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Critical Thinking Versus Clinical Reasoning Versus Clinical Judgment

Differential diagnosis.

Victor-Chmil, Joyce MS, RN-BC, MHA

Author Affiliation: Director, Clinical Nursing Simulation Center. School of Nursing, Wilkes University, Wilkes-Barre, Pennsylvania.

The author declares no conflict of interest.

Correspondence: Ms Victor-Chmil, Wilkes University School of Nursing, 84 West South St, Wilkes-Barre, PA 18766 ( [email protected] ).

Concepts of critical thinking, clinical reasoning, and clinical judgment are often used interchangeably. However, they are not one and the same, and understanding subtle difference among them is important. Following a review of the literature for definitions and uses of the terms, the author provides a summary focused on similarities and differences in the processes of critical thinking, clinical reasoning, and clinical judgment and notes suggested methods of measuring each.

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Clinical Reasoning In Nursing (Explained W/ Example)

Last updated on August 19th, 2023

In this article, we will cover:

What is Clinical Reasoning?

Definition of clinical reasoning in nursing.

• What is the concept of clinical reasoning?

Why is Clinical Reasoning Important in Nursing?

What are the types of clinical reasoning, what are the three elements of clinical reasoning, what are the steps of clinical reasoning, what is the importance of clinical reasoning and judgement in nursing, what is the difference between critical thinking and clinical reasoning, clinical reasoning in nursing example.

Clinical reasoning refers to the cognitive process that healthcare professionals, such as doctors, nurses, and other clinicians, use to analyze and make decisions about a patient’s condition and appropriate treatment.

It’s a complex and dynamic process that involves gathering and interpreting information from various sources, including patient history, physical examinations, laboratory tests, imaging studies, and the clinician’s own experience and knowledge.

Medicine, physical therapy, and occupational therapy were the first to introduce clinical reasoning to the healthcare disciplines. Since then, the nursing profession has used these strategies to improve patient care.

What is Clinical Reasoning in Nursing?

Clinical reasoning in nursing is dynamic and adaptive, as nurses continuously gather new information and adjust care plans based on patient responses.

It’s a crucial skill that guides nurses in providing safe, effective, and patient-centered care. Clinical reasoning involves the integration of clinical knowledge, critical thinking , and experience to address the complex and dynamic nature of patient situations.

It involves balancing medical knowledge with critical thinking , empathy, and ethical considerations to provide comprehensive and compassionate patient care.

Clinical reasoning in nursing refers to the cognitive process that nurses use to collect and assess patient information, analyze data, make informed judgments, and develop appropriate care plans.

What is the Concept of Clinical Reasoning?

Clinical reasoning is the cognitive process used by healthcare professionals to make informed decisions regarding patient care.

It encompasses tasks such as collecting information, analyzing data, identifying patterns, generating hypotheses, and making judgments for diagnosis and treatment.

Clinical reasoning blends science and intuition in medical practice. It combines evidence-based knowledge with experience-derived judgment to attain accurate diagnoses and treatments while addressing uncertainties.

As an essential component of clinical practice, clinical reasoning guides healthcare providers in delivering safe and effective patient care.

Clinical reasoning is important in nursing for several reasons. Some reasons are listed below.

Patient-Centered Care:

Clinical reasoning helps nurses tailor care plans to individual patients, considering their unique needs, preferences, and circumstances, leading to more personalized and effective care.

Safe and Effective Care:

It ensures that nurses make well-informed decisions based on thorough assessments, reducing the risk of errors and promoting patient safety.

Optimal Outcomes:

Through clinical reasoning, nurses can identify early signs of complications, make timely interventions, and contribute to better patient outcomes.

Nurtured Critical Thinking:

Clinical reasoning cultivates nurses’ critical thinking abilities, empowering them to dissect complex situations, appraise evidence, and make rational choices.

Efficient Resource Utilization:

It helps nurses prioritize care tasks, allocate resources effectively, and manage time efficiently, enhancing workflow and patient care delivery.

Evidence-Based Practice:

Nursing practice is constantly evolving with new research and evidence. Clinical reasoning involves integrating the latest evidence-based knowledge into decision-making, ensuring that care plans are aligned with the best available practices.

Complex Cases:

Nurses often encounter intricate patient cases; clinical reasoning equips them to navigate complexity, address multiple issues, and make comprehensive care plans.

Interdisciplinary Collaboration:

Effective clinical reasoning supports collaboration with other healthcare professionals, promoting well-rounded patient care.

Adaptation to Change:

In rapidly changing healthcare environments, clinical reasoning enables nurses to adapt to new information, technologies, and practices.

Critical Decision-Making:

Nurses face complex situations where quick and accurate decisions are critical. Clinical reasoning equips them with the ability to analyze data, identify patterns, and generate hypotheses. This enables nurses to make informed decisions about interventions, medications, and treatments, leading to effective care.

Early Detection and Prevention:

Through clinical reasoning, nurses can detect subtle changes in a patient’s condition that might signal complications or deterioration. This allows for early interventions, preventing potential health crises and improving patient prognosis.

Error Reduction:

Clinical reasoning encourages systematic thinking, reducing the likelihood of errors in administering medications, performing procedures, and assessing patients. This promotes patient safety and prevents adverse events.

Holistic Care:

Patient’s health is influenced by various factors beyond just medical conditions. Clinical reasoning enables nurses to consider the social, emotional, and psychological aspects of patients, promoting holistic care and overall well-being.

Ethical Dilemmas:

Nursing often involves ethical challenges. Clinical reasoning guides nurses in making ethically sound decisions by considering patients’ autonomy, values, and cultural beliefs.

Communication and Collaboration:

Clinical reasoning enhances nurses’ ability to communicate effectively with patients, families, and other healthcare professionals. It fosters collaboration by enabling nurses to articulate their assessments, interventions, and rationales clearly.

Professional Growth:

Developing strong clinical reasoning skills enhances nurses’ professional growth. It increases their confidence, competence, and ability to take on more complex patient cases and leadership roles.

In summary , clinical reasoning is an important component of nursing practice, allowing nurses to provide safe, effective, and patient-centered care.

It enables nurses to make informed decisions, improve patient outcomes, and navigate the dynamic and complex healthcare setting.

Clinical reasoning involves three key elements that healthcare professionals integrate to make informed decisions about patient care:

1. Patient Information:

This element encompasses all the relevant data about the patient’s medical history, current condition, symptoms, physical examination findings, diagnostic test results, and social and contextual factors.

Gathering comprehensive and accurate patient information is essential for forming an accurate understanding of the patient’s health status and needs.

2. Clinical Knowledge and Expertise:

Healthcare professionals draw upon their extensive medical knowledge, clinical experience, and expertise to interpret patient information.

This knowledge includes an understanding of anatomy, physiology, pathophysiology, pharmacology, and medical guidelines.

Clinical expertise is built over years of practice, exposure to a variety of cases, and ongoing learning.

3. Critical Thinking and Decision-Making Skills:

Critical thinking involves the analytical and logical thought processes that healthcare professionals use to evaluate patient information in the context of their clinical knowledge.

It includes the ability to identify patterns, assess potential diagnoses, consider alternative explanations, and weigh the pros and cons of different treatment options.

Effective decision-making is the outcome of critical thinking , as healthcare professionals choose the most appropriate course of action based on the available information.

These three elements are interdependent and work together to form the foundation of clinical reasoning.

Healthcare professionals integrate patient information with their clinical knowledge and expertise while applying critical thinking skills to reach accurate diagnoses, develop effective treatment plans, and provide high-quality patient care.

The balance between these elements varies based on the complexity of the clinical situation and the healthcare provider’s level of experience and expertise.

8 Stages of the Clinical Reasoning Cycle

Clinical reasoning involves several key steps:

1. Data Collection: Gathering relevant information about the patient’s medical history, symptoms, physical examination findings, and any diagnostic tests that have been conducted.

2. Pattern Recognition: Recognizing patterns and relationships in the collected data to identify potential diagnoses or issues. This involves comparing the patient’s presentation to previous cases and medical knowledge.

3. Hypothesis Generation: Formulating hypotheses or possible explanations for the patient’s condition based on the patterns and information observed. This step often involves generating a list of potential diagnoses that fit the available evidence.

4. Differential Diagnosis: Narrowing down the list of potential diagnoses by considering the likelihood of each condition and ruling out less likely options. This is where critical thinking and medical knowledge come into play.

5. Testing and Validation: Ordering further diagnostic tests or investigations to confirm or rule out specific diagnoses. This could include blood tests, imaging studies, biopsies, or other procedures.

6. Synthesis: Integrating the results of diagnostic tests and additional information to refine the diagnosis and treatment plan. This may involve adjusting the initial hypotheses based on new data.

7. Treatment Planning: Developing a comprehensive treatment plan that addresses the diagnosed condition, the patient’s unique circumstances, preferences, and any potential risks or benefits of various treatment options.

8. Monitoring and Adaptation: Continuously monitoring the patient’s progress and adjusting the treatment plan as needed based on how the patient responds and any new information that emerges.

Clinical reasoning requires a deep understanding of medical science, anatomy, physiology, and pathology, as well as the ability to apply this knowledge to real-world clinical scenarios.

It also involves critical thinking skills , logical reasoning, and the ability to handle uncertainty, as medical situations can be complex and patients may present with atypical symptoms.

Overall, clinical reasoning is a crucial skill for healthcare professionals, as it forms the foundation for making accurate diagnoses and providing effective patient care.

Clinical reasoning and judgment are of paramount importance in nursing for several reasons:

• Accurate Diagnosis and Treatment: Effective clinical reasoning enables nurses to accurately assess patients’ conditions, identify potential problems, and make informed decisions about appropriate interventions and treatments. Accurate diagnosis and treatment are crucial for improving patient outcomes and preventing complications.
• Patient Safety: Sound clinical judgment helps nurses recognize potential risks and make timely interventions to ensure patient safety. By identifying early signs of deterioration or complications, nurses can take appropriate actions to prevent adverse events.
• Individualized Care: Clinical reasoning allows nurses to tailor care plans to each patient’s unique needs, preferences, and circumstances. This patient-centered approach improves patient satisfaction and contributes to better treatment outcomes.
• Early Detection of Changes: Nurses often spend the most time with patients, which puts them in a prime position to notice subtle changes in a patient’s condition. Strong clinical reasoning skills enable nurses to detect these changes early and respond appropriately.
• Effective Communication: Nurses with strong clinical reasoning skills can communicate more effectively with patients, families, and interdisciplinary healthcare teams. They can convey complex medical information, treatment plans, and concerns in a clear and organized manner.
• Ethical Decision-Making: Clinical reasoning includes ethical considerations in decision-making. Nurses must weigh the ethical implications of their actions and decisions, especially when faced with complex situations that involve moral dilemmas.
• Resource Utilization: Effective clinical reasoning helps nurses allocate resources efficiently. By accurately assessing patient needs and prioritizing care, nurses can optimize the use of time, personnel, and equipment.
• Adaptation to Change: Healthcare is dynamic, and patients’ conditions can change rapidly. Nurses with strong clinical reasoning skills can adapt quickly to changing situations, making necessary adjustments to care plans and interventions.
• Continuity of Care: Nurses often play a critical role in ensuring continuity of care as patients transition between different healthcare settings. Effective clinical reasoning facilitates clear communication of patient information and ensures a smooth transition of care.
• Professional Growth: Developing clinical reasoning and judgment skills enhances a nurse’s professional growth. These skills are transferrable and applicable across various healthcare settings, allowing nurses to provide high-quality care regardless of the environment.
• Confidence and Job Satisfaction: Nurses who feel confident in their clinical reasoning abilities experience greater job satisfaction. Confidence comes from knowing that decisions are based on a solid foundation of knowledge, experience, and critical thinking.
• Advocacy: Nurses with strong clinical reasoning skills can effectively advocate for their patients, ensuring that their needs are met, their voices are heard, and their rights are respected within the healthcare system.
• Quality Improvement: Clinical reasoning plays a role in quality improvement efforts by identifying areas for improvement in patient care processes and outcomes.

In summary, clinical reasoning and judgment are essential for nurses to provide safe, effective, and patient-centered care.

These skills underpin the entire nursing process, enabling nurses to make informed decisions, communicate effectively, and positively impact patient outcomes and experiences.

Critical Thinking :

Critical thinking is a cognitive process that involves analyzing, evaluating, and synthesizing information, ideas, and arguments to make reasoned judgments and decisions.

It is a broader skill applicable to various aspects of life and professions, encouraging logical, evidence-based thinking and minimizing biases.

Critical thinking aims to enhance problem-solving, decision-making, and analytical abilities in a wide range of contexts beyond healthcare.

Clinical Reasoning:

Clinical reasoning, on the other hand, is a specialized form of critical thinking that is primarily focused on healthcare and clinical situations.

It specifically pertains to the cognitive process healthcare professionals, especially nurses and doctors, use to collect, assess, analyze, and apply information to make informed clinical judgments and decisions.

Clinical reasoning is crucial for providing safe and effective patient care, as it integrates medical knowledge, patient assessments, ethical considerations, and treatment planning.

Critical Thinking vs. Clinical Reasoning

Clinical reasoning can be categorized into different types or approaches. Each of which represents a particular way of thinking and making decisions in clinical practice.

Some of the commonly recognized types of clinical reasoning include:

• Deductive Reasoning: This type of reasoning starts with a general principle or theory and applies it to a specific case. Healthcare professionals use deductive reasoning to make predictions or decisions based on established medical knowledge. For example, if a patient presents with a set of symptoms consistent with a well-known disease, the clinician may deduce that the patient likely has that disease.
• Inductive Reasoning: In contrast to deductive reasoning, inductive reasoning involves making generalizations or conclusions based on specific observations or cases. Clinicians use inductive reasoning to form hypotheses or theories from individual patient experiences. For instance, a nurse may notice a pattern of symptoms in several patients and develop a hypothesis about a potential new condition.
• Abductive Reasoning: Abductive reasoning combines elements of both deductive and inductive reasoning. It involves making educated guesses or hypotheses to explain observations or data that don’t fit neatly into established patterns. Clinicians use abductive reasoning when they encounter cases that don’t seem to fit existing diagnoses or models, and they generate plausible explanations to guide further investigation.
• Analytical Reasoning: This type of reasoning involves systematically breaking down a complex situation or problem into smaller parts to understand its components and relationships. Healthcare professionals use analytical reasoning to dissect complex patient cases, focusing on details and relationships to arrive at a diagnosis or treatment plan.
• Intuitive Reasoning: Intuitive reasoning relies on a healthcare professional’s experience, intuition, and gut feeling. It involves drawing on one’s own clinical experience and recognizing patterns that may not be immediately apparent. Intuitive reasoning is often employed in situations where rapid decision-making is necessary.
• Procedural Reasoning: Procedural reasoning focuses on the steps or processes needed to manage a clinical situation. It involves thinking about the sequence of actions required to address a patient’s needs. For example, a nurse may use procedural reasoning when administering medications, performing wound care, or carrying out other routine clinical procedures.
• Narrative Reasoning: Narrative reasoning involves considering the patient’s story, values, and context as essential components of clinical decision-making. It emphasizes understanding the patient’s perspective and tailoring care plans to the individual’s unique circumstances.
• Hypothetico-Deductive Reasoning: This approach involves generating and testing hypotheses systematically to arrive at a diagnosis. Healthcare professionals consider various possible diagnoses, then order specific tests to confirm or rule out each hypothesis.
• Pattern Recognition Reasoning: This type of reasoning relies on recognizing familiar patterns based on clinical experience and knowledge. Healthcare providers quickly identify common clinical presentations and apply established treatment protocols.

Emily Davis, a 68-year-old woman, is admitted to the medical unit with a diagnosis of Acute Exacerbation of COPD. She has a history of chronic obstructive pulmonary disease (COPD) and has been experiencing increased shortness of breath, cough, and decreased oxygen saturation levels.

How does your understanding of nursing fundamentals influence your clinical reasoning?

Nursing Action:

• Reflect on the nursing care provided to patients with COPD and respiratory distress.

• Review the pharmacologic treatments that will improve the patient’s COPD.

• Reflect the non-pharmacologic measures that will help to improve the patient’s respiratory distress.

• Determine the most appropriate assessments and interventions for managing respiratory distress in patients with COPD.

Implementation of Interventions:

• Assess Emily’s respiratory rate, depth, and effort, as well as oxygen saturation levels.

• Administer prescribed bronchodilators, and nebulization to improve airway patency.

• Elevate the head of the bed to promote better lung expansion.

• Encourage deep breathing exercises and effective coughing techniques.

• Consult with the physician to determine pharmacologic therapy

• Monitor Emily’s response to interventions and adjust care as needed. How does your understanding of pathophysiology guide your clinical reasoning?

• Knowledge of COPD’s pathophysiology helps anticipate complications and tailor interventions.

In this scenario, the nurse’s grasp of nursing fundamentals enables them to provide appropriate care for a patient with COPD.

By considering the patient’s history and symptoms, the nurse takes action to manage respiratory distress.

Implementing interventions such as bronchodilators and elevation of the head of the bed aligns with nursing knowledge.

Additionally, understanding the pathophysiology of COPD aids in predicting potential complications and choosing interventions to support the patient’s respiratory function.

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Clinical reasoning in nursing involves the skillful integration of medical knowledge, critical thinking , and patient assessment to make informed decisions about patient care.

It enables nurses to provide safe, effective, and patient-centered interventions while considering individual needs and complex healthcare situations.

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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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Clinical Judgement

As one of the key attributes of professional nursing, clinical judgment refers to the process by which nurses make decisions based on nursing knowledge (evidence, theories, ways/patterns of knowing), other disciplinary knowledge, critical thinking, and clinical reasoning. This process is used to understand and interpret information in the delivery of care. Clinical decision making based on clinical judgment is directly related to care outcomes.

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Advanced practice: critical thinking and clinical reasoning

Affiliations.

• 1 Advanced Critical Care Practitioner, Newcastle upon Tyne NHS Foundation Trust / Senior Lecturer in Advanced Critical Care Practice, Department of Nursing, Midwifery and Health, Northumbria University.
• 2 Advanced Critical Care Practitioner, South Tees Hospitals NHS Foundation Trust.
• PMID: 33983801
• DOI: 10.12968/bjon.2021.30.9.526

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.

Keywords: Advanced practice; Clinical reasoning; Consultation; Critical thinking; Diagnostic accuracy.

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What is Critical Thinking?  Let us start with what it is NOT .  It is NOT being negative, showing displeasure or disapproval or being emotionally judgmental.  That is the social connotation of the word "critical".  In the academic and clinical practice setting, the phrase "critical thinking" has a positive meaning. 

Per Dictionary.com, critical thinking is defined as " disciplined thinking that is clear, rational, open-minded, and informed by evidence ".  ( http://www.dictionary.com/browse/critical-thinking )

Per Rasmussen College,  "Critical Thinking includes identifying a problem, determining the best solution and choosing the most effective method of reaching that solution. After executing the plan, critical thinkers reflect on the situation to figure out if the plan was effective and if it could have been done better."   ( http://www.rasmussen.edu/degrees/nursing/blog/understanding-why-nurses-need-critical-thinking-skills/ )  Critical thinking applies thinking, reading, writing, listening and speaking.  There are many factors in critical thinking, including gathering, focusing, organizing, analyzing, generating, integrating, and evaluating information.

Critical thinking in research is the method of evaluating all the information gathered, including the sources from which the information is obtained by and determining the value of the information in relationship to the situation.  It means evaluating the sources that you use to find the information to determine the value of the source.  Information from an undergraduate's blog post is not going to have as much weight as information from an article in JAMA . 

For nursing, it also means utilizing the Evidence-Based Practice methodology for determining the quality and strength of the information found.  It means developing the skills to become a critical thinker beyond the classroom.  This practice will allow you to develop deductive and sound reasoning skills and become self-confident in your thought process and your decision making skills.

What is synthesizing information? Synthesizing information is the process in which you connect multiple sources of information together and create a cohesive statement and/or argument.  Per Dictionary.com, synthesize is: "to form (a material or abstract entity) by combining parts or elements"  ( http://www.dictionary.com/browse/synthesize )  It is the method of pulling together information and finding the connection in that information (even if the information is in conflict) to say something new. 

According to California State University: "Synthesis refers to the ability to put parts together to form a new whole. This may involve the production of a unique communication (theme or speech), a plan of operations (research proposal), or a set of abstract relations (scheme for classifying information). Synthesis refers to the ability to put parts together to form a new whole. This may involve the production of a unique communication (theme or speech), a plan of operations (research proposal), or a set of abstract relations (scheme for classifying information)."  

http://www.csun.edu/science/ref/reasoning/questions_blooms/blooms.html   

Analysis and Synthesis are closely related. 

Although analysis and synthesis are closely related, there are differences between the styles.  The publication "Analysis, Synthesis and and Response Papers" from Grand Valley State University offers an excellent overview of the styles with a specific focus on writing for nurses. 

What is Clinical Judgment?

The clinical judgment model is a framework that guides nurses in their decision-making process. It helps to structure their thinking and enhance their ability to make accurate assessments and appropriate interventions. The model involves several stages, and by following this systematic approach, nurses can enhance their clinical judgement skills to provide efficient and effective care.

The model was developed by National Council of State Boards of Nursing (NCSBN) researchers.

The six steps of the Clinical Judgment Model are:

• Recognize Cues
• Analyze Cues
• Prioritize Hypotheses
• Generate Solutions
• Take Actions
• Evaluate Outcomes

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The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice. Nurses’ ability to recognize and respond to signs of patient deterioration in a timely manner plays a pivotal role in patient outcomes (Purling & King 2012). Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events (Tomlinson, 2015). The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement. Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010). At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction.

The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.

As lifelong learners, nurses are constantly accumulating more knowledge, expertise, and experience, and it’s a rare nurse indeed who chooses to not apply his or her mind towards the goal of constant learning and professional growth. Institute of Medicine (IOM) report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice. American Nurses Association (ANA), Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice (p.26)

Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier

The future of nursing: Leading change, advancing health, (2010). https://campaignforaction.org/resource/future-nursing-iom-report

Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today. 30(6), 515-520.

NMC (2010) New Standards for Pre-Registration Nursing. London: Nursing and Midwifery Council.

Purling A. & King L. (2012). A literature review: graduate nurses’ preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23–24), 3451–3465

Thompson, C., Aitken, l., Doran, D., Dowing, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50 (12), 1720 - 1726 Tomlinson, J. (2015). Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Medical Education, 15(103)

Competing interests: No competing interests

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Getting Ready for the Next-Generation NCLEX® (NGN): How to Shift from the Nursing Process to Clinical Judgment in Nursing

Authored by.

Donna D. Ignatavicius , MS, RN, CNE, CNEcl, ANEF, FAADN

Linda Silvestri , PhD, RN, FAAN

What is the Nursing Process?

The nursing process has been used for over 50 years as the systematic, stepwise method for problem solving to make safe, client-centered clinical decisions. Originally, there were four nursing process steps, published in the late 1960s. These were:

• Implementation

In the early 1970s, the North American Nursing Diagnosis Association (NANDA, currently called NANDA-I) was formed to develop a common language to identify standardized nursing diagnoses based on a nurse’s interpretation of assessment data. As a nurse educator, you likely include this additional step of Diagnosis as part of the nursing process, referred to as ADPIE:

Using a problem-solving approach as a basis for nursing practice requires the use of critical thinking and decision-making. Some experts have referred to that thinking more recently as clinical reasoning. The 2020 NCLEX-RN® Test Plan identifies the nursing process as one of five integrated processes which is defined as “a scientific, clinical reasoning approach to client care that includes assessment, analysis, planning, implementation, and evaluation” (NCSBN, 2019, p.5). Note that this definition does not include Diagnosis; rather the second step of the nursing process is labeled as Analysis.

The NCLEX-RN® and NCLEX-PN® do not measure the nursing graduate’s knowledge of nursing diagnoses (NDs) because NDs are not universally used as originally intended as a standardized language, even in the United States where the NANDA nursing diagnosis list began. Yet many faculty continue to teach the nursing process as a five-step ADPIE approach.

Comparing the Nursing Process and Clinical Judgment

While the nursing process has been taught in prelicensure programs for many years, nurses continue to make serious errors in practice, including failure-to-rescue clinical situations that sometimes result in sentinel events. Based on these errors and employer dissatisfaction with the clinical-decision ability of new graduates, the National Council of State Boards of Nursing (NCSBN) developed a model of clinical judgment that is built on and expands the nursing process. Officially entitled the NCSBN Clinical Judgment Measurement Model (NCJMM), this evidence-based model identifies six cognitive skills needed to make appropriate clinical judgments. These skills include:

• Recognize Cues
• Analyze Cues
• Prioritize Hypotheses
• Generate Solutions
• Take Action
• Evaluate Outcomes

The NCJMM will be the basis for the Next-Generation NCLEX-RN and NCLEX-PN (NGN) new test items that will be presented most often in an unfolding case format . These cases will present clinical situations in which the test candidate will need to use clinical judgment skills to answer questions about how to manage the presented client’s care.

If you are teaching in a state, province, or territory in which the nursing process is required as a regulation for prelicensure nursing education, follow these guidelines to help transition from the nursing process to clinical judgment:

• Use the term clinical judgment as part of your program’s definition of professional nursing and end-of-program student learning outcomes (also called program learning outcomes).
• Introduce the nursing process in your first basic nursing course as the foundation for clinical decision-making.
• Minimize emphasis on the NANDA nursing diagnosis list and ensure that students understand that the diagnostic labels and taxonomy are not universally used in health care today. Instead, assist students in learning the signs, symptoms, and behaviors that nurses and other interprofessional health care team members utilize and understand. For example, fever is a more commonly used term in nursing and health care than hyperthermia. A nurse can take a client’s body temperature and determine that he or she has a fever if the thermometer reads 103 o F (39.4 o C).     
• Introduce the NCSBN definition of clinical judgment and the six cognitive skills of the NCJMM early in your nursing program.
• Have students practice using the six cognitive skills in a variety of learning activities, including unfolding case studies in place of excessive lecture throughout your program.

Building on the Nursing Process to Transition to Clinical Judgment

As you and your students transition from the nursing process to clinical judgment, remember that clinical judgment is more closely aligned with how nurses in practice actually think to make the best possible decisions about client care. Also recall that clinical judgment in nursing is not a new concept. For example, Tanner, the National League for Nursing, and others have posited for almost 15 years that clinical judgment is a better problem-solving approach than the nursing process.

The NCJMM cognitive skills can be aligned with the nursing process steps and phases of Tanner’s clinical judgment model as illustrated below:

Comparison of the Nursing Process with Tanner’s Clinical Judgment Model and the NCSBN Clinical Judgment Measurement Model (NCJMM)

While these models may look very similar, the thinking processes differ. For example, in the Assessment step of the nursing process, the nurse collects subjective and objective client data using a systematic approach. By contrast, the Recognize Cues cognitive skill of clinical judgement requires the nurse to collect client data and then decide “What matters most?”—which client data (findings) are relevant in a specific contextual clinical situation and which data are not relevant? Two other examples comparing the nursing process steps and the cognitive skills of the NCJMM are described below:

As you begin or continue making the transition of building on the nursing process to emphasize clinical judgment in your program, remember that clinical judgment will be the focus of the new test item types for the NGN by no sooner than 2023. You still have time to begin the transition journey, but we suggest that you start it soon! More NGN resources are available on www.ncsbn.org and the Elsevier Evolve Faculty Resources webpage.

Reference :

National Council of State Boards of Nursing (NCSBN). (2018). NCLEX-RN® Examination: Test plan for the National Council Licensure Examination for Registered Nurses. Chicago, IL: Author.

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Developing clinical judgment skills in nursing students

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Critical thinking + clinical reasoning = strong clinical judgment

Critical thinking

To develop critical thinking skills, students must engage in activities encouraging analyzing, discriminating, information-seeking, and open-mindedness. Critical thinking requires students to think precisely and accurately and act on what they know and understand; critical thinking precedes clinical reasoning (Manetti, 2018; Potter & Perry, 2012; Alfaro-LeFevre, 2017).

Clinical reasoning

Clinical reasoning involves a student's ability to apply knowledge, think in action, and reason as a situation changes over time (Benner, et al., 2010). the analysis of data is done through four steps:

• noticing relevant clinical data
• interpreting the clinical significance of data
• responding appropriately by prioritizing responses and actions
• reflecting on the effectiveness of the response (Tanner, 2006).

Clinical judgment

Clinical judgment results in a student's conclusions after making a holistic assessment that correctly interprets clinical data to determine the best response. It is an outcome that depends on critical thinking, clinical reasoning, and intuition (Rischer, 2021). 

In nursing, for example, strong clinical judgment involves choosing the best response among alternative actions in light of expected outcomes, using ongoing evaluative reflection to monitor a patient's response, and modifying interventions accordingly. Reflecting on clinical decisions afterward improves judgment when caring for future patients (Alfaro-LeFevre, 2017; Tanner, 2006; Manetti, 2019).

Clinical judgment models for nursing instruction

Nursing process (american nurses association).

• Assessment — the nurse assesses patients on an in-depth physiological, economic, social, and lifestyle basis.
• Diagnosis and analysis — the nurse considers the physical symptoms and patient behavior and forms a diagnosis or analysis of cues to determine the current nursing priority.
• Outcomes and planning — the nurse uses their expertise to set realistic goals for the patient's recovery and monitors those objectives closely.
• Implementation — the nurse implements the care plan and documents the patient's progress.
• Evaluation — the nurse analyzes the effectiveness of the care plan, studies the patient response, and alters the plan of care to achieve the best patient outcomes. (ANA Standards of Critical Nursing Practice, 1988).

Tanner's Clinical Judgment Model

• Noticing — What clinical data does the nurse recognize as important and/or significant?
• Interpreting — What is the meaning or clinical significance of relevant clinical data that was noticed?
• Responding — How will the nurse respond with a nursing priority and care plan based on the clinical data that was noticed and interpreted?
• Reflecting — After responding, what is the evaluation, reflecting on clinical data noticed by the nurse? (Tanner, 2006)

Revised Clinical Judgment Model

Based on Tanner's Clinical Judgment Model and Neilsen, Stragnell, and Jester's article Guide for Reflection using the Clinical Judgment Model, instructors from the UW-Madison School of Nursing have developed a revised model that also addresses issues of diversity, equity, social justice, and health equity into the equation. This added element of Personalizing asks the nurse to consider the emotions, reactions, beliefs, and biases they bring to the care of a patient and develop a self-care plan that manages these feelings to ensure fair and equitable patient care.

• Alfaro-LeFevre, R. (2017). Critical thinking, clinical reasoning, and clinical judgment: A practical approach. (6th ed.). St. Louise, MO: Elsevier-Saudners.
• Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation . San Francisco, CA: Jossey-Bass.
• Manetti, W. (2019). Sound clinical judgment in nursing: A concept analysis: MANETTI. Nursing Forum, 54)1, 102-110.
• Nielsen, A., Stragnell, S., & Jester, P. (2007) Guide for reflection using the clinical judgment model.  The Journal of Nursing Education , 46(11), 513-516.
• Rischer, K. (2021). Faculty guide to develop clinical judgment: Transforming nursing education through the use of clinical reasoning case studies.
• Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. The Journal of Nursing Education, 45(6) , 204-211).

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Clinical Research Coordinator Lead

How to apply.

A cover letter is required for consideration for this position and should be attached as the first page of your resume. The cover letter should address your specific interest in the position and outline skills and experience that directly relate to this position.

Job Summary

An exceptional opportunity is available for a highly motivated and experienced Clinical Research Coordinator Lead to oversee the clinical research activities within the Obstetrics and Gynecology Department with the PEACE Project Grant. A $7.8 million grant from the National Institutes of Health will fund a joint research effort entitled Partnering for Equity: An Academic and Community Alliance to Eliminate Disparities throughout the Fibroid Experience (PEACE) by researchers from multiple institutions.

We are looking for a candidate who can work independently, and in collaboration with multiple project PIs and community members with guidance required in only the most complex situations. The candidate should be able to set up and streamline study operations, maximize efficiency, and ensure the successful completion of clinical studies.

The successful candidate will be experienced, positive, highly motivated, organized, and autonomous individual with excellent communication and multi-tasking skills to join our growing research team. This position will work closely with principal investigators and other research team members to accurately and efficiently carry out a range of tasks and provide study coordination for multiple research studies of high complexity across research sites.   The role will also provide functional supervision for one or more junior clinical research team members. The candidate should be able to gather and understand internal or external issues and recommend solutions/best practices and solve complex problems and take a broad perspective to identify solutions. They may lead functional teams as well. The characteristic duties and responsibilities of this position may evolve over time to match changing needs and priorities.

At onWHARD we celebrate diversity and are committed to creating an inclusive environment for all team members. We know that our differences fuel innovation and excellence and understand that diversity and inclusion are critical to our success. We welcome applicants from all backgrounds, cultures, orientations, and experiences.

CRC STATEMENT:

This clinical research coordinator (CRC) position may provide study coordination for multiple clinical research studies of any complexity. Coordinator experience and mastery of all job duties from the CRC-Lead position on the Michigan Medicine CRC Career Ladder is required. This position should begin to serve on various clinical research committees at the University level. This position demonstrates advanced skills and knowledge along with the ability to support, guide, train, and demonstrate the implementation of study related activities. This position applies critical thinking and creative problem-solving skills across a wide variety of clinical studies. This position contributes to the development of new processes, procedures, and tools to enhance clinical research activities across the competency domains and conducts quality assurance/quality control checks on their work. This level of CRC continues to build on their competency foundation by making greater investments in their ongoing continuing education and professional development. Key behavioral competency descriptors include: Design, demonstrate, develop, guide, and support.

Mission Statement

Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally.  Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.

Why Join Michigan Medicine?

Michigan Medicine is one of the largest health care complexes in the world and has been the site of many groundbreaking medical and technological advancements since the opening of the U-M Medical School in 1850. Michigan Medicine is comprised of over 30,000 employees and our vision is to attract, inspire, and develop outstanding people in medicine, sciences, and healthcare to become one of the world’s most distinguished academic health systems.  In some way, great or small, every person here helps to advance this world-class institution. Work at Michigan Medicine and become a victor for the greater good.

What Benefits can you Look Forward to?

• Excellent medical, dental and vision coverage effective on your very first day
• 2:1 Match on retirement savings

Responsibilities*

Expert level knowledge, skills, and abilities within all 8 competency domains is expected:

• Scientific Concepts and Research Design
• Ethical Participant Safety Considerations
• Investigational Products Development and Regulation
• Clinical Study Operations (GCPs)
• Study and Site Management
• Data Management and Informatics
• Leadership and Professionalism
• Communication and Teamwork

Specific duties will include:

Project Management and Research Administration Responsibilities

• Will serve as the central administrative coordinator, facilitating communication across research teams, sponsors, and other stakeholders across the different sites.
• Will independently oversee common project activities, establish administrative protocols, budget assessments, implementation methods, and track and maintain IT resources.
• Independently draft reports, organize meetings with detailed agendas and minutes, and manage project logistics including Community Advisory Board (CAB), Steering Comm. (SC), internal and external advisory board (IAB/EAB) meetings, and organizing of events for dissemination of research findings.
• Proactive and meticulous oversight of forms, databases, regulatory files, and creating SOPs.
• Responsible for financial and staff management to meet project goals and will have the autonomy to make significant decisions in line with project objectives.
• Maintain minutes and Action plans from standing meetings
• Other activities as needed for the overall PEACE grant

Clinical Research Coordinator Responsibilities

• As an integral part of the PEACE study team, works closely with Principal Investigators, program manager, and various teams to shape and execute the study's overarching strategy.
• Organize and facilitate all aspects of standing recurrent meetings including MPI meetings, monthly Steering Committee Meetings, and Project PI meetings
• Plan and execute national annual PEACE meeting.
• Be the primary administrative contact for the program
• Responsibilities also include handling start-up, active, and closing phases of the project and overseeing inventory.

Research Regulatory Coordinator Responsibilities

• Handle, support, oversee the submission of IRB applications for all projects, create study SOPs, and ensure compliance with all study-related submissions and quality assurance.
• Monitor and address site compliance for subject safety, develop methods to improve participant protection, and create tools to enhance site adherence to regulations for the safe development of investigational products.
• Maintain up to date knowledge of state and federal regulations as well as policies, guidelines and ethical codes related to research compliance.

Research Data Coordinator Responsibilities

• Create and manage databases, including designing logic, drafting Case Report Forms (CRFs), identifying data elements, and developing database in REDCap.
• Additionally, responsible for establishing processes, tools, and training to ensure data is captured accurately and consistently in line with ALCOA-C principles within the REDCap system.
• Candidate will work with other program staff, developing and presenting educational materials, to ensure uniformity of review and compliance with standard operating procedures and applicable federal and state regulations.

Training/Community Engagement/Other

• Facilitate effective communication between community and academic partners.
• Help initiate PEACE Pilot grant funding applications. Facilitate various aspects of the pilot grant process, including online application management, submission coordination, review and selection procedures, and compiling reports from pilot grantees.
• Work with Communications Specialist to maintain database of word and graphic based products including flyers, social media messages, etc.  
• Assist in supporting key personnel in project documentation and manuscript preparation; associated tasks with the Steering Committee's efforts and in align with NIH publication requirements.
• Provides mentorship of other clinical research staff; maintains certification.
• Employees in this classification typically analyze, compare and evaluate various courses of action and have the authority to make independent decisions on matters of significance, free from immediate direction, within the scope of their responsibilities.
• Primary activities and decision-making authority are predominantly performed independently affecting business operations to a substantial degree.

Supervision Received:

This position reports directly to the Research Operations Senior Manager for Women's Health and Reproductive Disparities Collaborative. 

Supervision Exercised:

Possibly provide Functional supervision, in a limited capacity, such as training of staff in titles within the CRC Career Ladder.

Required Qualifications*

• Bachelor's or Master's degree in Research Administration, Public Health, Social Work, Psychology, Business, Education, Social Sciences, or related field
• Certification is required through Association of Clinical Research Professionals ( ACRP ) as a Certified Clinical Research Coordinator (CCRC) or Society of Clinical Research Association ( SOCRA ) as a Certified Clinical Research Professionals (CCRP) or equivalent.   Candidates must be eligible to register or take the exam at date of hire and the certification must be completed or passed etc . within six months of date of hire.   (Please review eligibility criteria from SoCRA or ACRP prior to applying.)
• Medical or public health research background
• Fluency in Microsoft Software i.e. Word, PowerPoint, Excel, etc.
• At least 10 years of experience as a program or research coordinator/manager
• Fluency in REDCap database building and management skills required.
• Demonstrable experience in managing multidisciplinary and multicultural teams.
• A commitment to diversity, equity, and inclusion, and cultural sensitivity.
• Demonstrated high degree of initiative and resourcefulness
• Able to work independently and work collaboratively with diverse groups across the research continuum (e.g., faculty, patients, community members, frontline providers, research managers, policymakers, research administration, and administrative staff)
• Experience coordinating multisite research projects, including budgets and workplans.
• Knowledge of and experience with IRB processes, submitting research studies to the University of Michigan's Institutional Review Board (IRBMed or IRB-HSBS).
• Exceptional attention to detail, and excellent written and oral communication skills
• Excellent organizational, leadership, and decision-making skills.
• Willingness to travel throughout Michigan and nationally to conferences, as needed
• Proficiency in -and research management software including reference management and file sharing software (e.g., Dropbox, Google Drive, Trello, Zotero), communication and meeting management (e.g., Zoom, Teams, Slack); and presentation software (e.g., Canva, etc.)

Level Specific Requirements:

• CRC Governance Committee review and approval 
• Bachelor's degree in Health Science or an equivalent combination of related education and experience is necessary.
• Minimum 5+ years of directly related experience in clinical research and clinical trials is necessary

Desired Qualifications*

• Masters or PhD
• Experience using social media platforms
• Survey research experience and skills; Mixed-methods skills including qualitative and quantitative research methods
• Qualtrics experience
• Experience in mixed-methods or qualitative research
• Experience with data visualization and synthesis
• Ability to manage responsibilities and manage time effectively to meet deadlines.
• Demonstrate excellent problem-solving, analytical, and critical thinking skills
• Ability to set priorities, handle multiple assignments and deadlines and display excellent judgment while operating in a flexible and professional manner; strong ability to multitask while remaining focused is essential.
• Demonstrated ability to work independently with minimal supervision. and adapt to the needs of the program
• Demonstrated ability to work with diverse teams of people in a diplomatic, inclusive, collaborative and effective manner; Ability to effectively lead diverse work teams
• Working knowledge of applicable University policies and procedures preferred
• Ability to make independent decisions while working toward a shared strategic vision

Work Locations

This position is hybrid, with 2-3 days/week onsite work in Ann Arbor, MI *required* and/or community-based work throughout Michigan.   There will be some travel to national meetings.

Modes of Work

Positions that are eligible for hybrid or mobile/remote work mode are at the discretion of the hiring department. Work agreements are reviewed annually at a minimum and are subject to change at any time, and for any reason, throughout the course of employment. Learn more about the work modes .

Additional Information

The use of this title requires approval by the University of Michigan Clinical Research Coordinator Governance Board to ensure equity in title placement across Michigan Medicine.

Michigan Medicine is firmly committed to advancing inclusion, diversity, equity, accessibility, and belonging, which are core to the culture and values of the Medical School Office of Research. Our community supports recruiting and cultivating a diverse workforce as a reflection of our commitment to serve the diverse people of Michigan and the world. We strive to create a work culture where each team member feels respected, valued, and safe. 

Background Screening

Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings.  Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.

Application Deadline

Job openings are posted for a minimum of seven calendar days.  The review and selection process may begin as early as the eighth day after posting. This opening may be removed from posting boards and filled anytime after the minimum posting period has ended.

U-M EEO/AA Statement

The University of Michigan is an equal opportunity/affirmative action employer.