compare and contrast problem solving and nursing process

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)


Assessment	Noticing	Recognize Cues
Diagnosis/Analysis	Interpreting	Analyze Cues
Diagnosis/Analysis	Interpreting	Prioritize Hypotheses
Planning	Responding	Generate Solutions
Implementation	Responding	Take Action
Evaluation	Reflecting	Evaluate Outcomes

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:


: The nurse identifies the actual and potential client problem(s) based on review and interpretation of the client data.	: The nurse reviews the client data and determines what they mean. For example, the nurse may identify certain data that are consistent with common diseases or disorders. Or, the nurse may identify potential complications for which the client is at risk based on the assessment data.
The nurse performs appropriate interventions to meet the desired client outcomes. For example, if the client reports acute postoperative ORIF pain of 8/10, the nurse might administer an analgesic.	: The nurse performs an action which could be an intervention or an assessment. For example, if a client reports acute postoperative ORIF pain of 8/10, the nurse might perform a neurovascular assessment of the extremity to determine if the pain is due to decreased peripheral perfusion or the surgical incision. While that action is an assessment, it is also an action or intervention.

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.

The 5 Nursing Process Steps – (Learn Each Step in Detail)

compare and contrast problem solving and nursing process

One of the most important tools a nurse can use in practice is the nursing process. Although nursing schools teach first-year students about the nursing process, some nurses fail to grasp the impact its proper use can have on patient care. In this article, I will share information about the nursing process, its history, its purpose, its main characteristics, and the 5 steps involved in carrying out the nursing process. After reading this article, you will be able to answer the question, “what is the nursing process” and understand what is involved in each of the 5 steps of the nursing process. Additionally, throughout this article, after discussing a step of the nursing process, I will share an example of how the nurse would proceed with that step. For this article’s purposes, we will use information about the following patient: Mr. Collie, a fifty-four-year-old white male being admitted to the Medical-Surgical floor for acute congestive heart failure.

What is the Nursing Process in Simple Words?

When was the nursing process developed, who developed the nursing process, what is the purpose of the nursing process, what are the 7 main characteristics of the nursing process, 1. within the legal scope of practice, 2. based on sound knowledge, 4. client-centered, 5. goal-directed, 6. prioritized, 7. dynamic and cyclical, how many steps are there in the nursing process, what are the 5 steps of the nursing process, step #1: assessment phase.

The first phase of the nursing process is the assessment phase. In this phase, the nurse collects and organizes data related to the patient. Data includes information about the patient, family, caregivers, or the patient's community or environment as it is relevant to his health and well-being.

All phases of the nursing process are essential. The following are a few reasons why the assessment phase is important for nurses to provide care.

In the assessment phase of the nursing process steps, the nurse gathers all pertinent information that will be used to establish a care plan.
Every other step of the nursing process builds upon the previous. Without a thorough assessment, the other steps of nursing care may be negatively impacted, resulting in unfavorable outcomes.
When assessments are performed correctly, they help reduce risks to patient safety which could occur when symptoms or other factors are not considered.

The assessment phase of the nursing process involves gathering information about the patient which is used to guide planning care, setting goals for recovery, and evaluating patient progress. Nurses can obtain information about the patient by implementing the following objectives.

The patient is the nurse’s main source of information. Therefore, it is essential to establish rapport with them as soon as possible.

with the patient's family or caregivers when appropriate. Family members, friends, or other caregivers often offer insight into what is going on with the patient. It is important for nurses to listen to the patient’s support people and gather any information available.

When the patient feels comfortable, it makes it easier to get the necessary information that will be used to establish a plan of care. The patient interview is one of the main sources of information used to plan patient care.

Any information that is measurable or observable such as vital signs and test results is considered objective data.

Subjective data is information gathered from the patient.

Assessments are vital to the nursing process. The information gathered in the assessment phase impacts every component of patient care. Nurses must demonstrate excellent verbal and written communication skills, strong attention to detail, and possess an in-depth understanding of body systems. The most frequently used clinical skills for patient assessment are inspection, percussion, palpation, and auscultation.

The assessment phase is a critical component of the nursing process. Information gathered in this phase is used to establish a foundation upon which all patient care moving forward is established. Remember, it is normal for patients to feel nervous or fearful when they are sick and in an unfamiliar place, like a hospital. Therefore, the nurse needs to establish an environment conducive to patient comfort.

The assessment may include but is not limited to, the following aspects: environmental, physical, cultural, psychological, safety, and psychosocial assessments.

The following is a guideline of what should happen during the assessment phase.

During the assessment phase, the nurse collects objective and subjective data using proven methods to assess the patient. The most common methods for collecting data are the patient interview, physical examination, and observation.

The patient interview is a deliberate or intended communication or conversation with the patient. It is used to obtain information, identify problems that concern the patient and/or the nurse, evaluate changes, provide support, and educate the patient and family/caregivers.

The nurse will also conduct a head-to-toe nursing assessment addressing each body system and noting any abnormalities, complaints, or concerns. Observation requires the nurse to use all their senses (sight, touch, smell, hearing) to learn about the patient.

After collecting data, the nurse must organize and validate data and document about the patient's health status. Validation is the process of verifying data to be sure it is factual and accurate. Nurses must be careful to not come to conclusions without adequate data to support their conclusion.

It is also necessary to understand the difference between inferences and cues. Cues are signals the patient uses to alert the nurse about a concern or question or objective data the nurse can observe or measure. Inferences are the nurse's conclusion or interpretation based on cues.

For example, the patient may complain about a painful incision two days post-operatively, and the nurse may observe the incision site is red and feels hot. These are cues. The nurse then makes an inference that the operative incision is infected.

After data from the assessment is collected, organized, and validated, it must be recorded. One thing I always tell nursing students and cannot stress enough to any nurse is, "If you didn't document it, you didn't do it." While that may seem harsh, from a legal standpoint, if a nurse is asked to verify care or treatment and there is no supporting documentation, there is no way to prove the care occurred.

Thorough documentation is one of the best ways for everyone involved in patient care to be aware of changes in the patient's status, and it helps promote effective collaboration within the interdisciplinary team.

While all the nursing process steps are essential, without a thorough assessment, the other steps of the nursing process are not as easy to follow through. Nurses must recognize barriers that could impede the assessment phase and find ways to overcome them. The following are five common challenges you may face during the assessment phase and some suggestions on how to overcome them.

Limited Time There are days when nurses feel as though there aren’t enough hours to accomplish all the work that needs to be done. When you are short-staffed or have several patients waiting for a nursing assessment before you can initiate care, it can feel a bit overwhelming.

Even on the busiest of days, it is important for nurses to perform thorough nursing assessments for all patients assigned to them. That means it is necessary to learn to manage time efficiently. The first step in overcoming limited time is to be familiar with the format or forms your employer uses to record assessments.

For example, the Health Information Technology for Economic and Clinical Health Act of 2009 advanced the adoption and use of electronic health records. Nearly one hundred percent of hospitals use some type of EHR. Electronic health records have helped improve workflow by eliminating time spent pulling physical charts or documenting in paper charts.

Interruptions It is not uncommon for interruptions to occur when nurses are performing assessments. While some interruptions may be necessary, all are not. Interruptions during patient assessments can delay care and could result in errors or omissions.

The best way to overcome the challenge of interruptions during the assessment step of the nursing process is to provide for privacy before you begin the assessment.

Whether you are working in triage, assessing a patient newly admitted to your floor, or in a busy emergency room, it is possible to reduce interruption. Pull the privacy curtain closed if you are in an area with more than one patient or several staff close by. Some facilities use "Do Not Disturb" or "Room in Use" signs to provide privacy for nurses and patients.

Inexperience Every nurse knows the importance of a good nursing assessment. Newly graduated nurses are less experienced than other nurses and may feel uneasy about performing a nursing assessment alone. Additionally, if your facility changes its documentation format or implements a new program for charting, and you've not yet used the program, your inexperience could pose a challenge when doing an assessment.

The only way to overcome inexperience is to become experienced. Nursing assessments are typically classified as either a Complete Health Assessment or a Problem-Focused Assessment. Know which type of assessment you need to perform.

Gather basic equipment: gloves, thermometer, blood pressure cuff, stethoscope, penlight, and watch. Establish a sense of trust and respect between the patient and yourself.

No matter which type of assessment you perform, it should be systematic, making sure you cover each body system. If you assess each body system and make notes about what is normal/abnormal, you decrease the chances of omissions in documentation. Remember, take your time, trust your instincts, and if you need help, ask for it.

Patient Anxiety Patient anxiety can create a significant challenge for nurses during a patient assessment. Anxiety can hinder communication making it difficult to gather all the necessary data. If anxiety is bad enough, it can cause changes in vital signs, which could be misinterpreted as something more than an anxious reaction.

Before beginning an assessment, take the time to make your patient comfortable. While you may not have time for a long conversation or "get to know you" session, you can ease your patient's anxiety by being calm and friendly.

Some questions may make patients feel uncomfortable, especially teenagers. Allow them time to answer your questions without feeling rushed. Verify their understanding by asking if they can explain what you've discussed in their own words.

Remember, everyone gets nervous or anxious at times, and when we are sick, it can be worse. It's nothing personal against you or your skills. Make everything about the patient.

Patients Not Being Forthcoming About Symptoms Whether it is fear of the unknown, embarrassment, or another reason, there are times when patients may be apprehensive about sharing personal information.

Lack of information or omission of details that the patient may think is irrelevant may negatively impact the process of care planning. Therefore, while it is easy to understand a patient's apprehension, it is crucial for nurses to gather as much information as possible when performing a nursing assessment.

It can be easy to feel frustrated if a patient is not forthcoming about symptoms during an assessment. Keep in mind, being sick and needing medical care can be frightening.

The best way to get patients to talk to you is to be accepting of them, no matter what. Be sure to tell your patient you are there for them and will work with them to help them get better. When you say things like you will "work with them," it lets your patient know you are going to do your part, but you expect them to do theirs as well.

If you feel like your patient is withholding information, instead of making an accusation, try to rephrase the question. Make your questions clear so the patient knows what information you need.

The format for recording nursing assessment data may vary from one facility to another. However, the information gathered for the assessment is relatively similar. The following are examples of content the nurse should include in the initial nursing assessment phase of the nursing process.

04/19/22 13.30
J. Mock, LPN
54 yrs. 2 mos. M 6’2” 268lbs 4oz
Dr. Michael Coulvan
03/04/1968

CHF, acute
Temp 98.8, Resp. 20, Pulse 76, BP 136/80

NKDA, no food allergies

Jerold R. Collie
123 Blakely Lane, Clayton, MO. 1234
(318) 555-1234

Alert & Oriented x3; PERRLA, Unaided hearing; Bilateral hand grips equal; Bilateral foot push equal; no evidence of tremors; denies tingling, burning, loss of consciousness, hallucinations, disorientation, visual disturbances, or hx/o brain injury or stroke.

Pulses present, regular, and strong: x2 upper extremities (Radial); present X2 lower extremities (Pedal); heart rate regular, strong; capillary refill <3 second upper and lower extremities

Respirations even, labored; Dyspnea on exertion; Lungs: Bilateral rales in lung bases; Cough: Nonproductive; Oxygen: 2L per NC

Reports 10 lb weight gain in last two weeks. Continent of bowel; Last BM 4/19/22; Laxatives: No, Enemas: No; Hx of Constipation: No

Continent of bladder; Uses urinal prn; urinal emptied of approximately 200 cc clear, amber urine

Skin is pink, warm, and dry; Mucous membranes pink and moist

Reports pain and stiffness in joints of hands mostly in the a.m.; denies history of gout, arthritis, bursitis, or fractures; Negative paralysis; Negative contractures, No congenital anomalies; No prosthetic devices; Able to carry out most ADLs with minimal assist but may require periods of rest r/t dyspnea with exertion; Uses walker for ambulation.

Headache Constant, throbbing 5

Full weight-bearing; Ambulatory with 1 person assist; Client uses walker occasionally; No supportive devices

Client is alert, friendly, and answers questions readily; Comprehension: rapid.

Divorced; Client lives alone in his own home; Has two adult children who live nearby and visit frequently; Client reports he has several close friends who call or visit often.

History of hypertension; Denies any other medical issues prior to this admission.

Client reports previous substance abuse, methamphetamine was his drug of choice. Client states he has been substance and alcohol-free for three years.

Paternal hx/o CHF, HTN, and Lung Ca. Maternal hx/o DM, and HTN.

*In addition to the information the nurse will gather during her assessment, the assessment phase of the nursing process includes gathering objective data such as copies of laboratory or diagnostic testing. If the facility uses electronic health records, as most do, this information will probably already be uploaded to the patient’s electronic chart. It is, however, the nurse’s responsibility to gather and verify all data is available.

The assessment phase of the nursing process lays the foundation upon which all other nursing process steps build. The information gathered during the nursing assessment tells the nurse about the patient’s history, current complaints, medications, and any other pertinent information that may impact care planning. Without a thorough, proper patient assessment, it is impossible to develop a patient-specific care plan.

Nurses collect data during the assessment phase by communicating with the patient, spouse, and caregivers, reading patient records, nursing observation, and collecting measurable data such as vital signs.

Subjective data is any information the nurse collects through communication. A few examples of subjective data include the reason for the patient’s visit to the doctor, patient or family medical history, medications the patient is taking, and any symptoms such as chills, aches, or pain.

Objective data is any measurable information obtained from sources other than the patient. For example, the patient’s height, weight, vital signs, and laboratory or diagnostic test results are objective data collected during a patient assessment.

Nurses collect verbal data by talking to patients, their family members (when appropriate), and other members of the healthcare team. Subjective matter is usually often the result of verbal communication during the patient interview.

Nonverbal data is collected during the assessment phase of the nursing process by observing the patient's body language, reading patient charts, or medical test results. For example, the patient may not offer a verbal report of pain, but the nurse may observe him clutching or guarding his side, which could indicate pain.

The nurse can use the nonverbal data to form assessment questions as a way of following up with what she has observed or read.

The primary source of data collection during the nursing assessment is the patient. Other sources include family, friends, caregivers, and other members of the healthcare team. Data are also collected from laboratory or diagnostic reports, the patient’s medical records, and the nurse’s observations.

Tertiary data are data gathered from sources such as the patient's chart, lab, or x-ray reports. Nurses may also use tertiary sources such as diagnostic manuals or textbooks to verify or compare information.

Nurses can use a few methods to verify the accuracy of data collected during the assessment phase of the nursing process.

A few ways to verify data is to clarify information with the patient by asking additional questions, compare objective and subjective data to see if there are any discrepancies, recheck data by repeating the assessment, and verifying data with another nurse or healthcare team member.

One example of verifying data is to perform repeat vital sign check. For instance, if Mr. Jones has a blood pressure reading of 220/100 but has no history of hypertension, the nurse should retake his blood pressure to validate its accuracy. If the nurse feels it is necessary, they may use different equipment or ask someone else to perform the vital sign check to check for accuracy.

The primary methods nurses use to collect data are observation, patient interviews, and head-to-toe assessments.

Nurses use various tools and equipment to help gather data about patients. A few examples of tools and equipment nurses use include a stethoscope, blood pressure cuff, thermometer, pulse oximeter, and scales. You may need a glucometer and lancets to check blood sugar, as well.

Step #2: Diagnosis Phase

Diagnosis is the second phase of the nursing process. It is also designated by the American Nurses Association as the second Standard of Practice. The standard is defined by the ANA stating, "The registered nurse’s analysis of assessment data to determine actual or potential diagnoses, problems, and issues.” The nursing diagnosis reflects the nurse’s clinical judgment about a patient’s response to potential or actual health issues or needs.

Before a plan of care can be established, nurses must determine which nursing diagnosis/diagnoses apply to their patients. The following are a few reasons why the diagnosis phase of the nursing process is important.

The diagnosis phase of the nursing process helps nurses view the patient from a holistic perspective.
Using a nursing diagnosis can lead to higher quality nursing care and improved patient safety, as care is based upon the needs outlined in the diagnosis.
The diagnosis phase helps increase the nurse’s awareness and can strengthen their professional role.

In the diagnosis phase, the nurse follows a set of objectives that end with developing the nursing diagnosis/diagnoses used to establish patient care. These are the main objectives of the diagnosis phase:

The nurse must identify what problem the patient is experiencing related to the medical diagnosis.

Any situation or problem that could result because of the patient’s medical diagnosis is a risk factor for a nursing diagnosis and must be addressed.

All data gathered during the assessment phase of the nursing process must be compiled, validated, and analyzed to support an appropriate nursing diagnosis.

Nursing theories involve an organized framework of concepts and purposes that guide nursing practices. A nurse’s theory is their unique perspective about the patient’s status and measures needed to improve the patient’s outcome.

After identifying problems and risk factors, analyzing data, and developing a nursing theory, the nurse can then establish a nursing diagnosis or diagnoses which is used to establish a nursing care plan.

Nurses will utilize several skills in the diagnosis phase of the nursing process steps. Critical thinking, problem-solving, and communication skills are necessary to work in this phase. Nurses must also demonstrate the ability to prioritize patient needs.

The diagnosis phase of the nursing process involves three main steps: data analysis, identification of the patient’s health problems, risks, and strengths, and formation of diagnostic statements.

Data Analysis involves the nurse clustering cues, comparing patient data against standards, and identifying inconsistencies or gaps in the data.

After data analysis, the nurse will work with the client to identify actual, risk, and possible diagnoses. In this step, the nurse will determine if an identified problem classifies as a nursing diagnosis, medical diagnosis, or collaborative diagnosis/problem. It is important to involve the patient in this step whenever possible, to identify the client's resources, coping abilities, and strengths.

The last step of the diagnosis phase involves creating a nursing diagnosis. The nursing diagnosis may have up to three components: a NANDA-I approved , a which defines the cause of the diagnosis, and an as that uses patient-specific data to justify the diagnosis and diagnostic statement.

The nursing diagnosis is different from a medical diagnosis. It requires careful consideration of the patient’s individual problems, situation, and needs to develop appropriate nursing diagnoses. Here are a few examples of challenges that may occur during the diagnosis phase of the nursing process and some suggestions on how to overcome them.

Creating a Nursing Diagnosis Is Often a Complex Process Although there are resources and guidelines to help nurses develop nursing diagnoses, the process can be complex. Before nurses can create a nursing diagnosis, they must interview and assess the patient and review data, which can be time-consuming.

While you may not overcome the complexities of creating nursing diagnoses, it is possible to make the process easier.

For example, be sure to review all objective data, including baseline vitals, laboratory or diagnostic test results, and subjective data. Make sure the patient's medical history is accurate and find answers to any questions not yet answered. The more information you have to work with, the easier it becomes to develop diagnoses based on that data.

Nurses May Interpret Data Differently Some data are taken at face value, such as laboratory or diagnostic test results or vital signs, which are measurable. Subjective data is data reported by the patient. It is information given to the nurse by the patient based on the patient’s perception of what he is feeling. Despite efforts to appreciate the patient’s perception, nurses sometimes interpret data differently. When this happens, it can create a challenge when developing nursing diagnoses for the nursing care plan.

It is essential for nurses to have a clear understanding of which data is objective or subjective. Once the differences in data are realized, nurses must be careful to not rely upon only one piece of data or their own perception of data to create a nursing diagnosis. Instead, establishing nursing diagnoses should be a collaborative effort among the nursing care team. Nurses assigned to a patient’s care should discuss their perception of data and make informed decisions based on all data.

Insufficient Data to Support a Nursing Diagnosis Nurses must review all available data, including but not limited to subjective and objective findings, lab and diagnostic test results, and narrative notes from the patient interview before a nursing diagnosis can be made. If the nurse does not obtain enough data during the assessment, it will be difficult to establish appropriate nursing diagnoses.

The best way to overcome the challenge of insufficient data is to perform a thorough assessment, patient and/or family interview, and make sure all results from any tests are readily available for review.

If you have reached the diagnosis phase of the nursing process and find you do not have enough data, go back to the sources of information and gather data. You may find that you need to reassess the patient or ask additional questions.

Lack of Communication Between Nursing Staff Although patients are assigned a primary nurse, nursing is a team effort that requires collaboration. When there is a lack of communication between nursing team members, information may be inadvertently omitted from notes or reports. This failure in communication makes getting a complete view of the patient's status difficult, resulting in challenges in developing appropriate nursing diagnoses.

Nurses must be alert and responsive to patients and one another. End of shift report is an excellent way for nurses to communicate changes in a patient's status. Nurses should make notes of anything pertinent before handing off care to the next shift nurse and clearly communicate concerns about the patient's progress or lack thereof.

When the lack of communication is resolved, nurses can compare information to use when establishing nursing diagnoses, ensuring the patient gets the best care possible.

Deciding the Type of Nursing Diagnose to Use There are four main types of nursing diagnoses: Problem-focused, Risk, Health Promotion, and Syndrome.

When nurses get to the diagnosis phase of the nursing process, they must determine which type or types of diagnoses are relevant to their patients. While experienced nurses may find it easier to decide which type of diagnosis to use, new or less experienced nurses may find it challenging.

Additionally, some healthcare facilities prefer nurses to use a specific type of diagnosis, which can be frustrating, especially if the nurse feels a different type of nursing diagnosis is more appropriate.

Overcoming the challenge of choosing the right type of nursing diagnosis requires understanding when each type is most appropriate. If the nurse has sufficient data from the assessment phase, they can then identify potential diagnoses and determine which type of diagnosis to use.

The following are the four types of nursing diagnoses and examples of each.

focus on a specific problem the patient is experiencing. This type of diagnosis has three components: a nursing diagnosis, related factors or diagnosis statement, and defining characteristics or the as evidenced by statement.

For example, the patient with chronic obstructive pulmonary disease (COPD) could have a problem-focused nursing diagnosis of "Ineffective Breathing Pattern related to decreased lung expansion as evidenced by dyspnea and ineffective cough."

identify potential problems or risks the patient may experience because of his medical diagnosis. A risk nursing diagnosis typically has two components, the diagnosis, and risk factors. The patient with COPD may have a risk diagnosis of "Risk for Ineffective Airway Clearance related to decreased lung capacity."

(a.k.a. Wellness Nursing Diagnosis) is based on the nurse's clinical judgment about the patient's desire and motivation to increase his well-being. These diagnoses focus on the client's transition from one level of wellness to a higher level of wellness.

Health promotion nursing diagnoses are usually one-part statements or include only a diagnostic statement. The COPD patient's Health Promotion Nursing Diagnosis may state "Readiness for Enhanced Wellness."

are clinical judgments related to a cluster of risk nursing diagnoses predicted to occur because of a particular event or situation. The syndrome nursing diagnosis is also written as a one-part statement. For example, the COPD patient may have a syndrome diagnosis of “Ineffective Airway Clearance, Impaired Gas Exchange, Ineffective Breathing Pattern.”

After reviewing the data collected in the assessment phase of the nursing process, the nurse determines which type of diagnosis is appropriate and moves to the planning phase. In the case of Mr. Collie, the nurse chooses a problem-focused nursing diagnosis and a risk nursing diagnosis.

• Decreased Cardiac Output r/t impaired contractility and increased preload and afterload AEB irregular heartrate of 118, fatigue, and dyspnea on exertion (Problem-focused)
• Risk for Impaired Skin Integrity r/t edema, decreased tissue perfusion, and decreased activity. (Risk)

Although they share similarities, nursing and medical diagnoses are different. The nursing diagnosis is used by a nurse to identify a patient’s actual or potential risk(s), wellness, or responses to a health problem, condition, or state. A medical diagnosis is used by physicians to determine or identify a specific condition, disease, or pathologic state.

NANDA-I stands for North American Nursing Diagnosis Association International. NANDA-I is a professional organization that researches, develops, disseminates, and refines nursing diagnosis terminology. The organization was formed as NANDA in 1982, it was renamed NANDA-I in 2002 because of its increased worldwide membership.

Each nursing diagnosis is made up of four main components: problem and its definition, etiology, risk factors, and defining characteristics.

The primary purpose of establishing a nursing diagnosis is to communicate the healthcare needs of the patient among members of the healthcare team and within the delivery system. The nursing diagnosis allows nurses to facilitate individualized care for the patient and family and strengthens the profession.

The nursing diagnosis serves as the basis for selecting nursing interventions, which have a significant impact on patient outcomes. If an accurate nursing diagnosis is not chosen, the plan of care and subsequent nursing interventions may not address the patient’s issues appropriately resulting in negative patient outcomes.

Nursing diagnoses are ranked in order of importance. Immediate life-threatening problems or issues related to survival are given the highest priority.

Nursing diagnoses focus on the patient’s response to health conditions, and patients often respond differently. Therefore, it is not uncommon for patients with the same medical diagnosis to have different nursing diagnoses.

Step #3: Planning Phase

The planning phase of the nursing process is the stage where nursing care plans that outline goals and outcomes are created. The goals and outcomes formulated during this phase directly impact patient care and are based on evidence-based nursing practices.

The planning phase of the nursing process is essential in promoting high-quality patient care. It is considered the framework upon which scientific nursing practice is based. The following are three of the top reasons why the planning phase is so important.

Care planning provides direction for personalized patient care based on the client's unique needs.
The planning phase enhances communication between patients, nurses, and other members of the healthcare team.
Planning encourages continuity of care across the healthcare continuum and promotes positive patient outcomes.

The American Nurses Association's Standards of Clinical Nursing Practice identifies planning as one of the essential principles for promoting the delivery of competent nursing care. The planning phase of the nursing process has five main objectives, all of which focus on nursing interventions to promote positive patient outcomes. The following are the main objectives of the planning phase.

The nurse reviews the nursing diagnoses and prioritizes them according to physiological and psychological importance. This step helps the nurse organize the patient’s nursing diagnoses into a format that promotes effective planning.

This objective of the planning phase of the nursing process involves setting goals related to each diagnosis. Goal setting helps to provide guidelines for nursing interventions and establishes criteria by which the care plan's effectiveness is evaluated.

Remember the acronym SMART when developing goals. SMART goals are Specific, Measurable, Relevant, and Time-bound.

After goals are established, the nurse can identify expected outcomes based on each goal. Outcomes should be realistic, mutually desired by the patient and nurse, and attainable within a designated amount of time.

After goals are agreed upon and established, the nurse then implements decision-making skills to select nursing interventions that are relevant to the nursing diagnoses. Interventions are prioritized in order of planned implementation.

After priorities, goals, outcomes, and interventions are established, the nurse must document the care plan.

Documentation of the care plan includes nursing orders which communicate the interventions the nursing staff will implement for the client. Nursing orders must be well-written and should include the order date, which action will be performed, a detailed description, the time frame in which the intervention will be performed, and the nurse's signature.

Nurses utilize many of the same skills for each of the nursing process steps. In the planning phase, nurses must have strong communication skills, time management and organizational skills, and a willingness to work collaboratively with the patient and interdisciplinary team. Nurses must have strong critical thinking skills, as they must weigh the risks and consequences of each intervention.

The planning phase of the nursing process is when nurses formulate goals and outcomes that impact patient care. This step involves prioritizing patient needs, identifying expected outcomes, establishing nursing interventions, and identifying patient-centered goals.

In the planning phase, nurses identify goals and outcomes for patient care based on evidence-based practice guidelines. Once objectives of planning are met, the nurse creates a written plan of care, or care plan.

The care plan is a written guide organizing data about the patient's care into a formal statement of strategies or interventions the nurse will enact to help the patient achieve optimal outcomes.

It is normal to face challenges, no matter which phase of patient care you are involved with. The planning phase can feel a bit tricky because nurses need to be careful to develop plans considering the individuality of the patient. The following are a few examples of challenges you could phase when you begin planning patient care.

Not Knowing How to Format the Care Plan There are different formats for creating a care plan. If nurses do not know the format their facility uses, it can be easy to overlook components of the plan, which may impact the delivery of care and patient outcomes.

Not knowing how to format a care plan is probably one of the easiest challenges to overcome in the planning phase. With the implementation of electronic health records and programs that help nurses choose nursing diagnoses and interventions, creating care plans has become easier.

As a nurse creating a care plan, your job is to make sure all relevant information is included in the plan. The nursing diagnosis, interventions and expected outcomes, time frames in which outcomes should be accomplished, and a place to document evaluations should all be included.

Not Establishing Goals and Expected Outcomes Have you ever heard the saying, "Failure to plan is planning to fail"? That principle applies to everything in life, including patient care. No care plan is complete without clear goals and outcome identification. If there are no goals or an insufficient number of goals relevant to the nursing diagnoses, deciding on interventions is impossible.

The nursing care plan should always be patient-centered and individualized. Goals and outcomes should be tailored to meet each patient's needs and should be considerate of the patient's cultural beliefs and values.

Nurses use the nursing care plan as a road map that all members of the nursing team use to help the patient reach goals. It is vital that nurses establish goals that are attainable and relevant to the patient's specific needs.

In the planning phase of the nursing process, the nurse should establish short-term and long-term goals and determine the outcome associated with achieving those goals. Establishing goals and outcomes is vital to this step in the nursing process. Therefore, nurses should take the time to consider each goal and outcome carefully and discuss the plan with the patient and healthcare team.

Unrealistic Goals While it is okay to be optimistic about a patient’s ability to achieve goals, it is essential for nurses to be realistic about what their patients can or cannot do. If goals are unrealistic, patients can quickly become frustrated. Frustration often leads to noncompliance, which can negatively affect patient outcomes.

After carefully determining nursing diagnoses, the nurse must determine which goals the patient can achieve realistically. Realistic goals are specific and well-defined, measurable, achievable, relevant to the patient's status and needs, and achievable within a specific timeframe.

To overcome the challenge of unrealistic goals, identify what is essential in helping the patient achieve optimal outcomes. Discuss goals with the patient, family, care providers, and nurse manager. Once realistic goals are identified, offer support and encouragement to the patient. The nurse should continually monitor and assess the patient's progress toward meeting goals.

Limited Patient Input Although nurses can create nursing care plans independent of patient input, excluding patients from plans about their care may lead to distrust or confusion. If a patient feels he cannot communicate with nurses or his opinion is not valued, it can result in noncompliance with the care plan and negatively impact the patient’s outcome.

When patients are involved in their care, the processes of planning and implementation seem to flow easier.

Nurses can overcome the challenge of limited patient output by promoting a comfortable, trusting nurse-patient relationship which encourages patient participation. Ask the patient about their health goals and what limits they feel may affect their ability to reach goals. Offer suggestions about desired goals and expected outcomes and explain why they are relevant to the patient's health and long-term well-being.

Being Unsure of Appropriate Time Frames to Meet Expected Outcomes/Goals It is possible for nurses to create realistic goals and expected outcomes in the care plan but to set unrealistic time frames in which the patient is expected to meet those goals.

One reason this challenge occurs is nurses sometimes fail to plan care based on an individual patient’s abilities. Instead, they establish goals based on their perception of what any patient with the same diagnosis may be capable of achieving.

When working through the planning phase of the nursing process, nurses must consider patients as individuals with specific needs and abilities. The nurse should specify a time frame for achieving goals that is reasonable and that does not create undue stress or worry for the patient.

When discussing the care plan with the patient, it is important to explain each goal to the patient. Include education about why there is an anticipated time for accomplishing goals and what each person's responsibilities are to help make achieving the goals possible.

Once the nursing diagnosis or diagnoses are established, the nurse completes the planning phase of the nursing process by determining patient goals and expected outcomes and establishing which nursing interventions to initiate.

The following are goals and expected outcomes for Mr. Collie based on the nursing diagnoses of Decreased Cardiac Output and Risk for Impaired Skin Integrity.

The client will verbalize understanding of activities and lifestyle changes focused on reducing cardiac workload.
The client will demonstrate adequate cardiac output AEB vital signs within normal limits.
The client will report decreased episodes of dyspnea.

Monitor vital signs.
Palpate peripheral pulses.
Assess for signs of edema.
Monitor for signs of pallor or cyanosis.

Maintain skin integrity.
The client will verbalize understanding of techniques/behaviors to prevent skin breakdown by end of shift.

Inspect skin, noting areas of altered circulation, bony prominences, and/or signs of emaciation.
Encourage frequent position changes
Provide alternating pressure mattress, heel protectors, and elbow protectors

There are four main components of a nursing care plan: Client Assessment, including medical and diagnostic reports, Nursing Diagnosis, Desired Outcomes/Goals, Nursing Interventions with evidence-based rationale, and Evaluation.

The best way to write a nursing care plan is to include information associated with the nursing process steps.

Review all relevant data, medical history, vital signs and assessment data, physical, emotional, spiritual, ad psychosocial needs, identify areas where improvement is needed, and establish risk factors.
A nursing diagnosis is an actual or potential health problem that nurses can address without physician intervention. A few examples include risk for falls, risk for compromised skin integrity, and risk for dehydration.
Setting goals requires establishing desired outcomes and identifying measures by which the patient will achieve them. Although there may be situations where it is not possible, it is ideal to set goals with the patient when they are able.
Nursing interventions are actions taken by the nurse to help patients achieve goals and meet desired outcomes. Nursing interventions include initiating fall precautions, administering medications, and assessing the patient’s pain level.
of the plan and change or update, as needed or indicated.

The next two FAQs about the planning phase are related to setting goals. Goals are statements of purpose describing an objective to be accomplished. All goals in the nursing care plan should be client-centered and measurable.

Each goal should focus on the problem, measures to resolve the problem, and rehabilitation. The time frame given to accomplish goals in the care plan varies, depending on the setting where patient care is provided.

A tip I always share with students is, if you are not sure how to write a goal, try converting the nursing diagnosis into a positive statement of action.

A short-term goal in nursing care plans is a goal focused on demonstrating a change in behavior. Short-term goals can be completed in as little as a few minutes or up to a few days. The nurse should consider what behavior the patient can most easily exhibit or identify to show understanding of goals and attempts to achieve goals.

For example, let’s consider the following nursing diagnosis and determine a short-term goal.

Long-term goals are the desired outcome related to accomplishing one or more short-term goals for an extended period. In some cases, long-term goals can take weeks, months, or even years, to achieve.

Planning occurs in three stages: initial, ongoing, and discharge. Initial planning occurs when the nurse performing the admission assessment develops a preliminary plan of care. Ongoing planning is the process of updating the patient’s plan of care as new information is collected and evaluated. Discharge planning begins at admission and involves the anticipation of the client’s needs and plans to meet those needs after discharge from care.

When possible, the patient should be included in all phases of the nursing process. The patient is the best source of data, the person being treated, and usually the most reliable source of information used to determine the patient’s strengths, weaknesses, and likelihood of compliance with a plan of care.

Step #4: Implementation Phase

The fourth phase of the nursing process is the implementation phase. This phase is when nurses initiate the interventions established during the planning phase.

After the nursing assessment is performed, nursing diagnoses are established, and a care plan is developed, the plan must be initiated. All phases of the nursing process are essential. The following are three of the top reasons why the implementation phase is so important.

Implementation of the nursing process is significant because it involves action on the nurse's part to promote positive patient outcomes. Conversely, if the care plan is not implemented, there is a lack of nursing care, negatively impacting patient outcomes.
When the nursing care plan is implemented (implementation phase), nurses can begin to gauge patient responses to interventions.
Implementation supports continuity of care. Care begins from the first patient encounter and continues until discharge.

The implementation phase of the nursing process is an ongoing process in patient care. From the time a plan is established, the implementation process continues in a cycle which includes the five objectives below.

The nursing care plan is developed based on data from the initial nursing assessment. However, because a patient's condition can change quickly or nurses may obtain new data, ongoing assessments are necessary to validate the need for proposed interventions. Ongoing observations and assessments provide information supporting adaptations of the nursing care plan to promote improved, individualized care.

Utilizing data from initial and going assessments, the nurse then establishes priorities for implementing care. Prioritization is based upon which problems are considered most important by the nurse, patient, family/significant others, previously scheduled tests/treatments (diagnostic tests, surgery, therapy), and available resources.

Before implementing nursing interventions, the nurse must review proposed interventions and determine the skills and knowledge level required to safely and effectively implement them. For example, the nurse will consider if the patient can independently perform an activity, if a family member may assist, or if the activity requires assistance from a healthcare professional.

Although some interventions require the skills and knowledge of a registered nurse, others are less complex and may be delegated to licensed practical/vocational nurses or assistive personnel. The nurse allocates personnel resources by determining the needs of the client, the type of personnel who are available, and facility protocol for care.

After verifying priorities and determining resources, the nurse can initiate nursing interventions. Interventions are determined by the cause of the problem and often vary among patients with similar nursing diagnoses depending on expected outcomes for each patient.

When initiating nursing interventions, the patient's preference and developmental level should be considered. Additionally, nurses must review the physician's orders which may impact nursing interventions by imposing restrictions on specific factors such as the patient's allowed activity level or diet.

Nurses are legally obligated to document all interventions and any observations concerning the patient's response to those interventions. Documentation may be done on checklists, flow sheets, or in narrative form. Any verbal communication between the patient and nurse or among the healthcare team related to interventions and patient responses should be recorded, as well.

Like the other nursing process steps, the implementation phase requires broad clinical knowledge, critical thinking and analysis skills, and strong judgment.

Whether a nurse is caring for one patient, or several patients, careful planning and time management skills are essential in this phase. Nurses must have psychomotor, interpersonal, and cognitive skills as these serve as competencies through which high-quality nursing care is delivered.

Psychomotor skills are necessary to safely perform nursing activities such as handling medical equipment competently.

Interpersonal skills help nurses establish therapeutic nurse-patient relationships and promote interdisciplinary collaboration.

Cognitive skills are necessary to help the nurse understand the rationale for proposed interventions and make appropriate observations.

Implementation involves a focus on accomplishing predetermined goals and continuous progress toward achieving desired outcomes. This phase of the nursing process involves prioritizing nursing interventions, assessing patient safety during nursing interventions, delegating interventions when appropriate, and documenting all interventions performed.

Nursing interventions vary depending on the patient and the setting where care is provided. The following are examples of common challenges nurses face during the implementation phase of the nursing process and suggestions for how to overcome them.

Lack of Clinical Experience Even when goals and desired outcomes are clearly defined, inexperienced nurses may find implementing nursing interventions challenging. Inexperience may occur because the nurse is newly graduated or if a nurse is transferred to a department where they have never worked.

While the most effective way to overcome a lack of clinical experience is to work as much as you can and gain experience, patient care cannot wait for us to feel comfortable performing unfamiliar tasks.

When nurses face challenges implementing patient care because of inexperience, the best way to overcome it is to speak up and ask for help. As a nursing instructor, I always encouraged my students to ask questions about everything. The only bad question is the one you do not ask. Nurse leaders, supervisors, and administrators appreciate nurses who readily admit when they need help or guidance.

Patient Noncompliance Noncompliance is recognized by NANDA-I as a nursing diagnosis. It is defined as “the behavior of a patient or caregiver that does not correspond with the therapeutic plan agreed upon by the individual, family or guardian, and healthcare provider.” Noncompliance can negatively impact patient outcomes, reduce the patient’s quality of life, and result in increased healthcare costs.

One of the best ways to prevent or stop patient noncompliance is to involve the patient in all aspects of care planning.

Nurses should ensure the patient is educated about their illness, plans to manage the illness, and expected outcomes of therapies. Education should also include information about how noncompliance may negatively affect the patient's outcome. The patient's understanding of all education should be verified, and if the nurse is unsure the patient clearly understands, teaching should be repeated.

Psychosocial Factors Psychosocial factors can impact all aspects of patient care. For example, if there is a presence of domestic abuse or violence, the patient may be afraid to discuss important issues related to care, which could result in misunderstanding established goals.

Psychosocial factors may seem a little tricky to navigate. However, if they become a factor affecting the implementation of the nursing process steps, nurses must find a way to try and address the issues.

For instance, if the nurse suspects a patient is afraid to discuss certain issues in the presence of others, the nurse should ask for privacy while talking to the patient. By doing so, the nurse offers the patient the opportunity to speak openly without fear of retaliation by an abuser. Then the nurse can discuss options for care with the patient and how to proceed moving forward.

Nursing Care Plan Does Not Reflect Appropriate Care for the Nursing Diagnoses Every step of the nursing process builds upon the previous step. Nurses must perform a thorough assessment and collect sufficient data before making nursing diagnoses. After a nursing diagnosis is established, interventions are planned to help resolve the issue(s) the patient is experiencing. If the planned interventions do not align appropriately with the care expected for a nursing diagnosis, implementing the care plan properly cannot occur.

It is vital for nurses to handle each phase of the nursing process with deliberate care and appropriate actions. Nursing care plans should be evaluated by the nursing team to ensure that the patient’s needs are addressed, and planned interventions are relevant to the nursing diagnosis/diagnoses.

Nursing Shortage The World Health Organization estimates a shortage of more than four million nurses in the United States. No matter how well-written a nursing care plan is, if there is not enough staff to carry out the nursing interventions, the plan cannot be successfully implemented.

While it is understandable that one nurse cannot remedy the nursing shortage, there are things all nurses can do to help relieve the impact the shortage causes.

Implementation of the nursing care plan involves educating the patient and helping him achieve goals and expected outcomes. It also involves putting the planned nursing interventions into action. To implement the care plan, the nurse will establish priorities, delegate tasks to appropriate staff, initiate interventions, and document interventions and the patient’s response.

Nursing documentation should be accurate and relevant to the patient. Use appropriate nursing language and facility-approved abbreviations. In the case of Mr. Collie, the nurse's documentation may look like the following narrative.

04/19/22 @ 1430: Discussed plan of care with client and son who was present in the room, including educating about goals and expected outcomes. The client verbalizes understanding of the importance of lifestyle and activity changes to reduce cardiac workload, the need for vital signs to be within normal limits, and measures to decrease episodes of dyspnea, and safety precautions. The client also verbalizes understanding of the risk for impaired skin integrity and verbally recalls skin integrity is at risk due to "bad circulation and swelling." The client voices understanding that frequent position changes and keeping the skin clean and dry will decrease the likelihood of skin breakdown. Assessed peripheral pulses, which are present and strong bilaterally in upper and lower extremities X2, 2+ pitting edema noted in bilateral lower extremities. Skin remains intact, pink, warm, and dry, no signs of redness or pallor. Heel and elbow protectors applied. Alternating pressure mattress in place and operational. ------------D. Leonard, RN

The first step in the process of implementing a nursing care plan is to determine what, how, and when an intervention should be performed. Once you know the what, how, and when, you can determine if the task can be delegated and to whom.

The three types of interventions implemented in the nursing process are independent, dependent, and interdependent.

are actions nurses can perform on their own and do not require assistance from other team members. For example, routine tasks such as monitoring vital signs or assessing the patient's pain level are independent nursing interventions.
require instructions or input from the physician. For instance, if the patient needs a new medication, the physician must prescribe the medication and order the amount and frequency. Dependent nursing interventions are interventions the nurse may not initiate on her own.
are also known as collaborative interventions. These interventions involve all members of the interdisciplinary team. For example, if a patient had a total knee replacement, his recovery plan may include a prescription medication from the doctor, assistance with dressing from the nurse or unlicensed assistive personnel, and physical or occupational therapy by the physical therapist or occupational therapist.

While many sources use the words interchangeably, intervention and implementation are defined somewhat differently. Interventions are planned nursing activities performed on a patient's behalf. They include assessment, adherence to medication therapy, and problem-solving. Implementation is .

Strategies to prioritize patient care typically include the use of nursing diagnoses combined with Maslow’s Hierarchy of Needs Theory.

Any nursing diagnosis that suggests a risk or threat to the patient’s survival should be the nurse’s first priority. Remember your ABCs: Airway, Breathing, Circulation.

Other physiological needs necessary for survival are considered.

Psychosocial needs are then addressed.

Psychological needs including a sense of love or belonging, self-esteem, and self-actualization are prioritized last.

Medication administration is part of the implementation phase of the nursing process steps. The nursing interventions outlined in the planning phase should include information about medication administration. When the nurse initiates the action of administering the medication, she is implementing the plan of care.

All members of the nursing team have roles related to implementing the care plan. In the planning phase of the nursing process, the Registered Nurse determines which tasks may be delegated to Licensed Practical/Vocational Nurses, Nursing Assistants, or other members of the healthcare team. It is essential to remember that, even if a task is delegated, the RN in charge of the patient’s care is accountable for making sure all tasks are completed.

Step #5: Evaluation Phase

Evaluation is the final phase of the nursing process. Although evaluation is considered the last of the nursing process steps, it does not indicate an end to the nursing process. Instead, evaluation should be an ongoing process carried out in daily nursing activities that ensures quality nursing interventions and the effectiveness of those interventions.

The evaluation phase of the nursing process is important because it fulfills several purposes. The following are the top three reasons why this phase is essential in the nursing process.

The primary purpose of an evaluation is to determine the patient’s progress toward achieving established goals and outcomes.
Through evaluation, it is possible to determine a healthcare agency’s ability to provide safe and effective healthcare services.
Evaluation provides a mechanism to help nurses define, explain, and measure the results of nursing interventions.

The Standards of Clinical Nursing Practice established by the American Nurses Association designates evaluation as a fundamental component of the nursing process. This phase of the nursing process has the following objectives.

The effectiveness of nursing interventions is determined by evaluating goals and expected outcomes to determine if they provide direction for patient care. It is essential to evaluate nursing interventions because they serve as standards by which patient progress is measured.

The evaluation phase is not meant to make nurses feel as if their work is being critiqued or judged. Evaluation allows nurses to verify if the care they are providing meets the standard of care for the patient’s needs.

Evaluation involves reviewing all aspects of the patient’s care and determining its effectiveness in helping the patient recover. Because nurses work collaboratively with one another and other members of the healthcare team, the evaluation phase promotes the nurses’ sense of accountability to their patients and to one another.

In the evaluation phase of the nursing process, nurses compare and analyze data from the time the patient was admitted to care and determine if positive or negative trends are occurring. This data is helpful in deciding the next course of action to take in patient care.

Although the evaluation phase is the fifth and last step in the nursing process, nurses constantly evaluate patient progress. Evaluation allows nurses to establish a pattern of continuous care and attention, which helps promote positive patient outcomes.

The evaluation phase of the nursing process is primarily based on the nurse's accurate and efficient use of observation, critical thinking, and communication skills.

Some changes in a patient's status may be subtle, requiring sharp observational skills. The ability to analyze reassessment data and use critical thinking are necessary to determine if outcomes have been met or decide if changes in the care plan are needed. As in other phases of patient care, the nurse must demonstrate strong communication skills, as evaluation includes the patient and all members of the healthcare team.

During the evaluation phase of the nursing process, nurses determine the patient’s response to interventions and whether goals have been met. The evaluation process consists of seven steps, as follows.

Standards and goals are established during the planning phase of the nursing process steps and carried out in the implementation phase. Nurses use evaluation to determine the presence of changes in the patient's status relevant to the established standards.

The nurse uses assessment skills early in the nursing process to gather data used to establish goals and expected outcomes. Those same skills are vital for comprehensive, effective evaluation to occur. Nurses gather data to help determine the success of nursing interventions.

The data collected during the evaluation phase must answer the question, “Did the patient achieve the treatment goals and expected outcomes outlined in the care plan?” Nurses validate goal achievement by analyzing the patient’s response to nursing interventions outlined in the nursing care plan.

Effective nursing interventions address relevant patient needs. If the nursing intervention is efficient, it can be a primary factor related to helping clients resolve actual or potential problems or risk factors.

During the evaluation phase, the nurse must use critical thinking skills to determine which nursing actions contributed to improved patient outcomes and to what degree they were effective. This step in the evaluation process allows the nurse to analyze the patient's response to interventions, determine the benefits of those interventions, and identify opportunities or needs for change.

In the evaluation phase of the nursing process, the nurse uses observation and assessment skills to reevaluate the patient's status. In this step, the nurse compares baseline data collected in the initial nursing assessment with the patient's current health status.

If the evaluation determines a lack of progress toward established goals, the nursing care plan is revised or modified. At this point, revisions are developed by beginning the nursing process anew. The client is reassessed (Assessment), more appropriate nursing diagnoses are established (Diagnosis), new or revised goals and outcomes are developed (Planning), new nursing interventions are implemented, or previous interventions are repeated to maximize effectiveness (Implementation). Then the patient's response is reevaluated (Evaluation).

The evaluation phase of the nursing process is the point where nurses and patients hope to see measurable improvement. The following are a few challenges nurses may face when in the evaluation phase.

Incomplete Documentation Every nurse is responsible for documenting patient progress and other pertinent information. If one nurse fails to document and report patient changes or progress, or to record laboratory or diagnostic test results, it can lead to challenges when it is time for the evaluation phase.

The most effective way to overcome this challenge is to avoid it happening altogether. Be sure to document information about your patients during each shift. Any change in status, progress or lack of progress, subjective and objective findings, or other relevant information should be readily available for any nurse caring for that patient.

Patient Frustration In a perfect world, patients would be admitted to care, nursing interventions would be implemented, and we would see positive results. Unfortunately, it doesn’t always work that way. One of the challenges nurses face in the evaluation phase is frustration related to slow progress or failing to meet goals.

Overcoming the challenges that occur when patients become frustrated takes patience and understanding.

If you find yourself in the evaluation phase of the nursing process steps and faced with this situation, take the time to talk to your patient. Assure them that progress does not always happen as quickly as we would like and encourage them to keep pressing forward.

Let your patient know that you are there to support and help them and that your priority is to see them improve. Sometimes all it takes to calm a patient and help them regain focus is an assuring word and calming presence.

Patients Withholding Information It is not uncommon for patients to try and mask symptoms or deny concerns when nurses evaluate their progress. This is especially common when a patient has been hospitalized or in a care facility for an extended period and wants to return home.

In situations like this, a strong nurse-patient relationship and good communication skills are necessary. If you feel your patient is not being forthcoming about their progress, or perhaps new symptoms have emerged that they do not want to discuss, ask direct questions. Explain the importance of transparency when reporting progress, problems, or concerns.

Family Denial of the Patient’s Need for Continued Care As nurses, we naturally hope that interventions positively impact our patients and that we can see improvement when evaluating them. Family members hope to see their loved ones recover and return to normal, as well. A significant challenge nurses can face when evaluating patient progress occurs when the patient's status declines or there is little improvement and family members deny the reality of the patient's situation.

Many times, the fear of the unknown or lack of understanding is what causes family denial. If family members struggle with accepting the idea of continued care or changes in the plan of care, the nurse should acknowledge their concerns and offer support. When appropriate, talk with the patient and family together and discuss the previous plan of care and any suggestions for alterations or changes and the rationale for them.

Patient Wishing to Terminate Care Before Discharge Goals Are Met Nurses understand that patients respond differently to care with some progressing faster than others, and the evaluation process helps to identify those patients who need extra time or updated care plans.

Unfortunately, because patients do not always understand the complexities of interventions and expected outcomes, it can lead to feelings of despair. If patients slowly progress or fail to meet goals and expected outcomes, their frustration sometimes leads them to give up or desire to seek care elsewhere.

When faced with this challenge, it is crucial for nurses to approach the patient with an attitude of empathy and attempt to discuss the patient's concerns. Depending on the patient's status and ability to understand, it may take some time and reinforced teaching to help them understand that slow progress is not failure. Explain your view of your patient's current status compared to his status on admission. Encourage the patient by assuring him that even slow progress is progress. Offer ideas of ways you think the care plan can be amended to suit his needs and ask for input.

Remember, despite your best efforts, there may be times when patients decide to terminate care. Unless the patient has been deemed incapable of making informed decisions, you may not interfere with his choice to leave your care. It is necessary to document everything you discuss with the patient and his response to your instructions and education.

If the patient decides to leave your facility's care, there is appropriate paperwork to be signed, called an A.M.A. (Against Medical Advice) discharge. The charge nurse or physician is usually responsible for having the patient sign this form and submitting it to administration.

In the evaluation phase, the nurse reassesses the patient and determines if goals and outcomes are being met or if the care plan needs to be modified. Observations are recorded in the patient’s chart.

04/20/22 @ 1500: After twenty-four hours of nursing intervention, the client demonstrates adequate cardiac output as evidenced by decreased blood pressure of 130/78 and pulse rate of 72. The client states his breathing is less labored and that if he begins to feel short of breath, he lies still to rest. O2 per NC @ 2L continuous. Observed 500 cc clear, amber urine in the urinal. The patient continues to have 2+ pitting edema in bilateral lower extremities. MD notified, awaiting response/order. The client has turned/repositioned q2h to decrease the risk of impaired skin integrity. No signs of compromised skin integrity noted at this time. -------D. Leonard, RN

The primary purpose of evaluation in the nursing process steps is to determine if patient goals and expected outcomes have been met or if the nursing care plan needs to be modified.

The steps of evaluation in the nursing process include collecting data, comparing data with desired goals and expected outcomes, analyzing the patient’s response to nursing interventions, identifying factors impacting the success or failure of the nursing care plan, continuing, modifying, or terminating the care plan, and planning future nursing care.

Although the nursing process is focused on nursing diagnoses and interventions, each member of the patient’s healthcare team has a role and the actions they take in patient care can impact the effectiveness of the nursing care plan. Therefore, the most effective way of improving evaluation in the nursing process, is to include the patient, family (when appropriate), and all members of the interdisciplinary team in the process.

Although healthcare facilities and organizations have minimum guidelines for the frequency of nurse evaluations, it should be an ongoing process involved in patient care. The patient’s status and the effectiveness of nursing interventions should be continuously evaluated, and the care plan should be modified, when necessary.

In the evaluation phase, nurses gather much of the same type of information as what is gathered during the assessment. During this phase, nurses review current vital signs and laboratory or diagnostic test results. They use information entered into the patient’s chart, such as nurses’ notes, flow sheets, and other pertinent information. Additionally, during the evaluation, nurses reinterview the patient and look for both subjective and objective data to determine if the plan of care was effective.

The registered nurse assigned to the patient’s care is the primary person responsible for the evaluation phase of the nursing process. The RN evaluates all information necessary to determine if the goals and expected outcomes were met or if alterations in the plan are needed. Keep in mind, however, every member of the nursing care team plays a vital role in the RN's ability to conduct a thorough evaluation because each person is responsible for documenting their work and the patient’s response.

Useful Resources to Gain More Information About the Nursing Process

Blogs/websites, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. how is nursing process different from the scientific method, 2. do all nurses use the nursing process, 3. do doctors also use the nursing process, 4. what does adpie stand for, 5. is it always necessary for a nurse to follow all steps of the nursing process, 6. how does critical thinking impact the nursing process, 7. how does a health information system affect the nursing process, 8. how to use maslow hierarchy in the nursing process, 9. which nursing process step includes tasks that can be delegated, 10. which nursing process step includes tasks that cannot be delegated, 11. how does the nursing process apply to pharmacology.

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Problem Solving in Nursing: Strategies for Your Staff

4 min read • September, 15 2023

Problem solving is in a nurse manager’s DNA. As leaders, nurse managers solve problems every day on an individual level and with their teams. Effective leaders find innovative solutions to problems and encourage their staff to nurture their own critical thinking skills and see problems as opportunities rather than obstacles.

Health care constantly evolves, so problem solving and ingenuity are skills often used out of necessity. Tackling a problem requires considering multiple options to develop a solution. Problem solving in nursing requires a solid strategy.

Nurse problem solving

Nurse managers face challenges ranging from patient care matters to maintaining staff satisfaction. Encourage your staff to develop problem-solving nursing skills to cultivate new methods of improving patient care and to promote nurse-led innovation .

Critical thinking skills are fostered throughout a nurse’s education, training, and career. These skills help nurses make informed decisions based on facts, data, and evidence to determine the best solution to a problem.

Problem-Solving Examples in Nursing

To solve a problem, begin by identifying it. Then analyze the problem, formulate possible solutions, and determine the best course of action. Remind staff that nurses have been solving problems since Florence Nightingale invented the nurse call system.

Nurses can implement the original nursing process to guide patient care for problem solving in nursing. These steps include:

Assessment . Use critical thinking skills to brainstorm and gather information.
Diagnosis . Identify the problem and any triggers or obstacles.
Planning . Collaborate to formulate the desired outcome based on proven methods and resources.
Implementation . Carry out the actions identified to resolve the problem.
Evaluation . Reflect on the results and determine if the issue was resolved.

How to Develop Problem-Solving Strategies

Staff look to nurse managers to solve a problem, even when there’s not always an obvious solution. Leaders focused on problem solving encourage their team to work collaboratively to find an answer. Core leadership skills are a good way to nurture a health care environment that supports sharing concerns and innovation .

Here are some essentials for building a culture of innovation that encourages problem solving:

Present problems as opportunities instead of obstacles.
Strive to be a positive role model. Support creative thinking and staff collaboration.
Encourage feedback and embrace new ideas.
Respect staff knowledge and abilities.
Match competencies with specific needs and inspire effective decision-making.
Offer opportunities for continual learning and career growth.
Promote research and analysis opportunities.
Provide support and necessary resources.
Recognize contributions and reward efforts .

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Embrace Innovation to Find Solutions

Try this exercise:

Consider an ongoing departmental issue and encourage everyone to participate in brainstorming a solution. The team will:

Define the problem, including triggers or obstacles.
Determine methods that worked in the past to resolve similar issues.
Explore innovative solutions.
Develop a plan to implement a solution and monitor and evaluate results.

Problems arise unexpectedly in the fast-paced health care environment. Nurses must be able to react using critical thinking and quick decision-making skills to implement practical solutions. By employing problem-solving strategies, nurse leaders and their staff can improve patient outcomes and refine their nursing skills.

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Home > Online Programs > EVIDENCE-BASED PRACTICE (EBP): THE PROBLEM-SOLVING APPROACH

EVIDENCE-BASED PRACTICE (EBP): THE PROBLEM-SOLVING APPROACH

Published On: January 10, 2012

As the nursing profession continues to evolve, the educational focus is also changing. One of the most significant emerging trends in healthcare today is the focus on evidence-based practice, also known as EBP.

Evidenced-based practice is often described as an approach to patient care that involves considering the best available research and practice guidelines associated with a specific clinical situation. Key elements in the successful implementation of evidence-based practice in nursing include:

Reviewing research and studies that examine the best practices in clinical nursing.
Interactive decision-making regarding care and treatment planning which integrates care team members, as well as the opinion of the patient and his or her family.
Ongoing professional development education of nurses, including pursuit of advanced degree programs when available.
Addressing clinical issues and critically examining possible practice changes.
Strong emphasis on problem-solving skills, clinical judgment and the use of sound evidence to support clinical decisions based on research, experience and the environment.

Challenges to Evidence-Based Practice

Some of the impediments to evidence-based practice include a resistance to change practice and habits within the nursing community, the lack of ongoing education programs and poor administrative support. Although barriers exist, the successful patient outcomes from evidence-based practice have helped win support for this model of care among the medical profession as a whole.

Increased Responsibilities for Nurses Today

Because evidence-based practice places an emphasis on the knowledge, skills and experience of nurses, today’s nurses are being given more responsibility and respect than ever before. EBP focuses on specific nursing skills including critical decision-making founded in evidence and research, with a move away from traditional treatment regimes and habits that had been the hallmark of nursing for generations. Registered nurses now need strong analytic and academic research skills to complement clinic skills and hands-on patient care.

Options for Evidence-Based Practice Education

Nurses who are seeking to improve their clinical skills and expand both their knowledge base and career options should consider obtaining additional nursing education in programs that focus on EBP. Professional nursing today demands that nurses have a solid understanding of how to conduct research, critically review studies and medical reviews, and an EBP-focused education program will teach nurses these vital skills.

Some of the most accessible educational programs that include an emphasis on EBP the knowledge are the online nursing programs offered at the University of Texas at Arlington, including an RN to BSN and a Master of Science in Nursing Administration . The University of Texas at Arlington’s College of Nursing and Health Innovation, named one of the “Best of the West” by Princeton Review , offers a specialized program to allow RNs to obtain their BSN in just over a year. By pursuing an advanced nursing degree with a focus on evidence-based practice, working nurses will have access to a variety of career options in both clinical and administrative roles.

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Critical Thinking and the Nursing Process

In today’s health care arena, the nurse is faced with increasingly complex issues and situations resulting from advanced technology, greater acuity of patients in hospital and community settings, an aging population, and complex disease processes, as well as ethical and cultural factors. Traditionally, nurses have used a problem-solving approach in planning and providing nursing care. Today the decision-making part of problem solving has become increasingly complex and requires critical thinking.

Definition of Critical thinking

Critical thinking is a multidimensional skill, a cognitive or mental process or set of procedures. It involves reasoning and purposeful, systematic, reflective, rational, outcome-directed thinking based on a body of knowledge, as well as examination and analysis of all available information and ideas. Critical thinking leads to the formulation of conclusions and the most appropriate, often creative, decisions, options, or alternatives. Critical thinking includes metacognition, the examination of one’s own reasoning or thought processes while thinking, to help strengthen and refine thinking skills. Independent judgments and decisions evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Nursing practice in today’s society mandates the use of high-level critical thinking skills within the nursing process. Critical thinking enhances clinical decision making, helping to identify patient needs and to determine the best nursing actions that will assist the patient in meeting those needs. Critical thinking and critical thinkers have distinctive characteristics. As indicated in the above definition, critical thinking is a conscious, outcome-oriented activity; it is purposeful and intentional. The critical thinker is an inquisitive, fair-minded truth seeker with an open-mindedness to the alternative solutions that might surface.

Critical thinking Process: Rationality and Insight

Critical thinking is systematic and organized. The skills involved in critical thinking are developed over time through effort, practice, and experience. Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Critical thinking requires background knowledge and knowledge of key concepts as well as standards of good thinking. The critical thinker uses reality-based deliberation to validate the accuracy of data and the reliability of sources, being mindful of and questioning inconsistencies. Interpretation is used to determine the significance of data that are gathered, and analysis is used to identify patient problems indicated by the data. The nurse uses inference to draw conclusions. Explanation is the justification of actions or interventions used to address patient problems and to help a patient move toward desired outcomes. Evaluation is the process of determining whether outcomes have been or are being met, and self-regulation is the process of examining the care provided and adjusting the interventions as needed. Critical thinking is also reflective, involving metacognition, active evaluation, and refinement of the thinking process. The critical thinker considers the possibility of personal bias when interpreting data and determining appropriate actions. The critical thinker must be insightful and have a sense of fairness and integrity, the courage to question personal ethics, and the perseverance to strive continuously to minimize the effects of egocentricity, ethnocentricity, and other biases on the decision making process.

Components of Critical thinking

Certain cognitive or mental activities can be identified as key components of critical thinking. When thinking critically, a person will do the following:

Ask questions to determine the reason why certain developments have occurred and to see whether more information is needed to understand the situation accurately.
Gather as much relevant information as possible to consider as many factors as possible.
Validate the information presented to make sure that it is accurate (not just supposition or opinion), that it makes sense, and that it is based on fact and evidence.
Analyze the information to determine what it means and to see whether it forms clusters or patterns that point to certain conclusions.
Draw on past clinical experience and knowledge to explain what is happening and to anticipate what might happen next, acknowledging personal bias and cultural influences.
Maintain a flexible attitude that allows the facts to guide thinking and takes into account all possibilities.
Consider available options and examine each in terms of its advantages and disadvantages.
Formulate decisions that reflect creativity and independent decision making.

Critical thinking requires going beyond basic problem solving into a realm of inquisitive exploration, looking for all relevant factors that affect the issue, and being an “out-of-the-box” thinker. It includes questioning all findings until a comprehensive picture emerges that explains the phenomenon, possible solutions, and creative methods for proceeding. Critical thinking in nursing practice results in a comprehensive patient plan of care with maximized potential for success.

Critical thinking In Nursing Practice

Using critical thinking to develop a plan of nursing care requires considering the human factors that might influence the plan. The nurse interacts with the patient, family, and other health care providers in the process of providing appropriate, individualized nursing care. The culture, attitude, and thought processes of the nurse, the patient, and others will affect the critical thinking process from the data-gathering stage through the decision-making stage; therefore, aspects of the nurse-patient interaction must be considered. Nurses must use critical thinking skills in all practice settings—acute care, ambulatory care, extended care, and in the home and community. Regardless of the setting, each patient situation is viewed as unique and dynamic. The unique factors that the patient and nurse bring to the health care situation are considered, studied, analyzed, and interpreted. Interpretation of the information presented then allows the nurse to focus on those factors that are most relevant and mostsignificant to the clinical situation. Decisions about what to do and how to do it are then developed into a plan of action.

Fonteyn (1998) identified 12 predominant thinking strategies used by nurses, regardless of their area of clinical practice:

Recognizing a pattern

Setting priorities
Searching for information
Generating hypotheses
Making predictions
Forming relationships
Stating a proposition (“if–then”)
Asserting a practice rule
Making choices (alternative actions)
Judging the value
Drawing conclusions
Providing explanations

Fonteyn further identified other, less prominent thinking strategies the nurse might use:

Posing a question
Making assumptions (supposing)
Making generalizations

These thought processes are consistent with the characteristics of critical thinking and cognitive activities discussed earlier. Fonteyn asserted that exploring how these thinking strategies are used in various clinical situations, and practicing using the strategies, might assist the nurse–learner in examining and refining his or her own thinking skills.

Throughout the critical thinking process, a continuous flow of questions evolves in the thinker’s mind. Although the questions will vary according to the particular clinical situation, certain general inquiries can serve as a basis for reaching conclusions and determining a course of action. When faced with a patient situation, it is often helpful to seek answers to some or all of the following questions in an attempt to determine those actions that are most appropriate:

What relevant assessment information do I need, and how do I interpret this information? What does this information tell me?
To what problems does this information point? Have I identified the most important ones? Does the information point to any other problems that I should consider?
Have I gathered all the information I need (signs/symptoms, laboratory values, medication history, emotional factors, mental status)? Is anything missing?
Is there anything that needs to be reported immediately? Do I need to seek additional assistance?
Does this patient have any special risk factors? Which ones are most significant? What must I do to minimize these risks?
What possible complications must I anticipate?
What are the most important problems in this situation? Do the patient and the patient’s family recognize the same problems?
What are the desired outcomes for this patient? Which have the highest priority? Does the patient see eye to eye with me on these points?
What is going to be my first action in this situation? How can I construct a plan of care to achieve the goals?
Are there any age-related factors involved, and will they require some special approach? Will I need to make some change in the plan of care to take these factors into account?
How do the family dynamics affect this situation, and will this have an affect on my actions or the plan of care?
Are there cultural factors that I must address and consider?
Am I dealing with an ethical problem here? If so, how am I going to resolve it?
Has any nursing research been conducted on this subject?

Pulse oximetry, metro manila developmental screening test (mmdst), nursing process.

NRS401: Nursing Research Utilization: Evidence Based Practice

Finding Sources
Evidence Based Practice
Clinical Questions & PICO
Building the Grid
Poster Assignment
APA 7 (New)

What is Evidence-Based Practice?

Evidence-Based Practice (EBP): "EBP is a conscientious, problem-solving approach to clinical practice that incorporates the best evidence from well-designed studies, patient values and preferences, and a clinician's expertise in making decisions about a patient's care" (Nurse.com, 2020).

Difference Between EBP & Research

There is a common misconception that EBP and research are one in the same. Not true! While there are similarities, one of the fundamental differences lies in their purpose:

► Research: To generate new knowledge or validate existing knowledge based on theory.

► Evidence-Based Practice: To use best available evidence to make informed patient-care decisions.

In contrast, the purpose of EBP isn’t about developing new knowledge or validating existing knowledge—it’s about translating the evidence and applying it to clinical practice and decision-making. Most of the best evidence stems from research, but EBP goes beyond research and includes the clinical expertise of the clinician and healthcare teams, as well as patient preferences and values.

Source: What is Evidence-Based Practice? (University of Utah)

Components of Evidence-Based Practice

Image Source: What is Evidence-Based Practice? (University of Utah)

The 5 A's of Evidence-Based Practice

Image Source: HealthCatalyst , 2015

EBP Pyramid

Source: Duke University's Evidence Based Practice: Study Design

Helpful Links

What is Evidence-Based Practice? (University of Utah)

^This link provides a comprehensive overview of EBP.

Why is Evidence-Based Practice so Important?

^This link provides definitions and a brief historical overview of EBP.

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Next: Clinical Questions & PICO >>
Last Updated: Jul 3, 2024 11:41 AM
URL: https://libguides.dbq.edu/nrs401

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The relationship between research and the nursing process in clinical practice

Affiliation.

1 University of Manchester, England.
PMID: 9372412
DOI: 10.1046/j.1365-2648.1997.00472.x

The nursing process was originally adopted by the North American nursing profession from the general systems theory (GST) and quickly became a symbol of contemporary nursing as well as a professionalist nurse ideology. In contrast its initial introduction in the United Kingdom (UK) was not a complete success. This could be attributed to the mode of its implementation, which utilized a power-coercive change strategy, that is, comprising of imposition from above without sufficient time for education regarding its scientific and philosophical foundations. Consequently the nursing process was initially regarded as a professional and educational mandate rather than an organizational component of nursing care delivery. It has been maintained that the theoretical basis from which the nursing process was derived, together with the theoretical developments in diagnostic and intervention studies, has established the nursing process as a key element of the nurse's role in research, education and practice. This paper will briefly review the early theoretical developments and fate of the nursing process as a tool for clinical practice and research. It will then examine recent attempts to revitalize and modernize the theory for practice through research into nursing diagnosis.

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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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