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Critical thinking, the nursing process, and clinical judgment

CHAPTER 8 Critical thinking, the nursing process, and clinical judgment Learning outcomes After studying this chapter, students will be able to: •  Define critical thinking. •  Describe the importance of critical thinking in nursing. •  Contrast the characteristics of “novice thinking” with those of “expert thinking.” •  Explain the purpose and phases of the nursing process. •  Differentiate between nursing orders and medical orders. •  Explain the differences between independent, interdependent, and dependent nursing actions. •  Describe evaluation and its importance in the nursing process. •  Define clinical judgment in nursing practice and explain how it is developed. •  Devise a personal plan to use in developing sound clinical judgment. To enhance your understanding of this chapter, try the Student Exercises on the Evolve site at http://evolve.elsevier.com/Black/professional . Almost every encounter a nurse has with a patient is an opportunity for the nurse to assist the patient to a higher level of wellness or comfort. A nurse’s ability to think critically about a patient’s particular needs and how best to meet them will determine the extent to which a patient benefits from the nurse’s care. A nurse’s ability to use a reliable cognitive approach is crucial in determining a patient’s priorities for care and in making sound clinical decisions in addressing those priorities. This chapter explores several important and interdependent aspects of thinking and decision making in nursing: critical thinking, the nursing process, and clinical judgment. Chapter opening photo from istockphoto.com . Defining critical thinking Defining “critical thinking” is a complex task that requires an understanding of how people think through problems. Educators and philosophers struggled with definitions of critical thinking for several decades. Two decades ago, the American Philosophical Association published an expert consensus statement ( Box 8-1 ) describing critical thinking and attributes of the ideal critical thinker. This expert statement, still widely used, was the culmination of 3 years of work by Facione and others who synthesized the work of numerous persons who had defined critical thinking. More recently, Facione (2006) noted that giving a definition of critical thinking that can be memorized by the learner is actually antithetical to critical thinking! This means that the very definition of critical thinking does not lend itself to simplistic thinking and memorization. BOX 8-1     EXPERT CONSENSUS STATEMENT REGARDING CRITICAL THINKING AND THE IDEAL CRITICAL THINKER We understand critical thinking (CT) to be purposeful, self-regulatory judgment that results in interpretation, analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment is based. CT is essential as a tool of inquiry. As such, CT is a liberating force in education and a powerful resource in one’s personal and civic life. While not synonymous with good thinking, CT is a pervasive and self-rectifying human phenomenon. The ideal critical thinker is habitually inquisitive, well-informed, trustful of reason, open-minded, flexible, fair-minded in evaluation, honest in facing personal biases, prudent in making judgments, willing to reconsider, clear about issues, orderly in complex matters, diligent in seeking relevant information, reasonable in the selection of criteria, focused in inquiry, and persistent in seeking results that are as precise as the subject and the circumstances of inquiry permit. Thus educating good critical thinkers means working toward this ideal. It combines developing CT skills with nurturing those dispositions that consistently yield useful insights and that are the basis of a rational and democratic society. From American Philosophical Association : Critical Thinking: A Statement of Expert Consensus for Purposes of Educational Assessment and Instruction, The Delphi report: Research findings and recommendations prepared for the committee on pre-college philosophy, 1990, ERIC Document Reproduction Services, pp. 315–423. The Paul-Elder Critical Thinking Framework is grounded in this definition of critical thinking: “Critical thinking is that mode of thinking—about any subject, content, or problem—in which the thinker improves the quality of his or her thinking by skillfully taking charge of the structures inherent in thinking and imposing intellectual standards upon them.” Paul and Elder, 2012 Paul and Elder (2012) go on to describe a “well-cultivated critical thinker” as one who does the following: •  Raises questions and problems and formulates them clearly and precisely •  Gathers and assesses relevant information, using abstract ideas for interpretation •  Arrives at conclusions and solutions that are well-reasoned and tests them against relevant standards •  Is open-minded and recognizes alternative ways of seeing problems, and has the ability to assess the assumptions, implications, and consequences of alternative views of problems •  Communicates effectively with others as solutions to complex problems are formulated We live in a “new knowledge economy” driven by information and technology that changes quickly. Analyzing and integrating information across an increasing number of sources of knowledge requires that you have flexible intellectual skills. Being a good critical thinker makes you more adaptable in this new economy of knowledge ( Lau and Chan, 2012). An excellent website on critical thinking can be found at http://philosophy.hku.hk/think/ (OpenCourseWare on critical thinking, logic, and creativity). So what does this have to do with nursing? The answer is very simple: excellent critical thinking skills are required for you to make good clinical judgments. You will be responsible and accountable for your own decisions as a professional nurse. The development of critical thinking skills is crucial as you provide nursing care for patients with increasingly complex conditions. Critical thinking skills provide you with a powerful means of determining patient needs, interpreting physician orders, and intervening appropriately. Box 8-2 presents an example of the importance of critical thinking in the provision of safe care. BOX 8-2     USING CRITICAL THINKING SKILLS TO IMPROVE A PATIENT’S CARE Ms. George has recently undergone bariatric surgery after many attempts to lose weight over the years have failed. She is to be discharged home on postoperative day 2, as per the usual protocol. Although she describes herself as “not feeling well at all,” the physician writes the order for discharge and you, as the nurse who does postoperative discharge planning for the surgery practice, prepare Ms. George to go home with her new dietary guidelines and encouragement for her successful weight loss. You note that Ms. George does not seem as comfortable or pleased with her surgery as most patients with whom you have worked in the past. Ms. George has to wait 3 hours for her husband to drive her home, and you note that she continues to lie on the bed passively, and her lethargy is increasing. You take her vital signs and note that her temperature is 37.8° C and her pulse is 115. You listen to her chest and note that it is difficult to appreciate breath sounds due to the patient’s body habitus. Ms. George points to an area just below her left breast where she notes pain with inspiration. You call her physician to report your findings; she responds that Ms. George’s pain is “not unusual” with her type of bariatric surgery and that her slightly increased temperature is “most likely” related to her being somewhat dehydrated. She instructs you to have Ms. George force fluids to the extent that she can tolerate it, and to take mild pain medication for postoperative pain. You ask her to consider delaying her discharge home, but she refuses. You give Ms. George acetaminophen as ordered, but her pain on inspiration continues. Her temperature remains at 37.8° C, and her pulse is 120. You measure her O 2 saturation with a pulse oximeter, and it is 91%. Her respirations are 26 and somewhat shallow. Her surgeon does not respond to your page, so you call the nursing supervisor, explaining to him that you are concerned with Ms. George’s impending discharge. Although you are wary of the surgeon’s reaction, you call the hospitalist (a physician who sees inpatients in the absence of their attending physician), who orders a chest x-ray study. Ms. George has evidence of a consolidation in her left lower lobe, which turns out to be a pulmonary abscess. She is treated on intravenous antibiotics for 5 days, and the abscess eventually has to be aspirated and drained. Your critical thinking skills and willingness to advocate for your patient prevented an even worse postoperative course. You recognized that Ms. George’s lethargy was unusual, and the location and timing of her pain was of concern. You also realized that although her temperature appeared to be stable, she had been given a pain medicine (acetaminophen) that also reduces fever, so in fact, a temperature increase may have been masked by the antipyretic properties of the acetaminophen. You demonstrated excellent clinical judgment in measuring her O 2 saturation. Furthermore, you sought support through the nursing “chain of command” when you engaged the nursing supervisor, who supported you in contacting the hospitalist. The specific, detailed information that you were able to provide the hospitalist allowed him to follow a logical diagnostic path, determining that Ms. George did indeed have a significant postoperative complication. Two days later, Ms. George reports that she is “feeling much better” and is walking in the hallways several times a day. Critical thinking in nursing You may be wondering at this point, “How am I ever going to learn how to make connections among all of the data I have about a patient?” This is a common response for a nursing student who is just learning some of the most basic psychomotor skills in preparation for practice. You need to understand that, just like learning to give injections safely and maintaining a sterile field properly, you can learn to think critically. This involves paying attention to how you think and making thinking itself a focus of concern. A nurse who is exercising critical thinking asks the following questions: “What assumptions have I made about this patient?” “How do I know my assumptions are accurate?” “Do I need any additional information?” and “How might I look at this situation differently?” Nurses just beginning to pay attention to their thinking processes may ask these questions after nurse–patient interactions have ended. This is known as reflective thinking. Reflective thinking is an active process valuable in learning and changing behaviors, perspectives, or practices. Nurses can also learn to examine their thinking processes during an interaction as they learn to “think on their feet.” This is a characteristic of expert nurses. As you move from novice to expert, your ability to think critically will improve with practice. In Chapter 6 you read about Dr. Patricia Benner (1984, 1996), who studied the differences in expertise of nurses at different stages in their careers, from novice to expert. So it is with critical thinking: novices think differently from experts. Box 8-3 summarizes the differences in novice and expert thinking. BOX 8-3     NOVICE THINKING COMPARED WITH EXPERT THINKING Novice nurses •  Tend to organize knowledge as separate facts. Must rely heavily on resources (e.g., texts, notes, preceptors). Lack knowledge gained from actually doing (e.g., listening to breath sounds). •  Focus so much on actions that they may not fully assess before acting •  Need and follow clear-cut rules •  Are often hampered by unawareness of resources •  May be hindered by anxiety and lack of self-confidence •  Tend to rely on step-by-step procedures and follow standards and policies rigidly •  Tend to focus more on performing procedures correctly than on the patient’s response to the procedure •  Have limited knowledge of suspected problems; therefore they question and collect data more superficially or in a less focused way than more experienced nurses •  Learn more readily when matched with a supportive, knowledgeable preceptor or mentor Expert nurses •  Tend to store knowledge in a highly organized and structured manner, making recall of information easier. Have a large storehouse of experiential knowledge (e.g., what abnormal breath sounds sound like, what subtle changes look like). •  Assess and consider different options for intervening before acting •  Know which rules are flexible and when it is appropriate to bend the rules •  Are aware of resources and how to use them •  Are usually more self-confident, less anxious, and therefore more focused than less experienced nurses •  Know when it is safe to skip steps or do two steps together. Are able to focus on both the parts (the procedures) and the whole (the patient response). •  Are comfortable with rethinking a procedure if patient needs require modification of the procedure •  Have a better idea of suspected problems, allowing them to question more deeply and collect more relevant and in-depth data •  Analyze standards and policies, looking for ways to improve them •  Are challenged by novices’ questions, clarifying their own thinking when teaching novices From Alfaro-LeFevre R: Critical Thinking in Nursing: A Practical Approach, ed. 2, Philadelphia, 1999, Saunders. Reprinted with permission. Critical thinking is a complex, purposeful, disciplined process that has specific characteristics that make it different from run-of-the-mill problem solving. Critical thinking in nursing is undergirded by the standards and ethics of the profession. Consciously developed to improve patient outcomes, critical thinking by the nurse is driven by the needs of the patient and family. Nurses who think critically are engaged in a process of constant evaluation, redirection, improvement, and increased efficiency. Be aware that critical thinking involves far more than stating your opinion. You must be able to describe how you came to a conclusion and support your conclusions with explicit data and rationales. Becoming an excellent critical thinker is significantly related to increased years of work experience and to higher education level; moreover, nurses with critical thinking abilities tend to be more competent in their practice than nurses with less well-developed critical thinking skills ( Chang , Chang, Kuo et al., 2011). Box 8-4 summarizes these characteristics and offers an opportunity for you to evaluate your progress as a critical thinker. BOX 8-4     SELF-ASSESSMENT: CRITICAL THINKING Directions: Listed below are 15 characteristics of critical thinkers. Mark a plus sign (+) next to those you now possess, mark IP (in progress) next to those you have partially mastered, and mark a zero (0) next to those you have not yet mastered. When you are finished, make a plan for developing the areas that need improvement. Share it with at least one person, and report on progress weekly. Characteristics of critical thinkers: How do you measure up? ______ Inquisitive/curious/seeks truth ______ Self-informed/finds own answers ______ Analytic/confident in own reasoning skills ______ Open-minded ______ Flexible ______ Fair-minded ______ Honest about personal biases/self-aware ______ Prudent/exercises sound judgment ______ Willing to revise judgment when new evidence warrants ______ Clear about issues ______ Orderly in complex matters/organized approach to problems ______ Diligent in seeking information ______ Persistent ______ Reasonable ______ Focused on inquiry An excellent continuing education (CE) self-study module designed to improve your ability to think critically can be found online ( www.nurse.com/ce/CE168-60/Improving-Your-Ability-to-Think-Critically ). Continuing one’s education through lifelong learning is an excellent way to maintain and enhance your critical thinking skills. The website www.nurse.com has more than 500 CE opportunities available online and may be helpful to you as you seek to increase your knowledge base and improve your clinical judgment. Being intentional about improving your critical thinking skills ensures that you bring your best effort to the bedside in providing care for your patients. The nursing process: An intellectual standard Critical thinking requires systematic and disciplined use of universal intellectual standards ( Paul and Elder, 2012). In the practice of nursing, the nursing process represents a universal intellectual standard by which problems are addressed and solved. The nursing process is a method of critical thinking focused on solving patient problems in professional practice. The nursing process is “a conceptual framework that enables the student or the practicing nurse to think systematically and process pertinent information about the patient” ( Huckabay , 2009, p. 72). Humans are involved in problem solving on a daily basis. Suppose your favorite band is performing in a nearby city the night before your big exam in pathophysiology. Your exam counts 35% of your final grade. But you have wanted to see this band since you were 15, and you do not know when you will have another chance. You are faced with weighing a number of factors that will influence your decision about whether to go see the band: your grade going into the exam; how late you will be out the night before the exam; how far you will have to drive to see the band; and how much study time you will have to prepare for the exam in advance. You are really conflicted about this, so you decide to let another factor determine what you will do: the cost of the ticket. When you learn that the only seats available are near the back of the venue and cost $105.00 each, you decide to stay home, get a good night’s sleep before the big exam, and make a 98%. You then realize that with such a good grade on this exam, you will have much less pressure when studying for the final exam at the end of the semester. You have identified a problem (not a particularly serious one, but one with personal significance!), considered various factors related to the problem, identified possible actions, selected the best alternative, evaluated the success of the alternative selected, and made adjustments to the solution based on the evaluation. This is the same general process nurses use in solving patient problems through the nursing process. For individuals outside the profession, nursing is commonly and simplistically defined in terms of tasks nurses perform. Many students get frustrated with activities and courses in nursing school that are not focused on these tasks, believing themselves that the tasks of nursing are nursing. Even within the profession, the intellectual basis of nursing practice was not articulated until the 1960s, when nursing educators and leaders began to identify and name the components of nursing’s intellectual processes. This marked the beginning of the nursing process. In the 1970s and 1980s, debate about the use of the term “diagnosis” began. Until then, diagnosis was considered to be within the scope of practice of physicians only. Although nurses were not educated or licensed to diagnose medical conditions in patients, nurses recognized that there were human responses amenable to independent nursing intervention. A nursing diagnosis, then, is “a clinical judgment about individual, family or community responses to actual or potential health problems or life processes which provide the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability” (NANDA-I, 2012). These responses could be identified (diagnosed) through the careful application of specific defining characteristics. In 1973, the National Group for the Classification of Nursing Diagnosis published its first list of nursing diagnoses. This organization, which recently celebrated its 40th year, is now known as NANDA International (NANDA-I; NANDA is the acronym for North American Nursing Diagnosis Association). Its mission is to “facilitate the development, refinement, dissemination and use of standardized nursing diagnostic terminology” with the goal to “improve the health care of all people” (NANDA-I, 2012). In 2011, NANDA-I published its 2012–2014 edition of Nursing Diagnoses: Definitions and Classifications. Currently, NANDA-I has more than 200 diagnoses approved for clinical testing and has recently added 16 new diagnoses and 8 revised diagnoses. Diagnoses are also retired if it becomes evident that their usefulness is limited or outdated, such as the former diagnosis “disturbed thought processes.” Here is a simple example of how an approved nursing diagnosis may be used: Two days after a surgery for a large but benign abdominal mass, Mr. Stevens has not yet been able to tolerate solid food and has diminished bowel sounds. His abdomen is somewhat distended. Your diagnosis is that Mr. Stevens has dysfunctional gastrointestinal motility. This diagnosis is based on NANDA-I’s taxonomy because you have determined that the risk factors and physical signs and symptoms associated with this diagnosis apply to him. A more detailed discussion of nursing diagnosis is located in the next section of this chapter. The nursing process as a method of clinical problem solving is taught in schools of nursing across the United States, and many states refer to it in their nurse practice acts. The nursing process has sometimes been the subject of criticism among nurses. In recent years, some nursing leaders have questioned the use of the nursing process, describing it as linear, rigid, and mechanistic. They believe that the nursing process contributes to linear thinking and stymies critical thinking. They are concerned that the nursing process format, and rigid faculty adherence to it, encourages students to copy from published sources when writing care plans, thus inhibiting the development of a holistic, creative approach to patient care ( Mueller , Johnston, and Bligh, 2002). Certainly the nursing process can be taught, learned, and used in a rigid, mechanistic, and linear manner. Ideally the nursing process is used as a creative approach to thinking and decision making in nursing. Because the nursing process is an integral aspect of nursing education, practice, standards, and practice acts nationwide, learning to use it as a mechanism for critical thinking and as a dynamic and creative approach to patient care is a worthwhile endeavor. Despite reservations among some nurses about its use, the nursing process remains the cornerstone of nursing standards, legal definitions, and practice and, as such, should be well understood by every nurse. Phases of the nursing process Like many frameworks for thinking through problems, the nursing process is a series of organized steps, the purpose of which is to impose some discipline and critical thinking on the provision of excellent care. Identifying specific steps makes the process clear and concrete but can cause nurses to use them rigidly. Keep in mind that this is a process, that progression through the process may not be linear, and that it is a tool to use, not a road map to follow rigidly. More creative use of the nursing process may occur by expert nurses who have a greater repertoire of interventions from which to select. For example, if a newly hospitalized patient is experiencing a great deal of pain, a novice nurse might proceed by asking family members to leave so that he or she can provide a quiet environment in which the patient may rest. An expert nurse would realize that the family may be a source of distraction from the pain or may be a source of comfort in ways that the nurse may not be able to provide. The expert nurse, in addition to assessing the patient, is willing to consider alternative explanations and interventions, enhancing the possibility that the patient’s pain will be relieved. Phase 1: Assessment Assessment is the initial phase or operation in the nursing process. During this phase, information or data about the individual patient, family, or community are gathered. Data may include physiological, psychological, sociocultural, developmental, spiritual, and environmental information. The patient’s available financial or material resources also need to be assessed and recorded in a standard format; each institution usually has a slightly different method of recording assessment data. Types of data Nurses obtain two types of data about and from patients: subjective and objective. Subjective data are obtained from patients as they describe their needs, feelings, strengths, and perceptions of the problem. Subjective data are often referred to as symptoms. Examples of subjective data are statements such as, “I am in pain” and “I don’t have much energy.” The only source for these data is the patient. Subjective data should include physical, psychosocial, and spiritual information. Subjective data can be very private. Nurses must be sensitive to the patient’s need for confidence in the nurse’s trustworthiness. Objective data are the other types of data that the nurse will collect through observation, examination, or consultation with other health care providers. These data are measurable, such as pulse rate and blood pressure, and include observable patient behaviors. Objective data are often called signs. An example of objective data that a nurse might gather includes the observation that the patient, who is lying in bed, is diaphoretic, pale, and tachypneic, clutching his hands to his chest. Objective data and subjective data usually are congruent; that is, they usually are in agreement. In the situation just mentioned, if the patient told the nurse, “I feel like a rock is crushing my chest,” the subjective data would substantiate the nurse’s observations (objective data) that the patient is having chest pain. Occasionally, subjective and objective data are in conflict. A stark example of incongruent subjective and objective data well-known to labor and delivery nurses is when a pregnant woman in labor describes ongoing fetal activity (subjective data); however, there are no fetal heart tones (objective data), and the infant is stillborn. Incongruent objective and subjective data require further careful assessment to ascertain the patient’s situation more completely and accurately. Sometimes incongruent data reveal something about the patient’s concerns and fears. To get a clearer picture of the patient’s situation, the nurse should use the best communication skills he or she possesses to increase the patient’s trust, which will result in more openness.

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Week 6: Clinical Judgment Part A

Unit Learning Outcomes

At the end of this chapter, the learner will:

1. Compare and contrast three approaches to problem solving.

2. Describe models of clinical judgment for critical thinking and decision-making judgments.

3. Discuss clinical judgment and decision-making necessary to provide quality care.

Overview of this Chapter

This chapter will introduce the concept of clinical judgement, a vital  process where nurses make decisions using their knowledge, clinical  reasoning and critical thinking.  It is important to understand concepts related to clinical judgement(CJ) in nursing practice. This chapter is the part A of this concept and will include concepts related to clinical judgement, models of CJ and how important it is to provide safe nursing care to patients.

Nurses make decisions while providing patient care by using critical thinking  and clinical reasoning . Let’s review what is critical thinking, clinical reasoning and clinical judgement.

Critical thinking is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[1] Using critical thinking means that nurses take extra steps to maintain patient safety and don’t just “follow orders.” It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research. “Critical thinkers” possess certain attitudes that foster rational thinking. These attitudes are as follows:

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

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

Exercises: Pre-class:

Watch the video prior to class and be ready to discuss in the class. See the task below the video .

In-class discussion:

 Give an example of how you have used critical thinking, decision making & clinical reasoning in everyday life.  

I. Clinical Judgment and Nursing

When collecting subjective and objective data, you need to consider clinical judgment. In nursing, the purpose of health assessment is to facilitate  clinical judgment , which is defined as:

• A determination about a client’s health and illness status.
• Their health concerns and needs.
• The capacity to engage in their own care. AND
• The decision to intervene/act or not – and if action is required, what action (Tanner, 2006).

The nursing process is the foundation of clinical judgment. However, clinical judgment is more comprehensive, action-oriented, and guided by the philosophy of client safety. Thus, it is important to learn when to act to prevent  clinical   deterioration , a worsening clinical state related to physiological decompensation (Padilla & Mayo, 2017).

To facilitate clinical judgment, you must determine if the collected data represent normal findings or abnormal finding. When findings are abnormal, you must act on these cues as they signal a potential concern and require action. Failing to recognize abnormal findings and act on these cues can lead to negative consequences including sub-optimal health and wellness – and more importantly,  clinical   deterioration . Some abnormal findings are considered critical finding that place the client at further risk if the nurse does not act immediately.

The process leading to clinical judgment is described as  clinical   reasoning . This process involves:

• Thoughtfully considering all client data as a whole, whether each piece of information is relevant or irrelevant, and how each piece of information is related or not related.
• Recognizing and analyzing  cues. Is the information collected a normal, abnormal, or critical finding? Can the information be clustered to inform your clinical judgment?
• Interpreting problems. What is the priority problem and what are the factors causing it? What else do you need to assess to validate or invalidate your interpretation? What other information do you need to collect to make an accurate clinical judgment?

The clinical reasoning process is encompassed by  critical thinking . This means that when engaging in the process of clinical reasoning, you should systematically analyze your own thinking so that the outcomes are clear, rational, creative, and objective with limited risk of judgment and error.

Clinical Judgement 

A client tells you “I have a headache.” As the nurse, you immediately recognize the cue: headache. However, you do not have sufficient information to analyze this cue and identify the significance. Thus, you may ask a series of subjective questions such as “When did the headache start? What were you doing when it started? Have you ever had this type of headache before?” The client’s response will provide you detailed information to facilitate your critical thinking and the process of hypothesizing what is going on, and thereby helping you determine what actions to take.

Clinical judgement is facilitated by cognitive steps that help you determine when and how to act to prevent clinical deterioration; see  Table 6.1 . Like the nursing process, these steps should be performed in an iterative manner as per the client situation and your clinical reasoning process.

Table 6.1 : Clinical judgment steps (developed based on NCSBN, 2020)

Exercises:  Check Your Understanding

Discussion: Watch the video below and Discuss

 Video: NCSBN (National Council of State Boards of Nursing) : Clinical Judgment -The Next Generation NCLEX (NGN) – Right Decisions Come from Right Questions.

Discuss relevance of Clinical Judgment in nursing practice.

II. Priorities of Care

Why is clinical judgment important? How does it guide the provision of care?

Clinical judgment is important to ensure the nurse’s actions are based on the client’s most important needs. Clients often have several needs, and some are more important than others. As such, nurses need to assess and evaluate the  priorities   of care:  what actions are most important to take first, and then what actions can follow. Typically, priority actions are those that prevent clinical deterioration and death.

Exercises: CURE Hierarchy

• The CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to help guide prioritization based on identifying the differences among C ritical needs,  U rgent needs,  R outine needs, and  E xtras.

You are the nurse caring for the patients in the following table.  For each patient, indicate if this is a “critical,” “urgent,” “routine,” or “extra” need.

III. Maslow’s Hierarchy of Needs

Priorities of care can be determined using several frameworks such as  Maslow’s Hierarchy of Needs.  For example, at the most basic level, life requires an open airway to breathe, the physiological process of breathing, and the circulation of blood and oxygen throughout the body. Airway, breathing, and circulation are the ABCs, which you might have learned if you have taken a cardiopulmonary resuscitation (CPR) course.

Maslow’s Hierarchy of Needs was developed to consider  basic human needs  and motivations of healthy individuals (Bouzenita & Wood Boulanouar, 2016; Francis & Kritsonsis, 2006; Gambrel & Cianci, 2003). Although not well known, Maslow’s work was closely influenced by the Blackfoot tribe in Canada (James & Lunday, 2014). One version includes  five  levels of needs: those related to  physiological, safety, love, esteem,  and  self-actualization  (Maslow, 1943), which can help prioritize care in nursing.  Figure 6 .2  presents one adapted version of Maslow’s Hierarchy.

Figure 6.2 : Maslow’s Hierarchy of Needs (see attribution statement at bottom of page)

Drawing upon this framework, a nurse can use health assessments to explore five levels of needs:

• Are these basic physiological needs being met? Is the client’s breathing and circulation supported?
•  Does the client feel safe and secure in general in life? Does the client feel safe and secure in the healthcare environment? Is the bed lowered to the lowest position when you finish your assessment? Is the call bell in reach?
• Does the client feel love and belongingness in general in their relationships? More specifically, does the client feel cared for by nurses and other healthcare providers?
• Does the client feel respected and valued in general by others? Does the client feel respected and valued within the healthcare environment?
• What is important to the client in terms of what they want to achieve in life in general? What are the client’s goals that they may have for themselves in their own health and healing journey? Does the client feel satisfied, confident, and accomplished?

You can use Maslow’s Hierarchy of Needs as a guide, but it is important to be aware of the  critiques  and possible limitations in its application. See  Video 6.1  of a conversation between Dr. Lisa Seto Nielsen and Mahidhar Pemasani.

Video 6.1 : A discussion about Maslow’s Hierarchy of Needs

Criticisms of Maslow’s hierarchy  are related to it being ethnocentric, based on individualistic societies, and not necessarily taking into account diversity in culture, gender, and age (Bouzenita & Wood Boulanouar, 2016; Francis & Kritsonsis, 2006; Gambrel & Cianci, 2003). It should not be arbitrarily applied to all healthcare encounters. Although you may initially focus on physiological needs to ensure the client is stable, the client may have different priorities that are more important to them. By drawing upon Indigenous knowledge, it is vital to recognize the role of community and advocacy in reaching self actualization at every level (Bennett & Shangreaux, 2005). This is particularly important in the context of systemic racism and oppression and the existing disparities among racialized populations including Black communities and Indigenous People.

IV. Levels of Priority of Care

Because of the importance of recognizing clinical deterioration in a client, a nurse must always be attuned to the set of physiological needs that are important to maintain life and prevent death. These priorities of care are related to the ABCs – airway, breathing, and circulation – introduced above. These priorities of care are often categorized as first, second, or third level, with the first level taking a priority (see  Table 6.2 ).

Table 6.2 : Priorities of care

With regard to levels of care, it is essential to consider what is  most important to the client . You should treat the client as the expert in their own life – and also as the expert in decisions about their own healthcare, if they choose. Although a client may have plummeting blood pressure, you need to consider tailoring the intervening action to their wishes. Some clients may not wish for intervention in a life-threatening circumstance. Therefore, you always need to be open to the client’s wishes, but also consider whether they are able to weigh the consequences of their decision (i.e., are they competent to consent?).

Urgent Priorities of Care: Mental Health 

In practice, mental health is typically not categorized as a first- or second-level priority of care unless the client is showing signs of clinical deterioration based on the examples noted in  Table 6.3 . In some situations, mental health may be positioned as a third-level priority of care, for example when a client is experiencing anxiety, depression, grief, but shows no signs of suicidal ideation. These symptoms should be addressed, but according to this framework, they are considered less urgent compared to first- and second-level priorities of care. However, sometimes, you should think differently about how  mental health   is a priority of care .

In some situations,  mental health may take precedence.  For example, a client who has attempted suicide or has just overdosed will probably have other physical symptoms as a result and therefore require urgent intervention and constant observation as per  Table 6.3 . However, the descriptions of the priorities of care presented in the table do not account for a client who has voiced a specific plan for suicide and has identified when and how. This client is at very high risk and requires urgent intervention regardless of what may be viewed as their physical health state or history. The description of priorities of care listed above does not account for this except as a third-level priority – but a client with suicide ideation or has voiced wanting to hurt others requires urgent action to protect their own wellbeing and others and the possibility of clinical deterioration as a result of their actions.

V. Intervention Types

As illustrated by the text box above, you will need to use your own judgement to determine how to act when a cue presents itself and how to categorize these interventions. This could involve four general  types of interventions  that you need to be aware of (see  Table 6.3 ) including  effective, ineffective, unrelated,  and  contraindicated.  These types of interventions will become more clear as you begin to learn about normal, abnormal, and critical findings for various body systems, and how interventions and actions will affect these findings and the client.

Table 6.3:  Types of interventions

Exercises: In-Class

2. SPOTLIGHT APPLICATION: https://wtcs.pressbooks.pub/nursingmpc/chapter/2-6-spotlight-application/

Sam is a novice nurse who is reporting to work for his 0600 shift on the medical telemetry/progressive care floor. He is waiting to receive handoff report from the night shift nurse for his assigned patients. The information that he has received thus far regarding his patient assignment includes the following:

• Room 501:  64-year-old patient admitted last night with heart failure exacerbation. Patient received furosemide 80mg IV push at 2000 with 1600 mL urine output. He is receiving oxygen via nasal cannula at 2L/minute. According to the night shift aide, he has been resting comfortably overnight.
• Room 507:  74-year-old patient admitted yesterday for possible cardioversion due to new onset of atrial fibrillation with rapid ventricular response. Is scheduled for transesophageal echocardiogram and possible cardioversion at 1000.
• Room 512:  82-year-old patient who is scheduled for coronary artery bypass graft (CABG) surgery today at 0700 and is receiving an insulin infusion.
• Room 536:  72-year-old patient who had a negative heart catheterization yesterday but experienced a groin bleed; plans for discharge this morning.

Based on the limited information Sam has thus far, he begins to prioritize his activities for the morning. With what is known thus far regarding his patient assignment, whom might Sam plan to see first and why? What principles of prioritization might be applied?

  Clinical Judgment Review:  Think, Pair, Share

Read the case scenario and complete the activity below.

Case Scenario

Client admitted to orthopedic unit following an open reduction internal fixation of right lower tibia and fibula. Client was brought to the emergency department by family after falling on the stairs at home. Client reports pain currently 4 out of 10 and tolerable. Right lower leg in cast, elevated on pillows. Toes warm, capillary refill < 3 seconds, client denies numbness or tingling. Client reminded of non-weight bearing status on the right leg. Reviewed prescriptions and expectations for hospital stay. Client asks, “Why do I need insulin? I don’t have diabetes. The last time I saw my doctor, I was just told to eat less sweets and try to walk more often.”

  Instructions:

Pair with another student and complete the following activity on a 3×5 card.

Share your answers with the class.

Lab values are numbers (example: 2.5, 80, etc.)

• List three lab values that indicates your patient’s condition is improving
• List three lab values that indicates your patient’s condition is worsening
• List a priority nursing intervention based on one of these lab values

VI. Reflections

Prepare for the librarian visit.

• Have few EBP articles ready to discuss with the librarian
• Choose an EBP article for the EBP assignment

Key Takeaways

Type your key takeaways here.

Assignment: Review Blackboard for details

• MC Library Tutorial APA Format and Quiz (90%) 2.5 points.
• Library Tutorial- Academic Integrity & Avoiding Plagiarism Quiz (90%) 2.5 points.

VII. Recommended Resources

CLINICAL JUDGMENT MEASUREMENT MODEL: https://www.nclex.com/clinical-judgment-measurement-model.page

Getting Ready for the Next-Generation NCLEX ® (NGN): How to Shift from the Nursing Process to Clinical Judgment in Nursing: https://evolve.elsevier.com/education/expertise/next-generation-nclex/ngn-transitioning-from-the-nursing-process-to-clinical-judgment/

References and Attributes

• Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41(4), 215-221.
• Dickison, P., Haerling, K., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing Clinical Judgment Model into nursing educational frameworks.  Journal of Nursing Education ,  58 (2), 72-78.  https://doi.org/10.3928/01484834-20190122-03
• NCSBN (2020, Spring). Next Generation NCLEX news .  https://www.ncsbn.org/NGN_Spring20_Eng_02.pdf
• Padilla, R., & Mayo, A. (2017). Clinical deterioration: A concept analysis. Journal of Clinical Nursing ,  27 , 1360-1368.  https://doi.org/10.1111/jocn.14238
• Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education ,  45 (6), 204-211.  https://doi.org/10.3928/01484834-20060601-04
• Maslow, A. (1943). A theory of human motivation. Psychological Review ,  50 (4), 370-396.  https://doi .org/ 10.1037/h0054346
• Bennett, M., & Shangreaux, C. (2005). Applying Maslow’s Hierarchy Theory. First Peoples Child & Family Review: a Journal of Innovation and Best Practices in Aboriginal Child Welfare Administration, Research, Policy & Practice ,  2 (1)89-116. https://doi.org/10.7202/1069540ar
• Bouzenita, A. I. & Wood Boulanouar, A. (2016). Maslow’s hierarchy of needs: An Islamic critique. Intellectual Discourse ,  24 (1), 59-81.
• Francis, N.H. & Kritsonis, W.A. (2006). A brief analysis of Abraham Maslow’s original writing of self-actualizing people: A study of psychological health. Doctoral Forum: National Journal of Publishing and Mentoring Doctoral Student Research , 3(1), 1-7. 
• Critical Thinking and Clinical Reasoning: https://med.libretexts.org/Bookshelves/Nursing/Nursing_Management_and_Professional_Concepts_(OpenRN)/02%3A_Prioritization/2.04%3A_Critical_Thinking_and_Clinical_Reasoning
• Open Resources for Nursing (Open RN) Nursing Management and Professional Concepts   by Chippewa Valley Technical College 

The Novice Nurse's Guide to Professional Nursing Practice Copyright © by Kunjamma George and rbertiz is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Nurses are critical thinkers

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Margaret McCartney: Nurses must be allowed to exercise professional judgment

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Rapid Response:

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

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

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

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

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

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

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

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

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

Competing interests: No competing interests

What is Critical Thinking in Nursing? (With Examples, Importance, & How to Improve)

Successful nursing requires learning several skills used to communicate with patients, families, and healthcare teams. One of the most essential skills nurses must develop is the ability to demonstrate critical thinking. If you are a nurse, perhaps you have asked if there is a way to know how to improve critical thinking in nursing? As you read this article, you will learn what critical thinking in nursing is and why it is important. You will also find 18 simple tips to improve critical thinking in nursing and sample scenarios about how to apply critical thinking in your nursing career.

What Is Critical Thinking In Nursing?

4 reasons why critical thinking is so important in nursing, 1. critical thinking skills will help you anticipate and understand changes in your patient’s condition., 2. with strong critical thinking skills, you can make decisions about patient care that is most favorable for the patient and intended outcomes., 3. strong critical thinking skills in nursing can contribute to innovative improvements and professional development., 4. critical thinking skills in nursing contribute to rational decision-making, which improves patient outcomes., what are the 8 important attributes of excellent critical thinking in nursing, 1. the ability to interpret information:, 2. independent thought:, 3. impartiality:, 4. intuition:, 5. problem solving:, 6. flexibility:, 7. perseverance:, 8. integrity:, examples of poor critical thinking vs excellent critical thinking in nursing, 1. scenario: patient/caregiver interactions, poor critical thinking:, excellent critical thinking:, 2. scenario: improving patient care quality, 3. scenario: interdisciplinary collaboration, 4. scenario: precepting nursing students and other nurses, how to improve critical thinking in nursing, 1. demonstrate open-mindedness., 2. practice self-awareness., 3. avoid judgment., 4. eliminate personal biases., 5. do not be afraid to ask questions., 6. find an experienced mentor., 7. join professional nursing organizations., 8. establish a routine of self-reflection., 9. utilize the chain of command., 10. determine the significance of data and decide if it is sufficient for decision-making., 11. volunteer for leadership positions or opportunities., 12. use previous facts and experiences to help develop stronger critical thinking skills in nursing., 13. establish priorities., 14. trust your knowledge and be confident in your abilities., 15. be curious about everything., 16. practice fair-mindedness., 17. learn the value of intellectual humility., 18. never stop learning., 4 consequences of poor critical thinking in nursing, 1. the most significant risk associated with poor critical thinking in nursing is inadequate patient care., 2. failure to recognize changes in patient status:, 3. lack of effective critical thinking in nursing can impact the cost of healthcare., 4. lack of critical thinking skills in nursing can cause a breakdown in communication within the interdisciplinary team., useful resources to improve critical thinking in nursing, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. will lack of critical thinking impact my nursing career, 2. usually, how long does it take for a nurse to improve their critical thinking skills, 3. do all types of nurses require excellent critical thinking skills, 4. how can i assess my critical thinking skills in nursing.

• Ask relevant questions • Justify opinions • Address and evaluate multiple points of view • Explain assumptions and reasons related to your choice of patient care options

5. Can I Be a Nurse If I Cannot Think Critically?

Clinical Judgement

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

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Rethinking clinical decision-making to improve clinical reasoning

Salvatore corrao.

1 Department of Internal Medicine, National Relevance and High Specialization Hospital Trust ARNAS Civico, Palermo, Italy

2 Dipartimento di Promozione della Salute Materno Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), University of Palermo, Palermo, Italy

Christiano Argano

Associated data.

The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Improving clinical reasoning techniques is the right way to facilitate decision-making from prognostic, diagnostic, and therapeutic points of view. However, the process to do that is to fill knowledge gaps by studying and growing experience and knowing some cognitive aspects to raise the awareness of thinking mechanisms to avoid cognitive errors through correct educational training. This article examines clinical approaches and educational gaps in training medical students and young doctors. The authors explore the core elements of clinical reasoning, including metacognition, reasoning errors and cognitive biases, reasoning strategies, and ways to improve decision-making. The article addresses the dual-process theory of thought and the new Default Mode Network (DMN) theory. The reader may consider the article a first-level guide to deepen how to think and not what to think, knowing that this synthesis results from years of study and reasoning in clinical practice and educational settings.

Introduction

Clinical reasoning is based on complex and multifaceted cognitive processes, and the level of cognition is perhaps the most relevant factor that impacts the physician’s clinical reasoning. These topics have inspired considerable interest in the last years ( 1 , 2 ). According to Croskerry ( 3 ) and Croskerry and Norman ( 4 ), over 40 affective and cognitive biases may impact clinical reasoning. In addition, it should not be forgotten that both the processes and the subject matter are complex.

In medicine, there are thousands of known diagnoses, each with different complexity. Moreover, in line with Hammond’s view, a fundamental uncertainty will inevitably fail ( 5 ). Any mistake or failure in the diagnostic process leads to a delayed diagnosis, a misdiagnosis, or a missed diagnosis. The particular context in which a medical decision is made is highly relevant to the reasoning process and outcome ( 6 ).

More recently, there has been renewed interest in diagnostic reasoning, primarily diagnostic errors. Many researchers deepen inside the processes underpinning cognition, developing new universal reasoning and decision-making model: The Dual Process Theory.

This theory has a prompt implementation in medical decision-making and provides a comprehensive framework for understanding the gamma of theoretical approaches taken into consideration previously. This model has critical practical applications for medical decision-making and may be used as a model for teaching decision reasoning. Given this background, this manuscript must be considered a first-level guide to understanding how to think and not what to think, deepening clinical decision-making and providing tools for improving clinical reasoning.

Too much attention to the tip of the iceberg

The New England Journal of Medicine has recently published a fascinating article ( 7 ) in the “Perspective” section, whereon we must all reflect on it. The title is “At baseline” (the basic condition). Dr. Bergl, from the Department of Medicine of the Medical College of Wisconsin (Milwaukee), raised that his trainees no longer wonder about the underlying pathology but are focused solely on solving the acute problem. He wrote that, for many internal medicine teams, the question is not whether but to what extent we should juggle the treatment of critical health problems of patients with care for their coexisting chronic conditions. Doctors are under high pressure to discharge, and then they move patients to the next stage of treatment without questioning the reason that decompensated the clinical condition. Suppose the chronic condition or baseline was not the fundamental goal of our performance. In that case, our juggling is highly inconsistent because we are working on an intermediate outcome curing only the decompensation phase of a disease. Dr. Bergl raises another essential matter. Perhaps equally disturbing, by adopting a collective “base” mentality, we unintentionally create a group of doctors who prioritize productivity rather than developing critical skills and curiosity. We agree that empathy and patience are two other crucial elements in the training process of future internists. Nevertheless, how much do we stimulate all these qualities? Perhaps are not all part of cultural backgrounds necessary for a correct patient approach, the proper clinical reasoning, and balanced communication skills?

On the other hand, a chronic baseline condition is not always the real reason that justifies acute hospitalization. The lack of a careful approach to the baseline and clinical reasoning focused on the patient leads to this superficiality. We are focusing too much on our students’ practical skills and the amount of knowledge to learn. On the other hand, we do not teach how to think and the cognitive mechanisms of clinical reasoning.

Time to rethink the way of thinking and teaching courses

Back in 1910, John Dewey wrote in his book “How We Think” ( 8 ), “The aim of education should be to teach us rather how to think than what to think—rather improve our minds to enable us to think for ourselves than to load the memory with the thoughts of other men.”

Clinical reasoning concerns how to think and make the best decision-making process associated with the clinical practice ( 9 ). The core elements of clinical reasoning ( 10 ) can be summarized in:

• 1. Evidence-based skills,
• 2. Interpretation and use of diagnostic tests,
• 3. Understanding cognitive biases,
• 4. Human factors,
• 5. Metacognition (thinking about thinking), and
• 6. Patient-centered evidence-based medicine.

All these core elements are crucial for the best way of clinical reasoning. Each of them needs a correct learning path to be used in combination with developing the best thinking strategies ( Table 1 ). Reasoning strategies allow us to combine and synthesize diverse data into one or more diagnostic hypotheses, make the complex trade-off between the benefits and risks of tests and treatments, and formulate plans for patient management ( 10 ).

Set of some reasoning strategies (view the text for explanations).

However, among the abovementioned core element of clinical reasoning, two are often missing in the learning paths of students and trainees: metacognition and understanding cognitive biases.

Metacognition

We have to recall cognitive psychology, which investigates human thinking and describes how the human brain has two distinct mental processes that influence reasoning and decision-making. The first form of cognition is an ancient mechanism of thought shared with other animals where speed is more important than accuracy. In this case, thinking is characterized by a fast, intuitive way that uses pattern recognition and automated processes. The second one is a product of evolution, particularly in human beings, indicated by an analytical and hypothetical-deductive slow, controlled, but highly consuming way of thinking. Today, the psychology of thinking calls this idea “the dual-process theory of thought” ( 11 – 14 ). The Nobel Prize in Economic Sciences awardee Daniel Kahneman has extensively studied the dichotomy between the two modes of thought, calling them fast and slow thinking. “System 1” is fast, instinctive, and emotional; “System 2” is slower, more deliberative, and more logical ( 15 ). Different cerebral zones are involved: “System 1” includes the dorsomedial prefrontal cortex, the pregenual medial prefrontal cortex, and the ventromedial prefrontal cortex; “System 2” encompasses the dorsolateral prefrontal cortex. Glucose utilization is massive when System 2 is performing ( 16 ). System 1 is the leading way of thought used. None could live permanently in a deliberate, slow, effortful way. Driving a car, eating, and performing many activities over time become automatic and subconscious.

A recent brilliant review of Gronchi and Giovannelli ( 17 ) explores those things. Typically, when a mental effort is required for tasks requiring attention, every individual is subject to a phenomenon called “ego-depletion.” When forced to do something, each one has fewer cognitive resources available to activate slow thinking and thus is less able to exert self-control ( 18 , 19 ). In the same way, much clinical decision-making becomes intuitive rather than analytical, a phenomenon strongly affected by individual differences ( 20 , 21 ). Experimental evidence by functional magnetic resonance imaging and positron emission tomography studies supports that the “resting state” is spontaneously active during periods of “passivity” ( 22 – 25 ). The brain regions involved include the medial prefrontal cortex, the posterior cingulate cortex, the inferior parietal lobule, the lateral temporal cortex, the dorsal medial prefrontal cortex, and the hippocampal formation ( 26 ). Findings reporting high-metabolic activity in these regions at rest ( 27 ) constituted the first clear evidence of a cohesive default mode in the brain ( 28 ), leading to the widely acknowledged introduction of the Default Mode Network (DMN) concept. The DMN contains the medial prefrontal cortex, the posterior cingulate cortex, the inferior parietal lobule, the lateral temporal cortex, the dorsal medial prefrontal cortex, and the hippocampal formation. Lower activity levels characterize the DMN during goal-directed cognition and higher activity levels when an individual is awake and involved in the mental processes requiring low externally directed attention. All that is the neural basis of spontaneous cognition ( 26 ) that is responsible for thinking using internal representations. This paradigm is growing the idea of stimulus-independent thoughts (SITs), defined by Buckner et al. ( 26 ) as “thoughts about something other than events originating from the environment” that is covert and not directed toward the performance of a specific task. Very recently, the role of the DMN was highlighted in automatic behavior (the rapid selection of a response to a particular and predictable context) ( 29 ), as opposed to controlled decision making, suggesting that the DMN plays a role in the autopilot mode of brain functioning.

In light of these premises, everyone can pause to analyze what he is doing, improving self-control to avoid “ego-depletion.” Thus, one can actively switch between one type of thinking and the other. The ability to make this switch makes the physician more performing. In addition, a physician can be trained to understand the ways of thinking and which type of thinking is engaged in various situations. This way, experience and methodology knowledge can energize Systems 1 and 2 and how they interact, avoiding cognitive errors. Figure 1 summarizes all the concepts abovementioned about the Dual Mode Network and its relationship with the DMN.

Graphical representation of the characteristics of Dual Mode Network, including the relationship between the two systems by Default Mode Network (view the text for explanations).

Emotional intelligence is another crucial factor in boosting clinical reasoning for the best decision-making applied to a single patient. Emotional intelligence recognizes one’s emotions. Those others label different feelings appropriately and use emotional information to guide thinking and behavior, adjust emotions, and create empathy, adapt to environments, and achieve goals ( 30 ). According to the phenomenological account of Fuchs, bodily perception (proprioception) has a crucial role in understanding others ( 31 ). In this sense, the proprioceptive skills of a physician can help his empathic understanding become elementary for empathy and communication with the patient. In line with Fuchs’ view, empathic understanding encompasses a bodily resonance and mediates contextual knowledge about the patient. For medical education, empathy should help to relativize the singular experience, helping to prevent that own position becomes exclusive, bringing oneself out of the center of one’s own perspective.

Reasoning errors and cognitive biases

Errors in reasoning play a significant role in diagnostic errors and may compromise patient safety and quality of care. A recently published review by Norman et al. ( 32 ) examined clinical reasoning errors and how to avoid them. To simplify this complex issue, almost five types of diagnostic errors can be recognized: no-fault errors, system errors, errors due to the knowledge gap, errors due to misinterpretation, and cognitive biases ( 9 ). Apart from the first type of error, which is due to unavoidable errors due to various factors, we want to mention cognitive biases. They may occur at any stage of the reasoning process and may be linked to intuition and analytical systems. The most frequent cognitive biases in medicine are anchoring, confirmation bias, premature closure, search satisficing, posterior probability error, outcome bias, and commission bias ( 33 ). Anchoring is characterized by latching onto a particular aspect at the initial consultation, and then one refuses to change one’s mind about the importance of the later stages of reasoning. Confirmation bias ignores the evidence against an initial diagnosis. Premature closure leads to a misleading diagnosis by stopping the diagnostic process before all the information has been gathered or verified. Search satisficing blinds other additional diagnoses once the first diagnosis is made posterior probability error shortcuts to the usual patient diagnosis for previously recognized clinical presentations. Outcome bias impinges on our desire for a particular outcome that alters our judgment (e.g., a surgeon blaming sepsis on pneumonia rather than an anastomotic leak). Finally, commission bias is the tendency toward action rather than inaction, assuming that only good can come from doing something (rather than “watching and waiting”). These biases are only representative of the other types, and biases often work together. For example, in overconfidence bias (the tendency to believe we know more than we do), too much faith is placed in opinion instead of gathered evidence. This bias can be augmented by the anchoring effect or availability bias (when things are at the forefront of your mind because you have seen several cases recently or have been studying that condition in particular), and finally by commission bias—with disastrous results.

Novice vs. expert approaches

The reasoning strategies used by novices are different from those used by experts ( 34 ). Experts can usually gather beneficial information with highly effective problem-solving strategies. Heuristics are commonly, and most often successfully, used. The expert has a saved bank of illness scripts to compare and contrast the current case using more often type 1 thinking with much better results than the novice. Novices have little experience with their problems, do not have time to build a bank of illness scripts, and have no memories of previous similar cases and actions in such cases. Therefore, their mind search strategies will be weak, slow, and ponderous. Heuristics are poor and more often unsuccessful. They will consider a more comprehensive range of diagnostic possibilities and take longer to select approaches to discriminate among them. A novice needs specific knowledge and specific experience to become an expert. In our opinion, he also needs special training in the different ways of thinking. It is possible to study patterns, per se as well. It is, therefore, likely to guide the growth of knowledge for both fast thinking and slow one.

Moreover, learning by osmosis has traditionally been the method to move the novice toward expert capabilities by gradually gaining experience while observing experts’ reasoning. However, it seems likely that explicit teaching of clinical reasoning could make this process quicker and more effective. In this sense, an increased need for training and clinical knowledge along with the skill to apply the acquired knowledge is necessary. Students should learn disease pathophysiology, treatment concepts, and interdisciplinary team communication developing clinical decision-making through case-series-derived knowledge combining associative and procedural learning processes such as “Vienna Summer School on Oncology” ( 35 ).

Moreover, a refinement of the training of communicative skills is needed. Improving communication skills training for medical students and physicians should be the university’s primary goal. In fact, adequate communication leads to a correct diagnosis with 76% accuracy ( 36 ). The main challenge for students and physicians is the ability to respond to patients’ individual needs in an empathic and appreciated way. In this regard, it should be helpful to apply qualitative studies through the adoption of a semi-structured or structured interview using face-to-face in-depth interviews and e-learning platforms which can foster interdisciplinary learning by developing expertise for the clinical reasoning and decision-making in each area and integrating them. They could be effective tools to develop clinical reasoning and decision-making competencies and acquire effective communication skills to manage the relationship with patient ( 37 – 40 ).

Clinical reasoning ways

Clinical reasoning is complex: it often requires different mental processes operating simultaneously during the same clinical encounter and other procedures for different situations. The dual-process theory describes how humans have two distinct approaches to decision-making ( 41 ). When one uses heuristics, fast-thinking (system 1) is used ( 42 ). However, complex cases need slow analytical thinking or both systems involved ( 15 , 43 , 44 ). Slow thinking can use different ways of reasoning: deductive, hypothetic-deductive, inductive, abductive, probabilistic, rule-based/categorical/deterministic, and causal reasoning ( 9 ). We think that abductive and causal reasoning need further explanation. Abductive reasoning is necessary when no deductive argument (from general assumption to particular conclusion) nor inductive (the opposite of deduction) may be claimed.

In the real world, we often face a situation where we have information and move backward to the likely cause. We ask ourselves, what is the most plausible answer? What theory best explains this information? Abduction is just a process of choosing the hypothesis that would best explain the available evidence. On the other hand, causal reasoning uses knowledge of medical sciences to provide additional diagnostic information. For example, in a patient with dyspnea, if considering heart failure as a casual diagnosis, a raised BNP would be expected, and a dilated vena cava yet. Other diagnostic possibilities must be considered in the absence of these confirmatory findings (e.g., pneumonia). Causal reasoning does not produce hypotheses but is typically used to confirm or refute theories generated using other reasoning strategies.

Hypothesis generation and modification using deduction, induction/abduction, rule-based, causal reasoning, or mental shortcuts (heuristics and rule of thumbs) is the cognitive process for making a diagnosis ( 9 ). Clinicians develop a hypothesis, which may be specific or general, relating a particular situation to knowledge and experience. This process is referred to as generating a differential diagnosis. The process we use to produce a differential diagnosis from memory is unclear. The hypotheses chosen may be based on likelihood but might also reflect the need to rule out the worst-case scenario, even if the probability should always be considered.

Given the complexity of the involved process, there are numerous causes for failure in clinical reasoning. These can occur in any reasoning and at any stage in the process ( 33 ). We must be aware of subconscious errors in our thinking processes. Cognitive biases are subconscious deviations in judgment leading to perceptual distortion, inaccurate assessment, and misleading interpretation. From an evolutionary point of view, they have developed because, often, speed is more important than accuracy. Biases occur due to information processing heuristics, the brain’s limited capacity to process information, social influence, and emotional and moral motivations.

Heuristics are mind shortcuts and are not all bad. They refer to experience-based techniques for decision-making. Sometimes they may lead to cognitive biases (see above). They are also essential for mental processes, expressed by expert intuition that plays a vital role in clinical practice. Intuition is a heuristic that derives from a natural and direct outgrowth of experiences that are unconsciously linked to form patterns. Pattern recognition is just a quick shortcut commonly used by experts. Alternatively, we can create patterns by studying differently and adequately in a notional way that accumulates information. The heuristic that rules out the worst-case scenario is a forcing mind function that commits the clinician to consider the worst possible illness that might explain a particular clinical presentation and take steps to ensure it has been effectively excluded. The heuristic that considers the least probable diagnoses is a helpful approach to uncommon clinical pictures and thinking about and searching for a rare unrecognized condition. Clinical guidelines, scores, and decision rules function as externally constructed heuristics, usually to ensure the best evidence for the diagnosis and treatment of patients.

Hence, heuristics are helpful mind shortcuts, but the exact mechanisms may lead to errors. Fast-and-frugal tree and take-the-best heuristic are two formal models for deciding on the uncertainty domain ( 45 ).

In the recent times, clinicians have faced dramatic changes in the pattern of patients acutely admitted to hospital wards. Patients become older and older with comorbidities, rare diseases are frequent as a whole ( 46 ), new technologies are growing in a logarithmic way, and sustainability of the healthcare system is an increasingly important problem. In addition, uncommon clinical pictures represent a challenge for clinicians ( 47 – 50 ). In our opinion, it is time to claim clinical reasoning as a crucial way to deal with all complex matters. At first, we must ask ourselves if we have lost the teachings of ancient masters. Second, we have to rethink medical school courses and training ones. In this way, cognitive debiasing is needed to become a well-calibrated clinician. Fundamental tools are the comprehensive knowledge of nature and the extent of biases other than studying cognitive processes, including the interaction between fast and slow thinking. Cognitive debiasing requires the development of good mindware and the awareness that one debiasing strategy will not work for all biases. Finally, debiasing is generally a complicated process and requires lifelong maintenance.

We must remember that medicine is an art that operates in the field of science and must be able to cope with uncertainty. Managing uncertainty is the skill we have to develop against an excess of confidence that can lead to error. Sound clinical reasoning is directly linked to patient safety and quality of care.

Data availability statement

Author contributions.

SC and CA drafted the work and revised it critically. Both authors have approved the submission of the manuscript.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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An Update on Clinical Judgment in Nursing and Implications for Education, Practice, and Regulation

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The author would like to acknowledge the expertise and guidance of Ann Nielsen, PhD, RN; Janet Monagle, PhD, RN; Lisa Gonzalez, MSN, RN CNE, CCRN-K; and Kathie Lasater, EdD, RN, ANEF, FAAN.

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DOI: https://doi.org/10.1016/S2155-8256(21)00116-2

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The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

Chapter 1 – Introduction to Health Assessment

Clinical Judgment and Nursing

When collecting subjective and objective data, you need to consider clinical judgment. In nursing, the purpose of health assessment is to facilitate clinical judgment , which is defined as:

• A determination about a client’s health and illness status.
• Their health concerns and needs.
• The capacity to engage in their own care. AND
• The decision to intervene/act or not – and if action is required, what action (Tanner, 2006).

The nursing process is the foundation of clinical judgment. However, clinical judgment is more comprehensive, action-oriented, and guided by the philosophy of client safety. Thus, it is important to learn when to act to prevent clinical deterioration , a worsening clinical state related to physiological decompensation (Padilla & Mayo, 2017).

To facilitate clinical judgment, you must determine if the collected data represent normal findings  or abnormal findings . When findings are abnormal, you must act on these cues as they signal a potential concern and require action. Failing to recognize abnormal findings and act on these cues can lead to negative consequences including sub-optimal health and wellness – and more importantly, clinical deterioration . Some abnormal findings are considered critical findings that place the client at further risk if the nurse does not act immediately.

The process leading to clinical judgment is described as clinical reasoning . This process involves:

• Thoughtfully considering all client data as a whole, whether each piece of information is relevant or irrelevant, and how each piece of information is related or not related.
• Recognizing and analyzing cues . Is the information collected a normal, abnormal, or critical finding? Can the information be clustered to inform your clinical judgment?
• Interpreting problems. What is the priority problem and what are the factors causing it? What else do you need to assess to validate or invalidate your interpretation? What other information do you need to collect to make an accurate clinical judgment?
• Determining, implementing, and then evaluating appropriate actions (Dickison et al., 2019; Tanner, 2006).

The clinical reasoning process is encompassed by critical thinking . This means that when engaging in the process of clinical reasoning, you should systematically analyze your own thinking so that the outcomes are clear, rational, creative, and objective with limited risk of judgment and error.

Clinical Judgement 

A client tells you “I have a headache.” As the nurse, you immediately recognize the cue: headache. However, you do not have sufficient information to analyze this cue and identify the significance. Thus, you may ask a series of subjective questions such as “When did the headache start? What were you doing when it started? Have you ever had this type of headache before?” The client’s response will provide you detailed information to facilitate your critical thinking and the process of hypothesizing what is going on, and thereby helping you determine what actions to take.

Clinical judgement is facilitated by cognitive steps that help you determine when and how to act to prevent clinical deterioration; see Table 1.2 . Like the nursing process, these steps should be performed in an iterative manner as per the client situation and your clinical reasoning process.

Table 1.2 : Clinical judgment steps (developed based on NCSBN, 2020)

Activity: Check Your Understanding

Dickison, P., Haerling, K., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing Clinical Judgment Model into nursing educational frameworks.  Journal of Nursing Education ,  58 (2), 72-78.  https://doi.org/10.3928/01484834-20190122-03

NCSBN (2020, Spring).  Next Generation NCLEX news .  https://www.ncsbn.org/NGN_Spring20_Eng_02.pdf

Padilla, R., & Mayo, A. (2017). Clinical deterioration: A concept analysis.  Journal of Clinical Nursing ,  27 , 1360-1368.   https://doi.org/10.1111/jocn.14238

Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing.  Journal of Nursing Education ,  45 (6), 204-211.   https://doi.org/10.3928/01484834-20060601-04

are findings that are not of concern and expected for a client’s age, developmental stage, and sex.

are findings of concern because they are not normal and not consistent with a client’s age, developmental stage, and sex.

are findings that require prompt and immediate action to prevent clinical deterioration or intervene when a client is deteriorating.

are a sign or symptom that prompts an action such as an abnormal finding that signals a potential concern.

, in reference to solutions/interventions, refers to solutions and interventions that are suggested as a desirable or necessary course of action.

in reference to solutions/interventions, refers to solutions and interventions that are not needed and not absolutely necessary.

in reference to solutions/interventions, refers to solutions and interventions that are not connected or related to the problem.

in reference to solutions/interventions, refers to solutions and interventions that should not be used because they may be harmful.

Introduction to Health Assessment for the Nursing Professional - Part I Copyright © by December 2021 is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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