledge of causal pathways are important. 3

Pattern recognition is also common. A particular combination of symptoms, or even certain phrases used to describe a symptom, can suggest a diagnosis very strongly. People build up their own internal library of patterns on the basis of their experience and existing knowledge.

Finally, pathognomonic signs and symptoms exist where a particular finding almost guarantees a certain diagnosis. Ulnar deviation in rheumatoid arthritis, Kaiser-Fleischer rings in Wilson's disease, and the slow relaxing jerks of hypothyroidism are examples. Unfortunately, most of these findings are rare and of little help in day to day practice.

All diagnostic methods depend on breadth and depth of knowledge, but the application of knowledge is not as straightforward as it seems. The use of algorithms (following a structured guideline to reach a diagnosis) is not welcomed by many doctors, despite their accuracy and relative freedom from bias. Professionals may consider they have enough confidence in their unaided decision making, describing algorithms as too time consuming. 4

Biases in thinking

Several common features of thinking can occur during the clinical reasoning process. These are known as cognitive biases. Firstly, there is the difficulty in estimating probabilities accurately, giving undue weight to small samples, or overestimating the similarity between people or events (often known as representativeness bias). Secondly, there is a tendency to attribute too much weight to easily available information, or to an event that is easily remem- bered because of particularly salient features; an example is overestimation of the probability of death by lightning. Thirdly, some people, when asked to estimate the probability of an event, place the initial probability at too extreme a figure and then make insufficient adjustment for subsequent information. Finally, there is also a bias towards positive and confirming evidence at the expense of negative evidence.

The case studies illustrate these points. When you read case study 1 ( table ), imagine you are seeing a patient in an accident and emergency department, and think what is going through your mind at each point.

• View inline

When doctors are not certain about a diagnosis they search for more information, either from the history or examination or by performing investigations or tests. One important source of bias in handling information is incorrect application or interpretation of tests. Case study 2 ( box 1 ) considers these points (see below for answers).

Box 1: Case study 2

Estimate the probabilities for yourself. A 40 year old woman has intermittent chest pain, sometimes associated with exercise, for 6 weeks. She is worried about ischaemic heart disease as her cousin has just had a heart attack at the age of 47. History and examination are unhelpful. What do you estimate as the probability of her pain being angina? She now has an exercise electrocardiogram which shows positive changes after 5 minutes. What do you estimate the probability of angina to be after this? She also has a thallium scan, which is normal. What do you estimate the final probability of angina to be after these test results?

Bayes' theorem and its uses

Bayes' theorem is a simple formula which suggests how one should modify one's original idea in the light of new information. In the case above, the new information is in the form of test results. In order to work out how much modification is necessary with the positive exercise electrocardiogram, one needs to know what the chance of having a positive test result is when the disease is present and what the chance of having a positive test result is when the disease is absent. This gives an idea of the diagnostic value of a test, is called the likelihood ratio, and can be calculated from the sensitivity and specificity of tests (see box 2 ).

Box 2: Calculating likelihood ratios

In the example above, assume that the sensitivity of an exercise electrocardiogram is 60%, or 0.6, and the specificity is 91%, or 0.91, for the diagnosis of ischaemic heart disease. From these the likelihood ratio can be calculated. The formula for the likelihood ratio is

Sensitivity / 1-specificity

In this case the likelihood ratio is 0.6/0.09=6.7 In order to calculate the chance that disease is present when the test is positive, Bayes' theorem uses odds, rather than probabilities. (Odds range from 0 to infinity, probability is bounded between 0 and 1. A version of Bayes' theorem that uses probabilities is available, but is more complicated.) Chance of disease with positive test (posterior odds)=initial odds * likelihood ratio The prior probability of disease is 1%, or P=0.01. This needs to be converted to the prior odds of disease by using the formula “odds=P/1-P.” Here, prior odds are 0.0101. The posterior odds-the odds of disease after the test result is known-are:

0.0101*6.7=0.0677

Conversion of odds back to probabilities “probability=odds/(1+odds)” gives the final probability as 0.063 or 6.3%. As can be seen, when probabilities are small there is little difference between odds and probabilities, and a rough estimate can be made simply by multiplying the initial probability by the likelihood ratio. A similar calculation can be performed using the negative result of the thallium scan; a likelihood ratio for a negative test should be used.

The sensitivity of a test is equivalent to the chance of having a positive test result when the disease is present. The specificity of a test is equivalent to the chance of having a negative test result when the disease is absent, and therefore (12specificity) is the chance of having a positive test result when the disease is absent.

Bayes' theorem is perceived to be complicated and difficult to understand. If, however, the initial probability of disease can be estimated (which one does whether or not Bayes' theorem is being used), estimates of the sensitivity and specificity of tests can be used easily to arrive at a final (posterior) probability of a diagnosis, given a particular test result. Such data are available for many investigations, but the method is not generally taught when differential diagnosis is being discussed.

In the case study above, most people estimate the probabilities as about 5% initially, rising to about 70% with the positive exercise test and back to about 50% with a negative thallium scan. In fact the actual probabilities are 1%, 6%, and 2% respectively. So whereas the initial probability is not far wrong, the final estimate is markedly inaccurate. The positive exercise test seems much more important than it is, partly because the initial probability of disease is so low that more positive tests are false positives than true positives. What Bayes' theorem demonstrates is that for diseases that are initially unlikely, a positive test of reasonable sensitivity and specificity increases the absolute chance of disease by only a small amount. Conversely, for diseases where the prior probability is very high, a positive test may add very little, or a negative test may not substantially reduce the chances of disease. Box 3 shows some tips to improve clinical reasoning.

Box 3: Tips for improving clinical reasoning

Reflect on the reasons that make you consider a particular diagnosis in each case Estimate the initial probability as carefully as you can Ask what the sensitivity and specificity is when a test is being discussed Remember that negative results are just as important as positive ones

This article has covered only a basic introduction. There are several good texts that provide more information, such as Clinical Epidemiology by Sackett et al, and Professional Judgement , edited by Dowie et al. 5 6

For particularly interested readers, the publications by Elstein et al 7 and Kahnemann et al 8 are strongly recommended, as are articles discussing other theoretical approaches to clinical reasoning. 9

Originally published as: Student BMJ 2000;08:15

• ↵ Kassirer JP, Kuipers BJ, Gorry GA. Toward a theory of clinical expertise. Am J Med 1982 ; 73 : 251 –9. OpenUrl CrossRef PubMed Web of Science
• ↵ Tversky A, Kahnemann D. Judgement under uncertainty: heuristics and biases. Science 1974 ; 185 : 1124 –31. OpenUrl Abstract / FREE Full Text
• ↵ Kassirer JP. Diagnostic reasoning. Ann Intern Med 1989 ; 110 : 893 –900. OpenUrl CrossRef PubMed Web of Science
• ↵ Pearson SD, Goldman L, Garcia TB, Cook EF, Lee TH. Physician response to a prediction rule for the triage of emergency department patients with chest pain. J Gen Int Med 1994 9 ( 5 ): 241 –7. OpenUrl CrossRef PubMed Web of Science
• ↵ Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology. A basic science for clinical medicine . Boston : Little, Brown , 1991
• ↵ Dowie J, Elstein A. Professional judgement. A reader in clinical decision making . Cambridge , Cambridge University Press , 1988 .
• ↵ Elstein AS, Shulman LS, Sprafka SA. Medical problem solving-an analysis of clinical reasoning . Cambridge, Massachusetts , Harvard University Press , 1978 .
• ↵ Kahnemann D, Tversky A, eds. Judgement under uncertainty: heuristics and biases . New York : Cambridge University Press , 1982 : 359 –69.
• ↵ Greenwood J. Theoretical approaches to the study of nurses' clinical reasoning: getting things clear. Contemp Nurse 1998 ; 7 : 110 –6. OpenUrl PubMed

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Developing critical thinking skills for delivering optimal care

Scott IA, Hubbard RE, Crock C, et al. Developing critical thinking skills for delivering optimal care. Intern Med J. 2021;51(4):488-493. doi:&nbsp;10.1111/imj.15272

Sound critical thinking skills can help clinicians avoid cognitive biases and diagnostic errors. This article describes three critical thinking skills essential to effective clinical care – clinical reasoning, evidence-informed decision-making, and systems thinking – and approaches to develop these skills during clinician training.

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Annual Perspective

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Does a suggested diagnosis in a general practitioners' referral question impact diagnostic reasoning: an experimental study. April 27, 2022

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8 Stages Of The Clinical Reasoning Cycle

Last updated on August 19th, 2023

In this article, we will be exploring the clinical reasoning process and its importance in healthcare.

The clinical reasoning cycle, developed by Tracy-Levett Jones, breaks down this process into eight phases that healthcare professionals can follow to make informed decisions for their patients.

These phases include considering facts, collecting information, processing gathered information, identifying the problem, establishing goals, taking action, evaluating the effectiveness of the action, and reflecting on the experience.

By following this cycle, healthcare professionals can enhance their problem-solving and decision-making skills, leading to better patient care.

Related: Clinical Reasoning In Nursing (Explained W/ Example)

8 Stages of the Clinical Reasoning Cycle

The eight stages of the Clinical Reasoning Cycle are the following.

• considering the patient’s situation,
• collecting cues/information,
• processing information,
• identifying problems/issues,
• establishing goals,
• taking action,
• evaluating outcomes, and
• reflecting on the process.

These eight phases guide healthcare professionals in providing optimal care to patients.

Each stage is interconnected and builds upon the previous one, allowing for a comprehensive understanding of the patient’s needs and effective decision-making.

1. Consider the patient’s situation

The first phase of the Clinical Reasoning Cycle involves considering the facts presented by the patient or situation. This is where healthcare professionals receive the initial information and medical status of the patient.

For example , they may be given details about a newborn admitted to the Neonatal Intensive Care Unit (NICU) due to neonatal jaundice.

By carefully considering these facts, healthcare professionals can start to develop an understanding of the patient’s condition and determine the appropriate course of action.

2. Collect cues/ information

In the second phase, healthcare professionals gather additional information to gain a comprehensive understanding of the patient’s medical history, complaints, treatment plan, and current vital signs.

They may also review the results of any investigations or tests conducted. This information is then analyzed using the healthcare professional’s knowledge of physiology, pharmacology, pathology, culture, and ethics to establish cues and draw conclusions.

The collection of information is a crucial step in the clinical reasoning process, as it helps healthcare professionals to identify any underlying issues or potential challenges.

3. Process information

The third phase involves the processing of the information gathered in the previous step.

It is here that healthcare professionals critically analyze the data on the patient’s current health status in relation to pathophysiological and pharmacological patterns.

They determine which details are relevant and consider potential outcomes for the decisions they may make.

This phase requires healthcare professionals to use their expertise and judgment to identify the key issues that need to be addressed.

4. Identify problems/issues

Based on the processed information, healthcare professionals can identify any problems or issues that the patient may be facing.

This involves recognizing signs and symptoms, understanding the underlying causes, and determining the potential impact on the patient’s health.

5. Establish goals

Once the problems or issues are identified, healthcare professionals can establish goals for the patient.

These goals are aimed at addressing or resolving the identified problems and improving the patient’s health outcomes.

Goals should be specific, measurable, achievable, relevant, and time-bound (SMART).

6. Take action

After establishing goals, healthcare professionals take appropriate actions to address the identified problems and work towards achieving the established goals.

This may involve implementing treatment plans, providing interventions, administering medications, or coordinating care with other healthcare professionals.

7. Evaluate outcomes

The seventh phase of the Clinical Reasoning Cycle is evaluation. In this phase, healthcare professionals assess the effectiveness of the actions they have taken.

They evaluate whether the treatment plan has been successful in achieving the desired outcomes or if adjustments need to be made.

This phase allows healthcare professionals to reflect on their decisions and make informed judgments about the next steps in the patient’s care.

8. Reflect on the process and new learning

The final phase of the clinical reasoning cycle is reflection. Healthcare professionals reflect on the entire process, including their decision-making, actions taken, and the outcomes achieved.

This reflection allows for continuous learning and improvement, as healthcare professionals gain insights from their experiences and apply them to future situations.

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Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia.

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• Research article
• Open access
• Published: 30 January 2014

Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators

• Clare Delany 1 , 2 &
• Clinton Golding 3 , 4  

BMC Medical Education volume  14 , Article number:  20 ( 2014 ) Cite this article

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Clinical reasoning is fundamental to all forms of professional health practice, however it is also difficult to teach and learn because it is complex, tacit, and effectively invisible for students. In this paper we present an approach for teaching clinical reasoning based on making expert thinking visible and accessible to students.

Twenty-one experienced allied health clinical educators from three tertiary Australian hospitals attended up to seven action research discussion sessions, where they developed a tentative heuristic of their own clinical reasoning, trialled it with students, evaluated if it helped their students to reason clinically, and then refined it so the heuristic was targeted to developing each student’s reasoning skills. Data included participants’ written descriptions of the thinking routines they developed and trialed with their students and the transcribed action research discussion sessions. Content analysis was used to summarise this data and categorise themes about teaching and learning clinical reasoning.

Two overriding themes emerged from participants’ reports about using the ‘making thinking visible approach’. The first was a specific focus by participating educators on students’ understanding of the reasoning process and the second was heightened awareness of personal teaching styles and approaches to teaching clinical reasoning.

Conclusions

We suggest that the making thinking visible approach has potential to assist educators to become more reflective about their clinical reasoning teaching and acts as a scaffold to assist them to articulate their own expert reasoning and for students to access and use.

Peer Review reports

Clinical reasoning is fundamental to all forms of healthcare practice [ 1 ], but it is difficult to teach because it is complex, situation specific, built up through experience and frequently based on tacit, automatic processes of pattern recognition [ 2 – 6 ]. It involves gathering and analyzing information (diagnostic reasoning) as well as deciding on therapeutic actions specific to a patient’s circumstances and wishes (therapeutic reasoning) [ 4 ]. It combines cognitive strategies such as analysis and problem solving with situated reasoning about patient needs in their broader clinical context [ 2 , 7 ]. Comparative studies of experts and novices have highlighted important differences in these thinking processes. Expert practitioners rely on experience to recognise patterns [ 3 , 6 , 8 ], and they tacitly and automatically integrate disciplinary knowledge, clinical data, and client preferences [ 3 , 4 , 7 – 9 ].

In contrast, novices do not have experts’ prior experience to enable them to automatically integrate information, so they work through a series of distinct and explicit thinking steps in a more fixed pattern [ 10 ]. They also tend to ask more questions than experts, some of which may be irrelevant to the situation or a particular patient’s care [ 9 ].

The inherent complexity of and experience required for expert clinical reasoning skills leads to two related challenges for teaching clinical reasoning. First, clinical educators who are experienced clinicians may find it difficult to explain and teach clinical reasoning because it has become ingrained in their way of thinking and being for them [ 3 , 11 – 13 ]. Second, students may find it hard to grasp because it is effectively invisible and inaccessible to them [ 14 , 15 ]. In this article we introduce and evaluate (via a pilot action research project with allied health educators), an approach to teaching clinical reasoning based on the pedagogical method of making thinking visible [ 16 , 17 ]. The goal, when applied to teaching clinical reasoning is to assist educators to use a type of metacognition (thinking about their own thinking) [ 18 ] to reveal the otherwise ‘hidden’ elements of their reasoning [ 19 ], as an explicit scaffold to guide their students’ thinking and reasoning.

Standard approaches to teaching clinical reasoning have focused on broad thinking steps including to ‘gather information from a range of different sources’; ‘state the likely diagnosis’; ‘describe the presenting pattern of symptoms’ and ‘decide the most appropriate management for a particular patient’ [ 1 , 5 , 7 , 20 ]. However, because these broad steps provide little concrete detail about what types of knowledge a clinician is drawing from and how she or he is interpreting and synthesizing that knowledge, [ 14 ]. They may still be too abstract and detailed and some of the nuanced thinking steps of clinical reasoning may remain invisible or at least inaccessible for the learner.

The teaching method of ‘making thinking visible’ has previously been used successfully in classroom settings to promote and guide student thinking [ 21 ]. It involves identifying and then ‘repackaging’ the thinking steps used by experts when they engage in clinical reasoning into ‘thinking routines’. Thinking routines consist of short, repeatable actions that isolate a type of thinking and provide heuristics or ‘tools’ for enabling and promoting this thinking [ 21 ]. For example, a commonly used routine to encourage evaluative thinking is ‘Plus, Minus and Interesting’ or PMI [ 22 ]. When using this routine, students first consider the plus or positives, then the minus or negatives, and finally, any interesting questions or issues that arise. By doing these three actions students engage in evaluative thinking that is both expansive and inclusive. By repeating these actions regularly and frequently – making it a routine – they become more skilful at evaluation, until it becomes an automated way of thinking for them [ 17 ].

To make the structure of their thinking visible, clinical educators first identify the types of knowledge they are privileging, the cognitive processes they are using and the connections they are making in their mind. They then refine this thinking to concrete steps or thinking routines which capture the specific clinical context. (See Table  1 for detailed steps of this approach, as well as Golding [ 17 ] for the underlying principles). This approach is similar to other strategies that have been shown to be effective for teaching clinical reasoning, such as ‘think out loud’ [ 4 ] and using concept maps [ 23 , 24 ].

Three key pedagogical principles underpin this approach. The first recognises that reducing complex expert thinking to a thinking routine that a student can use, is a form of simplification of knowledge to reduce the cognitive work of clinical reasoning [ 25 – 27 ]. Simplification of knowledge is not designed to ignore or reduce the inherent complexity of clinical reasoning, but rather to provide an entry point for students to participate in disciplinary thinking and discourse. A second pedagogical premise is that students can be effectively facilitated to learn by participating in the daily activities of their community of practitioners, where peers, role models and mentors scaffold or extend learning through guidance, modelling and discussion [ 28 , 29 ]. Lave and Wenger [ 30 ] describe this conception of learning as a type of professional socialisation and Vygotsky’s [ 31 ] theories about the importance of explicit scaffolding and social inclusion of students is also educationally relevant [ 32 – 34 ]. The third pedagogical premise is that when educators think about their own thinking, they are engaging in reflective and metacognitive thinking Schön [ 35 ], and this assists them to develop a more explicit understanding of their own clinical reasoning prior to teaching others [ 36 ], even if their clinical reasoning is partly subconscious [ 11 ].

We used action research – a method widely used in primary and secondary education as a powerful means of professional learning for clinical educators [ 37 ]. The key tenets of action research are that real problems are discussed with the intention of improvement and empowerment [ 38 ]. Action research engages participants in a structured process of reflection [ 35 ] about their teaching, so they can generate new knowledge about their teaching practices [ 39 ]. This is consistent with the idea of mindfulness in education, described by Ritchhart and Perkins [ 16 ] as having an open and creative state of consciousness, in contrast to a passive, inert and superficial learning disposition. We purposefully chose action research methodology to enable participants to actively reflect on their styles and methods of clinical supervision and teaching [ 40 ]. Standard methods of professional learning for clinical teaching include lectures and workshops about teaching strategies [ 41 – 44 ]. While there is evidence that educators benefit from participating in lectures and short workshops [ 27 , 41 , 45 ], concerns remain that such courses may not provide sufficient opportunity for teachers learn through active participation.

Because action research empowers participants to construct, use and evaluate their own knowledge and understanding [ 46 , 47 ], it provides both a practical and theoretical frame for clinical educators to link their clinical thinking expertise to their teaching methods. Using an iterative learning cycle [ 48 , 49 ], it encourages them to construct their own teaching practices by developing, trialling and evaluating new teaching methods.

In our study (Figure  1 ), clinical educators reflected on how to teach clinical reasoning, using the lens of making thinking visible to focus their reflection. They were then encouraged to evaluate and refine how they teach clinical teaching within their own practice with the two authors and with their peers in the discussion sessions.

The cycle of action research.

The participants were recruited in the following way: We introduced the ‘Making thinking visible’ teaching approach (Table  1 ) at three 2-hour seminars at a large Australian metropolitan teaching hospital in May 2010. We surveyed the 70 allied health professionals who attended about how they teach clinical reasoning, and this is reported elsewhere [ 50 ]. In the third seminar, we invited the audience to indicate interest in participating in action research/learning project by leaving their contact details in a box at the back of the lecture theatre.

Twenty-one clinical educators from eight allied health disciplines (physiotherapy, social work, podiatry, occupational therapy, education play therapy, music therapy, prosthetics, and speech pathology), with an average of ten years clinical practice experience, and eight years clinical supervision provided their contact details. The participants all worked in one of three large public hospitals in Melbourne, Australia. All participants were involved in supervising undergraduate students, except for those from social work, where supervision involved postgraduate students. They attended an average of three sessions of a possible 7 (see Table  2 ). Ethics approval was obtained from The University of Melbourne Human Research Ethics Committee.

The action research followed a structured pattern of participant reflection and trialing of teaching heuristics (Figure  1 ):

Stage one and two

Participants were asked to identify an area of clinical reasoning or practice their students found challenging, or an area where their students rarely engaged in the necessary reasoning. They were then asked to identify how they would go about clinical reasoning in this same situation by stating the steps they followed when they consciously think through the same challenges faced by their students. The final step involved refining the steps into a ‘thinking routine’ that students could employ. We facilitated this process of reflection by asking the clinical educators to consider and discuss the following questions:

What questions would you ask yourself if you faced a challenging clinical scenario?

What type of thinking would you like your students to develop?

What would your students ask if they were engaged in this thinking?

What questions can you ask to encourage this thinking?

How can you turn these questions and thinking steps into a thinking routine/heuristic – a short, repeatable set of questions or actions that isolates and engages the same type of thinking?

The thinking routines that emerged typically comprised three short questions or single words, which gave concrete actions or thinking steps for students to follow (Table  3 ). These were listed on a whiteboard and checked with participants.

Stage three

Participating educators then trialed these routines with their students. They were asked to record the thinking routines they trialled; to state their teaching goal for using the routine; and to describe in concrete terms what happened after using the routine. They were also asked to evaluate the impact of using the thinking routine on student responses and on their own teaching styles by responding to the following questions:

What went well?

What didn’t go so well?

What did the students say or do?

Was their behaviour different? If so how?

Did the student engage in clinical reasoning? How was this demonstrated?

Have the routines impacted on your clinical education practice? If so how?

Educators’ written reflections were compared in the discussion sessions and they evaluated and further refined their thinking routine to better match their students’ learning needs. Any changes to thinking routines were recorded on the whiteboard and checked with participants.

The educators then trialed the refined routines.

Participating educators evaluated and further refined these routines.

Stage three and five of the action research cycle occurred during the participants’ clinical teaching. Stage one, two, four and six occurred through individual reflection, regular email interaction with the researchers, and during fortnightly discussion sessions. All participants engaged in the individual reflection. Five to eighteen participants attended each discussion session where they worked in multidisciplinary groups of three to four, and each participant attended an average of three sessions (Table  2 ). Participants took as many sessions as needed until they were satisfied that the routines they had refined would foster the relevant clinical thinking in their students.

Data analysis

Two sources of data were obtained and analysed. First, educators’ written reflections and observations of the thinking routines they developed and trialled, what happened during and after using the routine and the impact of the action research on their clinical teaching. Second, the researchers’ memos during the discussion groups documenting different types of thinking routines including refinements made over time (Table  3 ).

We used content analysis to summarise educators’ descriptions of their teaching trials and our own discussion group memos [ 51 – 53 ]. Both authors summarized and grouped the educators’ written reports into categories about teaching clinical reasoning and then refined these categories to reach a consensus of two overriding descriptive themes about the impact of using the ‘making thinking visible approach’ their clinical teaching. The first was an orientation by participating educators towards students’ understanding of the reasoning process. The second was heightened awareness of personal teaching styles and approaches to teaching clinical reasoning.

Theme 1: a focus on student understanding – through developing and refining thinking routines

Table  3 provides examples of thinking routines documented by participating educators and recorded by the researchers in the discussion groups. These examples demonstrate how participants refined their thinking routines when the initial formulation did not work for the student. Sometimes they judged that the routine did not fit the clinical situation or did not adequately support their students’ thinking and so it was abandoned in favour of a different routine.

“The routine didn’t really fit the scenario … On reflection I would use a slightly different routine myself with an inpatient such as that.” (music therapist)

In other cases educators noticed that a particular step of a routine was too difficult for a student and so they refined this step, as illustrated in the first example in Table  3 . In yet other cases, the entire routine was refined because it did not encourage the thinking needed for a particular aspect of a clinical task (see Table  3 ).

Theme 1: a focus on student understanding – noticing how routines influenced student reasoning

The participating educators documented examples of how they used the thinking routines to engage students in specific strategies of clinical reasoning and how students responded:

“The three words allowed for more concise documentation and kept her on track. It was useful in refining and reducing complex issues.” (social worker) “Both of the students were able to reflect on the thinking routine and explain how it had helped to guide their assessment of the infant.” (physiotherapist) “The student was able to go into more detail when asking questions.” (social worker)

Some of the more common observations were that after using the thinking routines, students began to justify their clinical judgements, explain their reasoning, and attempt to distinguish between clinical presentations:

“After they had tried to prioritise their problems, the students justified their choices to me by explaining the reasoning behind them.” (physiotherapist) “Using the routine, meant the student was able to reduce the complex issues that the patient presented with and focus on the fundamental issues at hand specifically for the patient.” (social worker) “The student did engage in clinical reasoning because they wanted to know what is normal, that is, to have a point of comparison to know the significance of their assessment findings.” (physiotherapist)

The educators also reported that the routines acted as a prompt, and provided a structure or framework for students’ thinking:

“The student reported that the routine ‘gave structure in my head’, and that it helped with on the spot thinking, especially using the prompt ‘clarify’.” (physiotherapist) “The student appreciated a structure to work with and was encouraged by having a strategy since she had struggled with other placements.” (occupational therapist) “The student was able to use the word cues from the routine to identify what they saw and heard during the session, it prompted them to tease out the specific details.” (podiatrist)

According to educators’ reports, some students became more focussed, confident and independent in their thinking, and had better management of their time as a result of using the thinking routines:

“Normally when you say to students: ‘please try to prioritise your problem list and then show it to me’, they immediately want to ask me the answers and talk it through with me. However, with these two students, they very quietly went about trying to prioritise themselves, using the thinking routine and without asking me at all.” (physiotherapist) “The student showed initiative with making plans and was more assertive with patients. Having a stronger plan allowed her to focus more on other elements of her interaction with patients.” (speech pathologist)

Theme 2: awareness of teaching styles for clinical reasoning

A focus on student thinking seemed to encourage the participating educators to become more specific in articulating the thinking steps they wanted their students to develop. They became more discerning about what they expected their students to learn, which they encapsulated in their thinking routines. They also developed greater awareness of the current thinking and reasoning of their students. They identified concrete instances of student thinking when it occurred:

“I noticed that she first wrote out a list of problems and then changed the order to reflect the correct prioritised order. I could really see her thinking through the process.” (physiotherapist) “The student watched and picked up on ‘non-verbal’ cues the patient was giving from the ‘look’ prompt. She was able to describe in detail what went on in the session, both verbally and non-verbally.” (social worker) “The word ‘describe’ worked really well in asking the student to be really detailed about what they had seen and heard. This included being specific about the movements the client did, how they did them and how they explained this.” (physiotherapist)

The participating educators also reported noticing when students had missed an important aspect of clinical reasoning, and they reflected on how they could encourage this missing thinking:

“The student needed extra prompts to pick out the key issues.” (educational play therapist) “She is struggling to ascertain what the patient’s problems are after her assessment, let alone prioritise them. So I think she wasn’t ready for this thinking routine, it is too advanced. She needs a thinking routine to help her work out the patient’s problems. This thinking routine I introduced to her today would be ideal (I think!) for a student who can get the main problems, but who is struggling to prioritise them.” (physiotherapist)

Theme 2: refining teaching styles for clinical reasoning

Participating educators recognised specific teaching opportunities and were motivated to continue with trialling and refining their teaching:

“I am more willing to try new things as it did work – the challenge is finding the right ‘set’ or ‘routine’ for the particular student.” (music therapist) “Using this particular thinking routine has encouraged me to think about how I can devise other thinking routines for the other clinical areas I work in.” (educational play therapist) “Once the undergraduate students return I would like to be able to try this thinking routine with them. I think it would be better to use it in a clinic that is less busy to allow more time and opportunity for the student to feedback on the process, and to gauge the usefulness of this thinking routine for them.” (physiotherapist)

In this action research project we trialled a method for teaching clinical reasoning. Participating educators developed a tentative heuristic of their own clinical reasoning, trialled it with students, evaluated if it helped their students to reason clinically, and then refined it so the heuristic was targeted to developing each student’s reasoning skills. As predicted by action research theories [ 50 , 54 – 56 ], the cycle of - developing, trialling, evaluating and refining – resulted in participating educators taking responsibility for their own specific professional learning [ 46 ]. It also encouraged them to examine the impact of their teaching on student learning [ 35 , 49 , 57 – 61 ]. This outcome reflects a key tenet of learning derived from action research. Concrete experience is the impetus for creating knowledge through a process of “observing and reflecting on that experience, forming abstract concepts and generalisations, and testing the implications of these new concepts in new situations” ([ 62 ], p.46).

Although aspects of expert clinical reasoning are considered to be subconscious and impossible to precisely describe [ 11 ], the clinical educators in our study were able to make visible and accessible some steps in their reasoning process by reflecting on what they would do or say in a specific clinical situation [ 3 ]. The multidisciplinary nature of discussion groups assisted in this process, because in order to describe their clinical thinking to a colleague from a different discipline, educators had to be more concrete and explicit about their knowledge and reasoning. The focus of the clinical educators shifted during their involvement in the project, from considering a) What their students should know and do; to encompass b) What students currently understood and did; to also include reflection on a third level c) How to enable students to move from their current understandings and behaviours to the desired learning outcomes. Recognising and moving through these essential elements of teaching [ 21 , 36 ], is an example of what Shulman refers to as developing pedagogical content-knowledge [ 63 ]. They became involved in actively constructing their own discipline’s curriculum to build student understanding of clinical reasoning [ 61 ].

The specific focus on creating thinking routines seemed to be useful for teaching clinical reasoning because it directed the clinicians to develop an understanding of their own clinical reasoning, which is a necessary precondition for teaching clinical reasoning [ 17 , 64 ]. It provided a method of working towards the pedagogical goal of aligning the learning outcome of developing expert clinical reasoning skills with specific teaching methods - in this case - the thinking steps used by expert clinicians [ 65 , 66 ]. Clinical educators were also able to use the routines to prompt their students to engage in independent clinical reasoning, rather than have them passively watch and wait for the answers [ 65 , 67 ].

These results suggest that making expert clinical thinking visible is a potentially valuable approach for assisting to bridge the gap between expert and novice reasoning [ 10 , 14 , 68 ]. The routines encouraged educators to provide students with access to their specific disciplinary language and to assist them to become part of their profession’s community of clinical practice [ 28 – 32 ]. They accord with the successful use of this method in classroom settings [ 21 ]. However, unlike the classroom research where routines were given to teachers, the thinking routines developed in this research were derived through action research from clinician/teachers’ own ‘expert’ thinking and were specifically focused on facilitating steps of thinking for disciplinary-specific clinical reasoning.

There are several important limitations to this research project. The overall sample of participating educators is limited to eight allied health disciplines with small numbers of participants. There was both a variable and declining attendance at each discussion session, which participating educators explained as being caused by changing student supervision loads and busy clinical commitments. Also, seven discussion groups of one-hour duration, scheduled every two weeks is a relatively small amount of time to effect a sustained change in teaching behaviour. A further factor which limits both generalizability and replication of this study is the dynamic and responsive nature of discussions between the authors, as facilitators, and the participants in each focus group session. The impact on students’ actual clinical reasoning capacities was not measured because the data comprised of educators’ descriptions of students’ responses and reasoning. Data which relies on participants’ descriptions and interpretations of their teaching practice, are always open to differing and subjective interpretations and reports [ 69 , 70 ].

Despite these limitations, we suggest that the key pedagogical tenets of the making thinking visible’ approach are potentially useful for clinical educators to assist in teaching students the steps of clinical reasoning. The making thinking visible approach encourages educators to become more reflective about their clinical reasoning teaching and acts as a scaffold to assist them to articulate their own expert reasoning and for students to access and use. The approach requires further testing and evaluating for its impact on clinical reasoning performance and in specific disciplines and clinical settings.

How can clinical educators learn to teach clinical reasoning, given it is second-nature to them, but inaccessible and unobservable to students? Our conclusion is that the making visible thinking approach in combination with an action research methodology could be useful as a form of professional learning. It guides educators to be learning and improvement oriented, to be explicit about their own clinical reasoning, and to develop and trial strategies to support student reasoning.

Authors’ information

Clare Delany (PhD) is Associate Professor and Director of Teaching and Learning at the School of Health Sciences, The University of Melbourne and Senior Ethics Associate at the Children’s Bioethics Centre, at the Royal Children’s Hospital. Research interests include clinical education pedagogy and practice and clinical ethics consultation and education.

Clinton Golding (PhD) is Senior Lecturer at the Higher Education Development Centre, University of Otago, an Honorary Senior Fellow of the Centre for the Study of Higher Education, University of Melbourne, and the Chair of the Higher Education Research and Development Society of Australasia, New Zealand. Research interests include educating for thinking across the disciplines, especially clinical reasoning in the medical disciplines and health professions.

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Acknowledgments

The authors would like to thank the clinical educators who took precious time to participate, the reviewers who made such useful comments, and Carol Jewell, Allied Health Clinical Education Coordinator at the Royal Melbourne Hospital in Melbourne, Australia, who provided much support and encouragement. This research was funded by a grant from the Australian Victorian Healthcare Association: 2009/10 Clinical Supervision Grants Program.

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Delany, C., Golding, C. Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators. BMC Med Educ 14 , 20 (2014). https://doi.org/10.1186/1472-6920-14-20

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Before learning how to use the nursing process, it is important to understand some basic concepts related to critical thinking and nursing practice. Let’s take a deeper look at how nurses think.

Critical Thinking and Clinical Reasoning

Nurses make decisions while providing patient care by using critical thinking and clinical reasoning. Critical thinking is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” [1] Using critical thinking means that nurses take extra steps to maintain patient safety and don’t just “follow orders.” It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research.

“Critical thinkers” possess certain attitudes that foster rational thinking. These attitudes are as follows:

• Independence of thought: Thinking on your own
• Fair-mindedness: Treating every viewpoint in an unbiased, unprejudiced way
• Insight into egocentricity and sociocentricity: Thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
• Intellectual humility: Recognizing your intellectual limitations and abilities
• Nonjudgmental: Using professional ethical standards and not basing your judgments on your own personal or moral standards
• Integrity: Being honest and demonstrating strong moral principles
• Perseverance: Persisting in doing something despite it being difficult
• Confidence: Believing in yourself to complete a task or activity
• Interest in exploring thoughts and feelings: Wanting to explore different ways of knowing
• Curiosity: Asking “why” and wanting to know more

Clinical reasoning is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.” [2] To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. [3]

Inductive and Deductive Reasoning and Clinical Judgment

Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process.

Inductive reasoning involves noticing cues, making generalizations, and creating hypotheses. Cues are data that fall outside of expected findings that give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A generalization is a judgment formed from a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes more clear. Based on generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. A hypothesis is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored.

No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. A nurse is similar to the detective looking for cues in Figure 4.1. [4] Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to take action quickly, especially in emergency situations. They can see how certain objects or events form a pattern (i.e., generalization) that indicates a common problem (i.e., hypothesis).

Example: A nurse assesses a patient and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.

Deductive reasoning is another type of critical thinking that is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.

Example: Based on research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. (See Figure 4.2). [5] The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking because the intervention is applied to all patients regardless if they have difficulty sleeping or not.

Clinical judgment is the result of critical thinking and clinical reasoning using inductive and deductive reasoning. Clinical judgment is defined by the National Council of State Boards of Nursing (NCSBN) as, “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.” [6] The NCSBN administers the national licensure exam (NCLEX) that measures nursing clinical judgment and decision-making ability of prospective entry-level nurses to assure safe and competent nursing care by licensed nurses.

Evidence-based practice (EBP) is defined by the American Nurses Association (ANA) as, “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.” [7]

Nursing Process

The nursing process is a critical thinking model based on a systematic approach to patient-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently. [8] The mnemonic ADOPIE is an easy way to remember the ANA Standards and the nursing process. Each letter refers to the six components of the nursing process: A ssessment, D iagnosis, O utcomes Identification, P lanning, I mplementation, and E valuation.

The nursing process is a continuous, cyclic process that is constantly adapting to the patient’s current health status. See Figure 4.3 [9] for an illustration of the nursing process.

Review Scenario A in the following box for an example of a nurse using the nursing process while providing patient care.

Patient Scenario A: Using the Nursing Process [10]

A hospitalized patient has a prescription to receive Lasix 80mg IV every morning for a medical diagnosis of heart failure. During the morning assessment, the nurse notes that the patient has a blood pressure of 98/60, heart rate of 100, respirations of 18, and a temperature of 98.7F. The nurse reviews the medical record for the patient’s vital signs baseline and observes the blood pressure trend is around 110/70 and the heart rate in the 80s. The nurse recognizes these cues form a pattern related to fluid imbalance and hypothesizes that the patient may be dehydrated. The nurse gathers additional information and notes the patient’s weight has decreased 4 pounds since yesterday. The nurse talks with the patient and validates the hypothesis when the patient reports that their mouth feels like cotton and they feel light-headed. By using critical thinking and clinical judgment, the nurse diagnoses the patient with the nursing diagnosis Fluid Volume Deficit and establishes outcomes for reestablishing fluid balance. The nurse withholds the administration of IV Lasix and contacts the health care provider to discuss the patient’s current fluid status. After contacting the provider, the nurse initiates additional nursing interventions to promote oral intake and closely monitor hydration status. By the end of the shift, the nurse evaluates the patient status and determines that fluid balance has been restored.

In Scenario A, the nurse is using clinical judgment and not just “following orders” to administer the Lasix as scheduled. The nurse assesses the patient, recognizes cues, creates a generalization and hypothesis regarding the fluid status, plans and implements nursing interventions, and evaluates the outcome. Additionally, the nurse promotes patient safety by contacting the provider before administering a medication that could cause harm to the patient at this time.

The ANA’s Standards of Professional Nursing Practice associated with each component of the nursing process are described below.

The “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” [11] A registered nurse uses a systematic method to collect and analyze patient data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. For example, a nurse’s assessment of a hospitalized patient in pain includes the patient’s response to pain, such as the inability to get out of bed, refusal to eat, withdrawal from family members, or anger directed at hospital staff. [12]

The “Assessment” component of the nursing process is further described in the “ Assessment ” section of this chapter.

The “Diagnosis” Standard of Practice is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.” [13] A nursing diagnosis is the nurse’s clinical judgment about the client's response to actual or potential health conditions or needs. Nursing diagnoses are the bases for the nurse’s care plan and are different than medical diagnoses. [14]

The “Diagnosis” component of the nursing process is further described in the “ Diagnosis ” section of this chapter.

Outcomes Identification

The “Outcomes Identification” Standard of Practice is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” [15] The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the patient based on their assessment data and nursing diagnoses.

The “Outcomes Identification” component of the nursing process is further described in the “ Outcomes Identification ” section of this chapter.

The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” [16] Assessment data, diagnoses, and goals are used to select evidence-based nursing interventions customized to each patient’s needs and concerns. Goals, expected outcomes, and nursing interventions are documented in the patient’s nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care. [17]

The “Planning” component of the nursing process is further described in the “ Planning ” section of this chapter.

Nursing Care Plans

Creating nursing care plans is a part of the “Planning” step of the nursing process. A nursing care plan is a type of documentation that demonstrates the individualized planning and delivery of nursing care for each specific patient using the nursing process. Registered nurses (RNs) create nursing care plans so that the care provided to the patient across shifts is consistent among health care personnel. Some interventions can be delegated to Licensed Practical Nurses (LPNs) or trained Unlicensed Assistive Personnel (UAPs) with the RN’s supervision. Developing nursing care plans and implementing appropriate delegation are further discussed under the “ Planning ” and “ Implementing ” sections of this chapter.

Implementation

The “Implementation” Standard of Practice is defined as, “The nurse implements the identified plan.” [18] Nursing interventions are implemented or delegated with supervision according to the care plan to assure continuity of care across multiple nurses and health professionals caring for the patient. Interventions are also documented in the patient’s electronic medical record as they are completed. [19]

The “Implementation” Standard of Professional Practice also includes the subcategories “Coordination of Care” and “Health Teaching and Health Promotion” to promote health and a safe environment. [20]

The “Implementation” component of the nursing process is further described in the “ Implementation ” section of this chapter.

The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” [21] During evaluation, nurses assess the patient and compare the findings against the initial assessment to determine the effectiveness of the interventions and overall nursing care plan. Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated and modified as needed. [22]

The “Evaluation” component of the nursing process is further described in the “ Evaluation ” section of this chapter.

Benefits of Using the Nursing Process

Using the nursing process has many benefits for nurses, patients, and other members of the health care team. The benefits of using the nursing process include the following:

• Promotes quality patient care
• Decreases omissions and duplications
• Provides a guide for all staff involved to provide consistent and responsive care
• Encourages collaborative management of a patient’s health care problems
• Improves patient safety
• Improves patient satisfaction
• Identifies a patient’s goals and strategies to attain them
• Increases the likelihood of achieving positive patient outcomes
• Saves time, energy, and frustration by creating a care plan or path to follow

By using these components of the nursing process as a critical thinking model, nurses plan interventions customized to the patient’s needs, plan outcomes and interventions, and determine whether those actions are effective in meeting the patient’s needs. In the remaining sections of this chapter, we will take an in-depth look at each of these components of the nursing process. Using the nursing process and implementing evidence-based practices are referred to as the “science of nursing.” Let’s review concepts related to the “art of nursing” while providing holistic care in a caring manner using the nursing process.

Holistic Nursing Care

The American Nurses Association (ANA) recently updated the definition of nursing as, “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.” [23]

The ANA further describes nursing is a learned profession built on a core body of knowledge that integrates both the art and science of nursing. The art of nursing is defined as, “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.” [24]

Nurses care for individuals holistically, including their emotional, spiritual, psychosocial, cultural, and physical needs. They consider problems, issues, and needs that the person experiences as a part of a family and a community as they use the nursing process. Review a scenario illustrating holistic nursing care provided to a patient and their family in the following box.

Holistic Nursing Care Scenario

A single mother brings her child to the emergency room for ear pain and a fever. The physician diagnoses the child with an ear infection and prescribes an antibiotic. The mother is advised to make a follow-up appointment with their primary provider in two weeks. While providing discharge teaching, the nurse discovers that the family is unable to afford the expensive antibiotic prescribed and cannot find a primary care provider in their community they can reach by a bus route. The nurse asks a social worker to speak with the mother about affordable health insurance options and available providers in her community and follows up with the prescribing physician to obtain a prescription for a less expensive generic antibiotic. In this manner, the nurse provides holistic care and advocates for improved health for the child and their family.

Review how to provide culturally responsive care and reduce health disparities in the “ Diverse Patients ” chapter.

Caring and the Nursing Process

The American Nurses Association (ANA) states, “The act of caring is foundational to the practice of nursing.” [25] Successful use of the nursing process requires the development of a care relationship with the patient. A care relationship is a mutual relationship that requires the development of trust between both parties. This trust is often referred to as the development of rapport and underlies the art of nursing. While establishing a caring relationship, the whole person is assessed, including the individual’s beliefs, values, and attitudes, while also acknowledging the vulnerability and dignity of the patient and family. Assessing and caring for the whole person takes into account the physical, mental, emotional, and spiritual aspects of being a human being. [26] Caring interventions can be demonstrated in simple gestures such as active listening, making eye contact, touching, and verbal reassurances while also respecting and being sensitive to the care recipient’s cultural beliefs and meanings associated with caring behaviors. [27] See Figure 4.4 [28] for an image of a nurse using touch as a therapeutic communication technique to communicate caring.

Review how to communicate with patients using therapeutic communication techniques like active listening in the “ Communication ” chapter.

Dr. Jean Watson is a nurse theorist who has published many works on the art and science of caring in the nursing profession. Her theory of human caring sought to balance the cure orientation of medicine, giving nursing its unique disciplinary, scientific, and professional standing with itself and the public. Dr. Watson’s caring philosophy encourages nurses to be authentically present with their patients while creating a healing environment. [29]

Read more about Dr. Watson’s theory of caring at the Watson Caring Science Institute .

Now that we have discussed basic concepts related to the nursing process, let’s look more deeply at each component of the nursing process in the following sections.

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