High quality, safe patient care is dependent upon the healthcare provider’s ability to reason, think, and make judgments about care. Critical thinking, clinical reasoning and judgment are integral to quality clinical decisions and actions. Today’s healthcare landscape has transitioned towards an environment where patients are more medically complex, an aging population with chronic illness, and increased socioeconomic diversity. In order to provide quality patient-centered care, nurses need to develop CT skills in order to provide patients with expert care (Brunt, 2005).
Developing CT is an ethical responsibility of professional nursing practice, and a component for sound clinical judgments and safe decision-making. Thinking in a logical, systematic way, being open to questioning current practice, and reflecting on one’s practice regularly are some key features that strengthen nurses’ CT skills.
The quality of clinical decision-making is influenced by a number of factors, including experience, level of education, time pressures, and also the culture of the nursing unit (Johansson, Pilhammar, & Willman 2009). Developing critical thinking skills has the potential to improve personal practice and patient outcomes.
Critical thinking (CT) is a process used for problem-solving and decision-making. CT is a broad term that encompasses clinical reasoning and clinical judgment. Clinical reasoning (CR) is a process of analyzing information that is relevant to patient care. When data is analyzed, clinical judgments about care is made. The process of analyzing the data, making decisions is the result of CT—thinking critically throughout the entire patient situation, weighing all relevant options and using CT skills to make the best decision for the patient.
While many definitions have been cited for CT (see below), there is a general agreement that CT is a purposeful action that includes analysis, logical reasoning, intuition, and reflection. Making a concerted effort to critically think during patient care leads to safe, effective decisions. Developing CT skills is key for all nurses, they spend the most time with patients, and are able to recognize subtle changes in their patients and are positioned to make quick, precise decisions, often lifesaving. Using effective CT skills allows nurses to shape the outcome of a patient’s experience with the healthcare system.
The concept of critical thinking has been an integral part of professional frameworks for generations, yet scholars still debate a universal accepted definition. Dozens of CT definitions have been published, with each of them sharing some common features, such as reflection, contemplation, holism, and intuition. The list below shares a variety of CT definitions:
“The rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, ideas, statement beliefs and action” (Bandman & Bandman, 1995, p. 7)
A reflective skepticism; “reflecting on the assumptions underlying our and others’ ideas and actions and contemplative alternative ways of thinking and living” (Brookfield, 1987, p. 18)
“The process of purposeful self-regulatory judgment . . . gives reasoned consideration to evidence, context, conceptualization, methods and criteria: (Facione, 2006, p. 21)
“Reasonable and reflective thinking that is focused upon deciding what to believe or do: (Kennedy, Fisher, & Ennis, 1991, p.46)
“An investigation whose purpose is to explore a situation, phenomenon, question, or problem to arrive at a hypothesis or conclusion about it that integrates all available information and that, therefore, can be convincingly justified” (Kurfiss, 1988, p. 37)
“The propensity and skill to engage in an activity with reflective skepticism” (McPeck, 1961, p. 8)
“The deliberative nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting and evaluating information that is both factual and belief based” (National League for Nursing Accrediting Commission, 2000, p. 8)
“A unique kind of purposeful thinking in which the thinker systematically and habitually imposes criteria and intellectual standards upon the thinking, taking charge of the construction of thinking, guiding the construction of the thinking according to the standard, and assessing the effectiveness of the thinking according to the purpose, the criteria and the standards” (Paul, 1993, p. 21)
“In nursing . . . an essential component of professional accountability and quality nursing care [that exhibits] confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance and reflection.” (Scheffer & Ruberfeld, 2000, p. 357)
Concepts Related to Critical Thinking
- A process where nurses integrate and analyze patient data to make decisions about patient care (Simmons, Lanuza, Fonteyn, & Hicks, 2003)
- A process of choosing between different options or alternatives (Thompson & Stapley, 2011)
- A cognitive process used to make judgments based on patient data and cues. Nurses interpret a patient’s concerns, needs, and health problems for proper decision-making (Tanner, 2006, p. 204)
- Outcome of critical thinking in nursing practice; judgments begin with the end goal in mind; outcomes are met, involves evidence (Pesut, 2001)
- Arriving at a conclusion based on relatively small amounts of knowledge and/or information (Westcott, 1968)
- “Drawing inferences or conclusions that are supported in or justified by evidence (Alfaro-LeFevre, 2015, p. 232)
- A purposeful analysis of one’s current and past actions (Schon, 1987)
According to Benner’s (1984) novice to expert model, expert nurses have an intuitive grasp of their patients’ problems, their approach is fluid, flexible, and proficient. Compared to novice nurses, they are more task oriented and require frequent verbal and physical cues to provide care.
Novice nurses are challenged with overcoming a knowledge gap, leading to less effective decisions and actions. Compared to experienced nurses, who are challenged with traditional thinking, leading to less effective clinical judgments and decisions (Cappelletti, Engel, & Prentice, 2014). Successful CR and decision-making require a balance of intuition and evidence-based thinking to make effective clinical decisions (Simmons et al., 2003).
Andersson, Klang, and Petersson (2012) found nurses who were specialized in their setting (more experience) used a more holistic approach to making decisions (p. 876), compared to less experienced nurses who used a “task-and action-oriented approach” (p. 873). Gaining experience and knowledge is one way to improve thinking and decision-making, though improving CT skills can close the gap. Being open-minded, self-aware, and reflective offers nurses important information that can improve CR and decision-making. Clinical judgment (akin to CR) improves over time with nurses who uses reflection as a guide for decisions and actions (Cappelletti et al., 2014).
Critical Thinking and Clinical Decision-Making
Lee, Abdullah, Subramanian, Bachmann, and Ong (2017) conducted an integrated review on nine studies to determine whether effective CT impacted clinical decision-making. Four studies found CT impacted decision-making, though five studies did not find a correlation. Due to poor study designs, Lee et al. (2017) could not come to a clear decision on whether there was as significant correlation.
CT continues to be an important factor for problem-solving, regardless if studies can confirm a correlation to decision-making. Developing CT skills, such as reflection, intuition, and logical reasoning, are essential behaviors that lead to a patient-centered approach. Nurses who stop and think about what worked for a patient in the past, may consider the same option again, or may choose an alternative. Considering all possibilities with the patient’s best interest in mind is part of CT and making clinical decisions.
Researchers will continue to study the impact of CT on nursing care. Nurse educators will continue emphasize CT in the curriculum and assist students in developing CT skills throughout all levels of education as they offer students tools and methods for problem-solving.
Rubenfeld and Scheffer (2001) explain the essence of CT in nursing practice:
Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge (2001, p. 125).
Critical thinking and clinical reasoning are weaved throughout the Nursing Scope and Standards of Practice and Code of Ethics (American Nurses Association [ANA], 2015c). The nursing process itself, Standards 1-6, are essentially a tool used for clinical reasoning. The standards require core cognitive competencies and guide nurses to use patient data to make effective clinical decisions.
Critical thinking and clinical reasoning are integrated throughout the curriculum for baccalaureate nursing education. Essential I: Liberal Education for Baccalaureate Generalist Nursing Practice (American Association of Colleges of Nursing, 2008), states, “Nursing graduates with a liberal education exercise appropriate clinical judgment, understand the reasoning behind policies and standards, and accept responsibility for continued development of self and the discipline of nursing.” (p. 11).
Additionally, a liberal arts education exposes nurses to coursework that educates nurses in a variety of general education areas, stating: “Skills of inquiry, analysis, critical thinking, and communication in a variety of modes, including the written and spoken word, prepare baccalaureate graduates to involve others in the common good through use of information technologies, team work, and interprofessional problem solving.” (p. 11).
Nurses are taught to approach care holistically, problem-solve in a systematic way by critically examining each element of care. Through careful communication and interprofessional collaboration, critical thinking is expanded as the nurse uses general knowledge, gains experiences, and is open to examining every facet of his or her practice.
Reflection is a powerful tool for recognizing errors in judgment, questioning one’s response, and ultimately improving outcomes. Below are two practice examples that illustrate the power of reflective thinking with interprofessional communication and patient care:
Novice and senior nurse communication
- Problem: A novice nurse is struggling with inserting IVs just about every shift. One day, the nurse asks the same more experienced nurse for help again. The nurse listens though does not turn around to face the nurse when questioned, and responds in a swift, aggressive way, “I’m swamped, we have no aides today and I’m falling behind with everything. I’ll help you when I get time, but it’s going to be a while.”
- Impact: The nurse’s patient is at risk for injury without an IV line. The patient may be upset and unsatisfied with care knowing the IV was out for an extended period of time. The nurse feels dejected, does not feel like she is a valued team member, and loses further confidence in her abilities. She considers quitting her job or transferring to another unit.
- Reflection: The experienced nurse realizes she was not empathetic to the nurse’s needs and impatient and aggressive in her response. She realizes the nurse is new and doesn’t have much confidence in her skills yet. She also knows the nurse is probably disappointed in the lack of teamwork and camaraderie. Most of all, she feels bad about disrespecting her coworker.
- Impact of reflection: After reflection of the situation, the nurse apologizes for her poor behavior. She states she will work with her each shift they work together, she will share personal tips and review educational materials. Additionally, she will offer to have her observe her IV insertions until she has mastered the skill. She will also make sure the new nurse feels like she is part of the team, not just the new nurse.
- Problem: The oncoming nurse enters his patient room for the first time and finds the foley bag is full and the patient is complaining of abdominal discomfort.
- Impact: The patient is at risk for infection and may be disappointed with the quality of nursing care.
- Reflection: The oncoming nurse realizes there is always one or two problems or inconsistencies when he assesses his patients for the first time. He knows the outgoing nurses are skilled and provide quality care and considers another reason for the errors. After thinking about this for a while, he believes the process for shift report can help reduce change of shift errors. The nurse realizes there needs to be a better way for sharing patient information during change of shift.
- Impact of reflection: The nurse researches evidence-based practices to improve safety and quality during shift change. The nurse shares a copy of the review article on bedside report with his manager. The nurse offers to be a change champion on the unit to implement a new process for shift report.
Long-term impact of reflection:
- Improved team cohesiveness, nurse retention and job satisfaction
- Improved patient satisfaction experience and quality of care, leading to higher insurance reimbursement
Glynn (2012) states reflective thinking enhances clinical judgment and gives nurses the opportunity to learn from actual or perceived errors. In regard to the communication scenario, it’s through reflection that nurses can think about their behaviors and responses. Reflect on the message for clarity, and whether it was shared in an empathetic and respective way.
As discussed in the communication chapter, poor communication is the number one reason for medication errors and sentinel events. Through reflection, miscommunication can be identified, solutions found, and implemented. In order for this process to come to fruition, nurses must take the initiative to reflect on their practice.
Creative thinking helps nurses generate alternative approaches to clinical decision-making. This type of thinking works especially well with medically complex patients, where care needs to be individualized to reach desired outcomes.
Akin to the concept of “thinking outside the box”, finding a novel approach to patient care prevents traditional, stagnant thinking. Choosing alternatives based solely on creative thinking can negatively impact outcomes unless it is paired with the skill of critical thinking. Critical thinking requires the nurse to view the patient holistically,
Nurses access knowledge unconsciously and trust this information as fact. Often referred to as a “gut feeling”, intuition comes naturally. Intuition is not a tool that is sought out at will, instead the knowledge emerges naturally during a care experience, resulting in firm actions and decisions. Intuition is a measure of professional expertise (Smith, Thurkettle, & Cruz, 2004), a type of clinical judgement that develops over time (Benner, 1984). Since this knowledge is considered intangible or irrelevant, some disregard it, though many studies have shown its positive influence in making accurate decisions and improving the quality of care (Robert, Tilley & Petersen, 2014).
- Nurses will recognize something about their patient that they can’t explain, and will make decisions on care without concrete evidence to back up their actions. Such actions can be lifesaving (Billay, Myrick, Luhanga & Yonge 2007). Each clinical experience acts as a learning experience for which lessons are learned and applied to the next experience (McCutcheon & Pincombe, 2001).
- Holtslander (2008) states Carper’s (1978) seminal work on the fundamental ways of knowing was published as a reaction to the overemphasis of empirical (scientific) knowledge in nursing practice. One of the four ways of knowing, called aesthetic knowing, explains the component of art within nursing practice, an, awareness of the patient, viewing the patient as unique. This viewpoint allows nurses to consider more than just empirical knowledge to guide practice.
As discussed earlier, CT encompasses a broad range of reasoning skills that lead to effective decision-making. Through the process of clinical reasoning and judgment, nurses make best choice after assembling and analyzing patient data.
White (2003) studied senior baccalaureate nurses and found the following five themes were essential to developing clinical decision-making skills:
- Gaining confidence in clinical skills
- Building relationships with staff
- Connecting with patients
- Gaining comfort in self as a nurse
- Understanding the clinical picture
Scheffer and Rubenfeld (2000) found CT is comprised of affective and cognitive components. Affective components refer to an individual’s feelings and attitudes, and cognitive components refer to thought processes. The CT components include 10 habits of the mind (affective components) and seven skills (cognitive components), as follows:
Habits of the mind
- Confidence: assurance of one’s reasoning abilities
- Contextual perspective: considerate of the whole situation, including relationships, background and environment relevant to some happening
- Creativity: intellectual inventiveness used to generate, discover, or restructure ideas; imagining alternatives
- Flexibility: capacity to adapt, accommodate, modify or change thoughts, ideas, and behaviors
- Inquisitiveness: an eagerness to know by seeking knowledge and understanding through observation and thoughtful questioning in order to explore possibilities and alternatives
- Intellectual integrity: seeking the truth through sincere, honest processes, even if the results are contrary to one’s assumptions and beliefs
- Intuition: insightful sense of knowing without conscious use of reason
- Open-mindedness: a viewpoint characterized by being receptive to divergent views and sensitive to one’s biases
- Perseverance: pursuit of a course with determination to overcome obstacles
- Reflection: contemplation upon a subject, especially one’s assumptions and thinking for the purposes of deeper understanding and self-evaluation (Scheffer & Rubenfeld, 2000, p. 358)
- Analyzing: separating or breaking a whole into parts to discover their nature, function and relationships
- Applying standards: judging according to established personal, professional or social rules or criteria
- Discriminating: recognizing differences and similarities among things or situations and distinguishing carefully as to category or rank
- Information seeking: searching for evidence, facts or knowledge by identifying relevant sources and gathering objective, subjective, historical, and current data from those sources
- Logical reasoning: drawing inferences or conclusions that are supported in or justified by evidence
- Predicting: envisioning a plan and its consequences
- Transforming knowledge: changing or converting the condition, nature, form, or function of concepts among contexts (Scheffer & Rubenfeld, 2000, p. 358)
Development of CT is a lifelong process that requires nurses to be self-aware, and to use knowledge and experience as a tool to become a critical thinker. As nurses move along the continuum from novice to expert, one’s competence and ability to critically think will expand (Brunt, 2005).