Critical thinking and clinical reasoning in nursing

E-mail: nuofeigenrac@nehptusbackgroundthis 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 expert performance of nurses is dependent upon continual learning and evaluation of al thinkingnursing education has emphasized critical thinking as an essential nursing skill for more than 50 years. 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. 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. 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. Scheffer and rubenfeld5 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 knowledge6 (scheffer & rubenfeld, p. 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 research7 (p. 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 creativity8 (p. 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 solving8 (p. 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 sional 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 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. 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. 12 clinicians pool their wisdom and multiple perspectives, yet some clinical knowledge can be demonstrated only in the situation (e. 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 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 al reflection, critical reasoning, and judgmentcritical 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. 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 al reflection is a crucial professional skill, but it is not the only reasoning skill or logic clinicians require.

Critical thinking and clinical reasoning

The ability to think critically uses reflection, induction, deduction, analysis, challenging assumptions, and evaluation of data and information to guide decisionmaking. 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. Sometimes clinical reasoning is presented as a form of evaluating scientific knowledge, sometimes even as a form of scientific reasoning. 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 al 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. In dong so, the clinician considers the patient’s particular clinical trajectory, their concerns and preferences, and their particular vulnerabilities (e. Known drug allergies, other conflicting comorbid conditions, incompatible therapies, and past responses to therapies) when forming clinical decisions or ed in a practice setting, clinical reasoning occurs within social relationships or situations involving patient, family, community, and a team of health care providers. 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. Halpern19 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. 20clergy educators21 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. 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. 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 al 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. Snapshot reasoning), in contrast to a clinician who must always reason about transitions over time. For example, was the refusal based upon catastrophic thinking, unrealistic fears, misunderstanding, or even clinical depression? 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 sis, 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. 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. Individual practitioners can be mistaken in their judgments because practices such as medicine and nursing are inherently underdetermined. 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. 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 practice, nursing and medicine require both techne and phronesis. 22rational 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 ng criticallybeing 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. Skillful practitioners can think critically because they have the following cognitive skills: information seeking, discriminating, analyzing, transforming knowledge, predicating, applying standards, and logical reasoning. One’s ability to think critically can be affected by age, length of education (e. 37 the skillful practitioner can think critically because of having the following characteristics: motivation, perseverance, fair-mindedness, and deliberate and careful attention to thinking. 9thinking critically implies that one has a knowledge base from which to reason and the ability to analyze and evaluate evidence.

Clinical decisionmaking is particularly influenced by interpersonal relationships with colleagues,39 patient conditions, availability of resources,40 knowledge, and experience. 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 ion of the clinician’s character, skills, and habits are developed in schools and particular practice communities within a larger practice tradition. 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 sional 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. 30, 47in 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. 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. 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 enceone 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. 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. Beyond that, the proficient nurse acknowledged the changing relevance of clinical situations requiring action beyond what was planned or anticipated. 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. Clinical perceptual and skilled know-how helps the practitioner discern when particular scientific findings might be relevant. 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. Conversely, the ability to proficiently conduct a series of tasks without nursing diagnoses is the hallmark of expertise. As expertise develops from experience and gaining knowledge and transitions to the proficiency stage, the nurses’ thinking moves from steps and procedures (i. 60experts are thought to eventually develop the ability to intuitively know what to do and to quickly recognize critical aspects of the situation. 64in a review of the literature on expertise in nursing, ericsson and colleagues65 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. 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. 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. 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. Perceptual skills, like those of the expert nurse, are essential to recognizing current and changing clinical conditions. Often in nursing and medicine, means and ends are fused, as is the case for a “good enough” birth experience and a peaceful ng practice evidenceresearch continues to find that using evidence-based guidelines in practice, informed through research evidence, improves patients’ outcomes. 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 ting evidencebefore research should be used in practice, it must be evaluated. Critical thinking is required for evaluating the best available scientific evidence for the treatment and care of a particular 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. To evolve to this level of judgment, additional education beyond clinical preparation if often s of evidenceevidence that can be used in clinical practice has different sources and can be derived from research, patient’s preferences, and work-related experience. 86 nurses have been found to obtain evidence from experienced colleagues believed to have clinical expertise and research-based knowledge87 as well as other many years now, randomized controlled trials (rcts) have often been considered the best standard for evaluating clinical practice. 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 r 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 clinical practice, the particular is examined in relation to the established generalizations of science. The clinician’s sense of salience in any given situation depends on past clinical experience and current scientific ce-based practicethe 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. 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 tually, evidence used in practice advances clinical knowledge, and that knowledge supports independent clinical decisions in the best interest of the patient.

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 lly, before evidence-based practice can begin, there needs to be an accurate clinical judgment of patient responses and needs. 100once 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 evidence101 and evaluates potential discrepancies. 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. Evidence is missingin many clinical situations, there may be no clear guidelines and few or even no relevant clinical trials to guide decisionmaking. But scientific, formal, discipline-specific knowledge are not sufficient for good clinical practice, whether the discipline be law, medicine, nursing, teaching, or social work. 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 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. 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 three apprenticeships of professional educationwe 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. 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 ch 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. 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. Yet when these students transition from school and clinicals to their job as a nurse, they will understand what’s going on and 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. 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 al judgment or phronesis is required to evaluate and integrate techne and scientific 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. 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 al 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. 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 qualitative distinctionsqualitative distinctions refer to those distinctions that can be made only in a particular contextual or historical situation. In detective work, modus operandi thinking, and clinical puzzle solvingclinical 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 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. 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 izing changing clinical relevancethe meanings of signs and symptoms are changed by sequencing and history. 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 ping clinical knowledge in specific patient populationsextensive 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. Over time, the clinician develops a deep background understanding that allows for expert diagnostic and interventions al forethoughtclinical 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 thinkfuture think is the broadest category of this logic of practice. 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. Whether in a fast-paced care environment or a slower-paced rehabilitation setting, thinking and acting with anticipated futures guide clinical thinking and judgment. Clinical forethought involves much local specific knowledge about who is a good resource and how to marshal support services and equipment for particular es 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 pation of crises, risks, and vulnerabilities for particular patientsthis aspect of clinical forethought is central to knowing the particular patient, family, or community.

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. Providing comfort measures turns out to be a central background practice for making clinical judgments and contains within it much judgment and experiential 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. 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. 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. In rapidly moving clinical situations, perceptual grasp is the starting point for clarification, confirmation, and action. 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 sionlearning to provide safe and quality health care requires technical expertise, the ability to think critically, experience, and clinical judgment. Chapter version of this page (147k)in this pagebackgroundcritical thinkingapplying practice evidenceclinical graspconclusionreferencesother titles in this collectionadvances in patient safetyrelated informationpmcpubmed central citationspubmedlinks to pubmedsimilar articles in pubmednurses' reasoning process during care planning taking pressure ulcer prevention as an example. Reasoning, decisionmaking, and action: thinking critically and clinically - patient safety and qualityyour browsing activity is ty recording is turned recording back onsee more... Article   clinical reasoning and critical thinking     josinete aparecida da silva bastos cerulloi; diná de almeida lopes monteiro da cruzii escola de enfermagem, universidade de são paulo, brazil: irn, doctoral student, e-mail: josinet@ iipost-doctoral degree in nursing, full professor, e-mail: mtmllf@ corresponding author     abstract this study identifies and analyzes nursing literature on clinical reasoning and critical thinking. Through the review we verified that clinical reasoning develops from scientific and professional knowledge, is permeated by ethical decisions and nurses’ values and also that there are different personal and institutional strategies that might improve the critical thinking and clinical reasoning of nurses. Further research and evaluation of educational programs on clinical reasoning that integrate psychosocial responses to physiological responses of people cared by nurses is needed. Introduction the term clinical reasoning is used in scientific literature to describe the mental processes involved in the care delivered to users of healthcare systems. The word reasoning comes from the latin word raciocinium - calculation, evaluation, use of reason, whereas clinical derives from the greek word klinikos - bed, clinic, place where preventive, curative and palliative procedures are carried out or analysis of the signs and symptoms manifested by patients(1). This article presents an overview of strategies to improve clinical reasoning, based on the scientific nursing literature on this topic. The terms raciocínio clínico and ‘clinical reasoning’ were not found either in mesh (pubmed) or decs (bireme), so the search focused on the use of these words in titles and abstracts. After the initial search, we found that many articles addressed the issue pensamento crítico and ‘critical thinking’, so new searches were conducted using these terms, since these were not indexers either. Specific reasoning in clinical nursing clinical reasoning is present in all nurses’ care actions and decisions: in diagnosing phenomena, in choosing appropriate interventions and evaluating results. The studies on clinical reasoning in nursing can be divided according to date of publication and thematic influence: the 1970s - based on statistical theory, the 1980s - theory of information processing, 1990 - intuitive reasoning. Decisions based on inductive, deductive and intuitive analyses are also permeated by ethical thinking, so that clinical reasoning is fundamentally an interactive process, contextualized in care practice. Thus, several authors have proposed the integration of these logics existent in the concept of clinical reasoning. One proposal of a theoretical model of clinical reasoning integrates three dimensions in clinical judgments: the diagnostic dimension, the therapeutic dimension and the ethical dimension(4). According to this model, the collection and processing of information is strongly influenced by ethno-cultural and motivational aspects of subjects, by the nurses’ interests and philosophical foundations, their beliefs about nursing’s conceptual focus and its social function, and their implicit and explicit values, especially when there is little time for decision-making. A study in the health milieu(5) ratifies the view that the clinical reasoning of specialist nurses occurs in their experience in delivering care and in attributing values for such care. After analyzing interviews carried out with 11 nurses through grounded theory, the author developed a theoretical model of clinical reasoning, which has three main elements: “finding oneself in the challenge of caring,” “caring” and “assigning value to care”. To like providing care or not, value or devalue nursing, be aware of ethical-moral dilemmas or not, to know the patient or not, to trust in one’s own intellectual abilities or not). The author stresses that such features summarize how clinical reasoning is developed based on professional knowledge and attention to nurses’ internal and external environments, which might generate involvement (or not) and nurse’s decision-making about the person to be cared for.

Use of critical thinking and improvement of clinical reasoning clinical reasoning and critical thinking are frequently used in nursing literature as synonyms to describe processes associated with the work of nurses with patients. Other terms are used­­–analytical thinking, clinical judgment, critical judgment, clinical decision-making, creative thinking, problem solving, reflective thinking, diagnostic reasoning–however, the way authors explain concepts related to these terms differ considerably. It does not seem appropriate to consider clinical reasoning and critical thinking as synonymous: critical thinking involves some skills and attitudes necessary for the development of clinical reasoning, which is based on existing knowledge and context (possible goals, needs of patients, available resources). In an analysis of the literature from 1981-2002, 198 attributes for the term critical thinking were found(6). In this and other studies, the authors mentioned that critical thinking is still an evolving concept in nursing, that there is not a sufficiently clear model of critical thinking and recommend further research on the subject (quantitative or qualitative). Critical thinking would not be a method to be learned, but a process, an orientation of the mind, incorporating the cognitive and affective domains(7). Two studies, however, are cited as helpful in understanding critical thinking in nursing: one(8) addresses the characterization of critical thinking of nurses through habits of the mind and cognitive skills, and the second(9), presents a theoretical framework that characterizes the clinical experience as the main ally in improving critical thinking. The enhancement of critical thinking is key to achieving high standards of diagnostic accuracy, since the proposition of diagnoses and interventions is a complex task(10). The strategies that can be employed to improve critical thinking are(11-14): - to reflect on one’s own life and personal values and the development of relationships with patients and one’s profession; - to recognize and promote a work environment that values nurses as knowledgeable workers and invites them to debate and question; - to think about one’s own thinking (for example, following the proposal of the 7 cognitive skills and 10 habits of mind); - to connect with the thinking of others; - to identify and challenge assumptions, inferences and other interpretations; - to consider alternative possibilities and make use of reflective skepticism; - to balance reflective skepticism – one’s own truth and those of others; - to develop sensitivity to contextual factors; - to assess the credibility of evidence; - to recognize and accept intuitive knowledge; - to tolerate the ambiguity of clinical judgments; - to control anxiety about the possibility of being “wrong”. Institutions can also promote the improvement of critical thinking(7, 12-13, 15) through: - the offering of educational opportunities appropriate to different learning styles; - teaching approaches that encourage creativity, testing, discovery and questions (e-mails, texts, poetry, debate); - carrying out activities in small groups; - the use of role development techniques; - reading articles and writing critical essays; - simulations, puzzles and analysis of representations in the media (newspapers, magazines); - analysis of case studies and clinical scenarios; - development of projects proposing changes; - adopting the strategy of pbl (problem based learning); - encouraging the participation of nurses in the decision-making process in clinical units; - encouraging dialogue among peers, which favors proactive processes; - supporting a formal and informal organizational culture for nursing professional development. Potential barriers to improved critical thinking are: conflicts at the work place (repetitive solutions, impaired ability to listen, troubled relationships among nurses or nurses and physicians), the stereotyped use of diagnostic categories, specialization and excessive demands on nurses’ time(13). Methods to evaluate critical thinking the evaluation of critical thinking can be accomplished through several strategies: through instruments, observation of performance in a practical environment, use of questions for clarification, discussions about patient care, problem-solving strategies using case scenarios and the indication of interventions, analysis of written portfolios, documentation of situational analysis and conceptual maps. The found instruments that measure critical thinking were: - watson-glaser critical thinking appraisal(16); - california critical thinking skills test(17); - ennis weir critical thinking essay test(18); - cornell critical thinking test(19); - california critical thinking disposition inventory(20). The main limitations for the use of these instruments in nursing are that they do not capture the specific nature of nursing, do not incorporate nurses’ practical reality, are usually applied to populations of students, are not randomized and do not have well-established psychometric properties. A review of the concept of critical thinking, as well as the evaluation of critical thinking in the clinical context with multiple measurements, is recommended(21-23). There is also specific criticism about existent research - that the use of critical thinking (focused on analytical and individual thinking) would not ensure the development of the nursing profession because it would decrease creativity, the dialogical interaction with people and communities and would not structure practice in nursing theories(21,24). This view seems to be very extreme because, by themselves, skills and attitudes relevant to critical thinking do not limit any human interaction, or the choice of certain theoretical frameworks. There is no need, however, to transform critical thinking into a unit of course content to be taught in the nursing curriculum, which would indicate an overvalued belief in the ability of transformation that this concept would generate. Nonetheless, paradoxically, faculty members and students should be able to observe their own processes of thinking in the cognitive, affective and psychomotor domains, using strategies associated with different contents so that they are able to provide safe and effective care(25). Conclusions constant improvement of clinical reasoning is a challenge for all professionals in the health field. There are several studies in the field of hospital nursing that aim to encourage the improvement of clinical reasoning through activities involving information processing, such as discussions of patients’ cases. However there are few studies favoring the improvement of clinical reasoning, including reflexive strategies, which seem more appropriate when one considers clinical reasoning models that also include psychosocial issues and stress the expression of nurses’ values and the ethical and moral dilemmas they experience. Conducting studies on the improvement of clinical reasoning with the integration of psychosocial responses to the physiological ones is a challenge, since both interfere with the complex health/disease process and demand specific care for individuals and populations. All the contents of this journal, except where otherwise noted, is licensed under a creative commons attribution overview of how to design instruction using critical thinking endations for departmental e-wide grading course: american history: 1600 to us - psychology i. Sample assignment al thinking class: student ures for student al thinking class: grading stuart mill: on instruction, intellectual development, and disciplined al thinking and ate this page from english... What makes the thinking of a nurse different from a doctor, a dentist or an engineer? To think like a nurse requires that we learn the content of nursing; the ideas, concepts and theories of nursing and develop our intellectual capacities and skills so that we become disciplined, self-directed, critical thinkers. Critical thinking is the disciplined, intellectual process of applying skilful reasoning as a guide to belief or action (paul, ennis & norris). In nursing, critical thinking for clinical decision-making is the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care (heaslip). Critical thinking when developed in the practitioner includes adherence to intellectual standards, proficiency in using reasoning, a commitment to develop and maintain intellectual traits of the mind and habits of thought and the competent use of thinking skills and abilities for sound clinical judgments and safe decision-making. Intellectual standards for reasoning practitioners in nursing who are critical thinkers value and adhere to intellectual standards. Critical thinkers strive to be clear, accurate, precise, logical complete, significant and fair when they listen, speak, read and write. All thinking can be examined in light of these standards and as we reflect on the quality of our thinking we begin to recognize when we are being unclear, imprecise, vague or inaccurate. Nurses who are critical thinkers hold all their views and reasoning to these standards as well as, the claims of others such that the quality of nurse's thinking improves over time thus eliminating confusion and ambiguity in the presentation and understanding of thoughts and ideas.

Critical thinking involves trying to figure out something; a problem, an issue, the views of another person, a theory or an idea. To figure things out we need to enter into the thinking of the other person and then to comprehend as best we can the structure of their thinking. I want to understand the interpretations and claims the author is making and the assumptions that underlie his thinking. As i come to understand the author in-depth i will also begin to recognize the strength and weakness of his reasoning. The elements of thought all thinking, if it is purposeful, includes the following elements of thought (paul, 1990). The central concepts, ideas, principles and theories that we use in reasoning about the problem. When nurses reason they use these elements of thought to figure out difficult questions and recognize that their thinking could be flawed or limited by lack of in-depth understanding of the problem at issue therefore, they critically monitor their thinking to ensure that their thinking meets the standards for intellectual thought. In summary, as a critical thinker, i am able to figure out by reading or listening critically what nurse scholars believe about nursing and on what basis nurses act as they practice nursing. To do this i must clearly comprehend the thinking of another person by figuring out the logic of their thinking. I must comprehend clearly the thinking of myself by figuring out my own thoughts on the subject at hand. Finally, i must use intellectual standards to evaluate my thinking and the thinking of others on a given problem such that i can come to a defensible, well reasoned view of the problem and therefore, know what to believe or do in a given circumstance. To do this i must be committed to developing my mind as a self-directed, independent critical thinker. I must value above all else the intellectual traits and habits of thought that critical thinkers possess. Intellectual traits and habits of thought to develop as a critical thinker one must be motivated to develop the attitudes and dispositions of a fair-minded thinker. They continually monitor their thinking; questioning and reflecting on the quality of thinking occurring in how they reason about nursing practice. Critical thinkers in nursing are truth seekers and demonstrate open-mindedness and tolerance for others' views with constant sensitivity to the possibility of their own bias. Nurse's who are critical thinkers value intellectually challenging situations and are self-confident in their well reasoned thoughts. Critical thinking skills and abilities critical thinkers in nursing are skilful in applying intellectual skills for sound reasoning. The focus of classroom and clinical activities is to develop the nurse's understanding of scholarly, academic work through the effective use of intellectual abilities and skills. As you encounter increasingly more complex practice situations you will be required to think through and reason about nursing in greater depth and draw on deeper, more sophisticated comprehension of what it means to be a nurse in clinical practice. All acts in nursing are deeply significant and require of the nurse a mind fully engaged in the practice of nursing. This is the challenge of nursing; critical, reflective practice based on the sound reasoning of intelligent minds committed to safe, effective client care. To accomplish this goal, students will be required to reason about nursing by reading, writing, listening and speaking critically. By doing so you will be thinking critically about nursing and ensuring that you gain in-depth knowledge about nursing as a practice profession. Holistic approach critical listening: a mode of monitoring how we are listening so as to maximize our accurate understanding of what another person is saying. Critical thinkers can listen so as to enter empathetically and analytically into the perspective of others. Critical thinking: 1) disciplined, self-directed thinking which implies the perfection of thinking appropriate to a particular mode or domain of thinking. 3) the art of thinking about your thinking while you are thinking in order to make your thinking better: more clear, more accurate, or more defensible. Critical writing: to express oneself in languages required that one arrange ideas in some relationships to each other. Critical reading: critical reading is an active, intellectually engaged process in which the reader participates in an inner dialogue with the writer. Most people read uncritically and so miss some part of what is expressed while distorting other parts. A critical reader realizes the way in which reading, by its very nature, means entering into a point of view other than our own, the point of view of the writer. A critical reader actively looks for assumptions, key concepts and ideas, reasons and justifications, supporting examples, parallel experiences, implications and consequences, and any other structural features of the written text to interpret and assess it accurately and fairly. Paul, 1990, pp 554 & 545 ) critical speaking: critical speaking is an active process of expressing verbally a point of view, ideas and thoughts such that others attain an in-depth understanding of the speaker's personal perspective on an issue.

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