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CRITICAL THINKING AND THE NURSING PROCESS

Oct 09, 2014

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CRITICAL THINKING AND THE NURSING PROCESS. NRS 101 Unit III Session 3. Critical Thinking and Nursing Judgment. How do we make decisions? How do nurses make decisions about patient care? What do we rely on to help us in decision making?. Critical Thinking and Nursing Judgment.

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CRITICAL THINKING AND THE NURSING PROCESS NRS 101 Unit III Session 3

Critical Thinking and Nursing Judgment • How do we make decisions? • How do nurses make decisions about patient care? • What do we rely on to help us in decision making?

Critical Thinking and Nursing Judgment • Not a linear step by step process • Process acquired through hard work, commitment, and an active curiosity toward learning • Decision making is the skill that separates the professional nurse from technical or ancillary staff

Critical Thinking and Nursing Judgment • Good problem solving skills • Not always a clear textbook answer • Nurse must learn to question, look at alternatives

How do nurse's accomplish this? • Learns to be flexible in clinical decision making • Reflect on past experiences and previous knowledge • Listen to others point of view • Identify the nature of the problem • Select the best solution for improving client’s health

Definition of Critical Thinking • Cognitive process during which an individual reviews data and considers potential explanations and outcomes before forming an opinion or making a decision • “Critical thinking in nursing practice is a discipline specific, reflective reasoning process that guides the nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns.” NLN 2000

Critical Thinking in Nursing • Purposeful, outcome-directed • Essential to safe, competent, skillful nursing practice • Based on principles of nursing process and the scientific method • Requires specific knowledge, skills, and experience • New nurses must question

Critical Thinking in Nursing • Guided by professional standards and ethic codes • Requires strategies that maximize potential and compensate for problems • Constantly reevaluating, self-correcting, and striving to improve

Formula for Critical Thinking • Start Thinking • Why Ask Why • Ask the Right Questions • Are you an expert?

Aspects of Critical Thinking • Reflection • Language • Intuition

Levels of Critical Thinking • Basic • Complex • Commitment

Critical Thinking Competencies • Scientific method • Problem Solving • Decision Making • Diagnostic Reasoning and Inferences • Clinical Decision Making • Nursing Process

Developing Critical Thinking Attitudes/Skills Not easy Not “either or” Self-assessment Tolerating dissonance and ambiguity Seeking situations where good thinking practiced Creating environments that support critical thinking

Nursing Process • Systematic approach that is used by all nurses to gather data, critically examine and analyze the data, identify client responses, design outcomes, take appropriate action, then evaluate the effectiveness of action • Involves the use of critical thinking skills • Common language for nurses to “think through” clinical problems

Nursing Process

Thinking and Learning • Lifelong process • Flexible, open process • Learn to think and to ANTICIPATE • What, why, how questions • Look beyond the obvious • Reflect on past experience • New knowledge challenges the traditional way

Components Of Critical Thinking • Scientific Knowledge Base • Experience • Competencies • Attitudes • Standards

Attitudes That Foster Critical Thinking • Independence • Fair-mindedness • Insight into ethnocentricity • Intellectual humility • Intellectual courage to challenge status quo • Integrity • Preserverance • Confidence • Curiosity

Professional Standards • Ethical criteria for Nursing judgment- Code of Ethics • Criteria for evaluation- Standards of care • Standards of professional responsibility that nurses strive to achieve are cited in Nurse Practice Acts, TJC guidelines, institutional policy and procedure, ANA Standards of Nursing Practice

Critical Thinking Synthesis • Reasoning process by which individuals reflect on and analyze their own thoughts, actions, & decisions and those of others • Not a step by step process

Nursing Process • Traditional critical thinking competency • 5 Step circular, ongoing process • Continuous until clients health is improved, restored or maintained • Must involve assessment and changes in condition

When using the Nursing Process • Identify health care needs • Determine Priorities • Establish goals & expected outcomes • Provide appropriate interventions • Evaluate effectiveness

Nursing Process • Assessment • Diagnosis • Planning • Implementation • Evaluation

Assessment • Systemically collects, verifies, analyzes and communicates data • Two step process- Collection and Verification of data & Analysis of data • Establishes a data base about client needs, health problems, responses, related experiences, health practices, values. lifestyle, & expectations

Critical Thinking and Assessment Process • Brings knowledge from biological, physical, & social sciences as basis for the nurse to ask relevant questions. Need knowledge of communication skills • Prior clinical experience contributes to assessment skills • Apply Standards of Practice • Personal Attitudes

Assessment Data • Subjective Data • Objective Data • Sources of Data • Methods of Data Collection-Interview • Interview initiates nurse-client relationship • Use open-ended questions • Nursing health history

Nursing Diagnosis • Statement that describes the client’s actual or potential response to a health problem • Focuses on client-centered problems • First introduced in the 1950’s • NANDA established in 1982 • Step of the nursing process that allows nurse to individualize care

Planning for Nursing Care • Client-centered goals and expected outcomes are established • Priorities are set relating to unmet needs • Maslow’s Hierarchy of Needs is a useful method for setting priorities • Priorities are classifies as high, intermediate, or low

Purpose of Goals and Outcomes • Provides direction for individualized nursing interventions • Sets standards of determining the effectiveness of interventions • Indicates anticipated client behavior or response to nursing care • End point of nursing care

Goals of Care • Goal: Guideposts to the selection of nursing interventions and criteria in the evaluation of interventions • What you want to achieve with your patient and in what time frame • Short term vs. Long term • Outcome Of Care: What was actually achieved, was goal met or not met

Nursing Interventions • Interventions are selected after goals and outcomes are determined • Actions designed to assist client in moving from the present level of health to that which is described in the goal and measured with outcome criteria • Utilizes critical thinking by applying attitudes and standards and synthesizing data

Types of Interventions • Nurse-Initiated • Physician-Initiated • Collaborative Interventions

Selection Of Intervention • Using clinical decision making skills, the nurse deliberates 6 factors: • Diagnosis, expected outcomes, research base, feasibility, acceptability to client, competency of nurse

Nursing Care Plans • Written guidelines for client care • Organized so nurse can quickly identify nursing actions to be delivered • Coordinates resources for care • Enhances the continuity of care • Organizes information for change of shift report

Nursing Care Plans vs Concept Maps NCP Concept/Mind Map

Implementation of Nursing Interventions • Describes a category of nursing behaviors in which the actions necessary for achieving the goals and outcomes are initiated and completed • Action taken by nurse

Types of Nursing Interventions • Standing Orders: Document containing orders for the use of routine therapies, monitoring guidelines, and/or diagnostic procedure for specific condition • Protocols: Written plan specifying the procedures to be followed during care of a client with a select clinical condition or situation (Pneumonia, MI, CVA)

Implementation Process involves: • Reassessing the client • Reviewing and revising the existing care plan • Organizing resources and care delivery (equipment, personnel, environment)

Evaluation • Step of the nursing process that measures the client’s response to nursing actions and the client’s progress toward achieving goals • Data collected on an on-going basis • Supports the basis of the usefulness and effectiveness of nursing practice • Involves measurement of Quality of Care

Evaluation of Goal Achievement • Measures and Sources: Assessment skills and techniques • As goals are evaluated, adjustments of the care plan are made • If the goal was met, that part of the care plan is discontinued • Redefines priorities

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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

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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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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Chapter 6 clinical reasoning, decisionmaking, and action: thinking critically and clinically.

Patricia Benner ; Ronda G. Hughes ; Molly Sutphen .

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This chapter examines multiple thinking strategies that are needed for high-quality clinical practice. Clinical reasoning and judgment are examined in relation to other modes of thinking used by clinical nurses in providing quality health care to patients that avoids adverse events and patient harm. The clinician’s ability to provide safe, high-quality care can be dependent upon their ability to reason, think, and judge, which can be limited by lack of experience. The expert performance of nurses is dependent upon continual learning and evaluation of performance.

• Critical Thinking

Nursing education has emphasized critical thinking as an essential nursing skill for more than 50 years. 1 The definitions of critical thinking have evolved over the years. There are several key definitions for critical thinking to consider. The American Philosophical Association (APA) defined critical thinking as purposeful, self-regulatory judgment that uses cognitive tools such as interpretation, analysis, evaluation, inference, and explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations on which judgment is based. 2 A more expansive general definition of critical thinking is

. . . in short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposes assent to rigorous standards of excellence and mindful command of their use. It entails effective communication and problem solving abilities and a commitment to overcome our native egocentrism and sociocentrism. Every clinician must develop rigorous habits of critical thinking, but they cannot escape completely the situatedness and structures of the clinical traditions and practices in which they must make decisions and act quickly in specific clinical situations. 3

There are three key definitions for nursing, which differ slightly. Bittner and Tobin defined critical thinking as being “influenced by knowledge and experience, using strategies such as reflective thinking as a part of learning to identify the issues and opportunities, and holistically synthesize the information in nursing practice” 4 (p. 268). Scheffer and Rubenfeld 5 expanded on the APA definition for nurses through a consensus process, resulting in the following definition:

Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, openmindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge 6 (Scheffer & Rubenfeld, p. 357).

The National League for Nursing Accreditation Commission (NLNAC) defined critical thinking as:

the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research 7 (p. 8).

These concepts are furthered by the American Association of Colleges of Nurses’ definition of critical thinking in their Essentials of Baccalaureate Nursing :

Critical thinking underlies independent and interdependent decision making. Critical thinking includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity 8 (p. 9).

Course work or ethical experiences should provide the graduate with the knowledge and skills to:

• Use nursing and other appropriate theories and models, and an appropriate ethical framework;
• Apply research-based knowledge from nursing and the sciences as the basis for practice;
• Use clinical judgment and decision-making skills;
• Engage in self-reflective and collegial dialogue about professional practice;
• Evaluate nursing care outcomes through the acquisition of data and the questioning of inconsistencies, allowing for the revision of actions and goals;
• Engage in creative problem solving 8 (p. 10).

Taken together, these definitions of critical thinking set forth the scope and key elements of thought processes involved in providing clinical care. Exactly how critical thinking is defined will influence how it is taught and to what standard of care nurses will be held accountable.

Professional and regulatory bodies in nursing education have required that critical thinking be central to all nursing curricula, but they have not adequately distinguished critical reflection from ethical, clinical, or even creative thinking for decisionmaking or actions required by the clinician. Other essential modes of thought such as clinical reasoning, evaluation of evidence, creative thinking, or the application of well-established standards of practice—all distinct from critical reflection—have been subsumed under the rubric of critical thinking. In the nursing education literature, clinical reasoning and judgment are often conflated with critical thinking. The accrediting bodies and nursing scholars have included decisionmaking and action-oriented, practical, ethical, and clinical reasoning in the rubric of critical reflection and thinking. One might say that this harmless semantic confusion is corrected by actual practices, except that students need to understand the distinctions between critical reflection and clinical reasoning, and they need to learn to discern when each is better suited, just as students need to also engage in applying standards, evidence-based practices, and creative thinking.

The growing body of research, patient acuity, and complexity of care demand higher-order thinking skills. Critical thinking involves the application of knowledge and experience to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. These skills can be cultivated by educators who display the virtues of critical thinking, including independence of thought, intellectual curiosity, courage, humility, empathy, integrity, perseverance, and fair-mindedness. 9

The process of critical thinking is stimulated by integrating the essential knowledge, experiences, and clinical reasoning that support professional practice. The emerging paradigm for clinical thinking and cognition is that it is social and dialogical rather than monological and individual. 10–12 Clinicians pool their wisdom and multiple perspectives, yet some clinical knowledge can be demonstrated only in the situation (e.g., how to suction an extremely fragile patient whose oxygen saturations sink too low). Early warnings of problematic situations are made possible by clinicians comparing their observations to that of other providers. Clinicians form practice communities that create styles of practice, including ways of doing things, communication styles and mechanisms, and shared expectations about performance and expertise of team members.

By holding up critical thinking as a large umbrella for different modes of thinking, students can easily misconstrue the logic and purposes of different modes of thinking. Clinicians and scientists alike need multiple thinking strategies, such as critical thinking, clinical judgment, diagnostic reasoning, deliberative rationality, scientific reasoning, dialogue, argument, creative thinking, and so on. In particular, clinicians need forethought and an ongoing grasp of a patient’s health status and care needs trajectory, which requires an assessment of their own clarity and understanding of the situation at hand, critical reflection, critical reasoning, and clinical judgment.

Critical Reflection, Critical Reasoning, and Judgment

Critical reflection requires that the thinker examine the underlying assumptions and radically question or doubt the validity of arguments, assertions, and even facts of the case. Critical reflective skills are essential for clinicians; however, these skills are not sufficient for the clinician who must decide how to act in particular situations and avoid patient injury. For example, in everyday practice, clinicians cannot afford to critically reflect on the well-established tenets of “normal” or “typical” human circulatory systems when trying to figure out a particular patient’s alterations from that typical, well-grounded understanding that has existed since Harvey’s work in 1628. 13 Yet critical reflection can generate new scientifically based ideas. For example, there is a lack of adequate research on the differences between women’s and men’s circulatory systems and the typical pathophysiology related to heart attacks. Available research is based upon multiple, taken-for-granted starting points about the general nature of the circulatory system. As such, critical reflection may not provide what is needed for a clinician to act in a situation. This idea can be considered reasonable since critical reflective thinking is not sufficient for good clinical reasoning and judgment. The clinician’s development of skillful critical reflection depends upon being taught what to pay attention to, and thus gaining a sense of salience that informs the powers of perceptual grasp. The powers of noticing or perceptual grasp depend upon noticing what is salient and the capacity to respond to the situation.

Critical reflection is a crucial professional skill, but it is not the only reasoning skill or logic clinicians require. The ability to think critically uses reflection, induction, deduction, analysis, challenging assumptions, and evaluation of data and information to guide decisionmaking. 9 , 14 , 15 Critical reasoning is a process whereby knowledge and experience are applied in considering multiple possibilities to achieve the desired goals, 16 while considering the patient’s situation. 14 It is a process where both inductive and deductive cognitive skills are used. 17 Sometimes clinical reasoning is presented as a form of evaluating scientific knowledge, sometimes even as a form of scientific reasoning. Critical thinking is inherent in making sound clinical reasoning. 18

An essential point of tension and confusion exists in practice traditions such as nursing and medicine when clinical reasoning and critical reflection become entangled, because the clinician must have some established bases that are not questioned when engaging in clinical decisions and actions, such as standing orders. The clinician must act in the particular situation and time with the best clinical and scientific knowledge available. The clinician cannot afford to indulge in either ritualistic unexamined knowledge or diagnostic or therapeutic nihilism caused by radical doubt, as in critical reflection, because they must find an intelligent and effective way to think and act in particular clinical situations. Critical reflection skills are essential to assist practitioners to rethink outmoded or even wrong-headed approaches to health care, health promotion, and prevention of illness and complications, especially when new evidence is available. Breakdowns in practice, high failure rates in particular therapies, new diseases, new scientific discoveries, and societal changes call for critical reflection about past assumptions and no-longer-tenable beliefs.

Clinical reasoning stands out as a situated, practice-based form of reasoning that requires a background of scientific and technological research-based knowledge about general cases, more so than any particular instance. It also requires practical ability to discern the relevance of the evidence behind general scientific and technical knowledge and how it applies to a particular patient. In dong so, the clinician considers the patient’s particular clinical trajectory, their concerns and preferences, and their particular vulnerabilities (e.g., having multiple comorbidities) and sensitivities to care interventions (e.g., known drug allergies, other conflicting comorbid conditions, incompatible therapies, and past responses to therapies) when forming clinical decisions or conclusions.

Situated in a practice setting, clinical reasoning occurs within social relationships or situations involving patient, family, community, and a team of health care providers. The expert clinician situates themselves within a nexus of relationships, with concerns that are bounded by the situation. Expert clinical reasoning is socially engaged with the relationships and concerns of those who are affected by the caregiving situation, and when certain circumstances are present, the adverse event. Halpern 19 has called excellent clinical ethical reasoning “emotional reasoning” in that the clinicians have emotional access to the patient/family concerns and their understanding of the particular care needs. Expert clinicians also seek an optimal perceptual grasp, one based on understanding and as undistorted as possible, based on an attuned emotional engagement and expert clinical knowledge. 19 , 20

Clergy educators 21 and nursing and medical educators have begun to recognize the wisdom of broadening their narrow vision of rationality beyond simple rational calculation (exemplified by cost-benefit analysis) to reconsider the need for character development—including emotional engagement, perception, habits of thought, and skill acquisition—as essential to the development of expert clinical reasoning, judgment, and action. 10 , 22–24 Practitioners of engineering, law, medicine, and nursing, like the clergy, have to develop a place to stand in their discipline’s tradition of knowledge and science in order to recognize and evaluate salient evidence in the moment. Diagnostic confusion and disciplinary nihilism are both threats to the clinician’s ability to act in particular situations. However, the practice and practitioners will not be self-improving and vital if they cannot engage in critical reflection on what is not of value, what is outmoded, and what does not work. As evidence evolves and expands, so too must clinical thought.

Clinical judgment requires clinical reasoning across time about the particular, and because of the relevance of this immediate historical unfolding, clinical reasoning can be very different from the scientific reasoning used to formulate, conduct, and assess clinical experiments. While scientific reasoning is also socially embedded in a nexus of social relationships and concerns, the goal of detached, critical objectivity used to conduct scientific experiments minimizes the interactive influence of the research on the experiment once it has begun. Scientific research in the natural and clinical sciences typically uses formal criteria to develop “yes” and “no” judgments at prespecified times. The scientist is always situated in past and immediate scientific history, preferring to evaluate static and predetermined points in time (e.g., snapshot reasoning), in contrast to a clinician who must always reason about transitions over time. 25 , 26

Techne and Phronesis

Distinctions between the mere scientific making of things and practice was first explored by Aristotle as distinctions between techne and phronesis. 27 Learning to be a good practitioner requires developing the requisite moral imagination for good practice. If, for example, patients exercise their rights and refuse treatments, practitioners are required to have the moral imagination to understand the probable basis for the patient’s refusal. For example, was the refusal based upon catastrophic thinking, unrealistic fears, misunderstanding, or even clinical depression?

Techne, as defined by Aristotle, encompasses the notion of formation of character and habitus 28 as embodied beings. In Aristotle’s terms, techne refers to the making of things or producing outcomes. 11 Joseph Dunne defines techne as “the activity of producing outcomes,” and it “is governed by a means-ends rationality where the maker or producer governs the thing or outcomes produced or made through gaining mastery over the means of producing the outcomes, to the point of being able to separate means and ends” 11 (p. 54). While some aspects of medical and nursing practice fall into the category of techne, much of nursing and medical practice falls outside means-ends rationality and must be governed by concern for doing good or what is best for the patient in particular circumstances, where being in a relationship and discerning particular human concerns at stake guide action.

Phronesis, in contrast to techne, includes reasoning about the particular, across time, through changes or transitions in the patient’s and/or the clinician’s understanding. As noted by Dunne, phronesis is “characterized at least as much by a perceptiveness with regard to concrete particulars as by a knowledge of universal principles” 11 (p. 273). This type of practical reasoning often takes the form of puzzle solving or the evaluation of immediate past “hot” history of the patient’s situation. Such a particular clinical situation is necessarily particular, even though many commonalities and similarities with other disease syndromes can be recognized through signs and symptoms and laboratory tests. 11 , 29 , 30 Pointing to knowledge embedded in a practice makes no claim for infallibility or “correctness.” Individual practitioners can be mistaken in their judgments because practices such as medicine and nursing are inherently underdetermined. 31

While phronetic knowledge must remain open to correction and improvement, real events, and consequences, it cannot consistently transcend the institutional setting’s capacities and supports for good practice. Phronesis is also dependent on ongoing experiential learning of the practitioner, where knowledge is refined, corrected, or refuted. The Western tradition, with the notable exception of Aristotle, valued knowledge that could be made universal and devalued practical know-how and experiential learning. Descartes codified this preference for formal logic and rational calculation.

Aristotle recognized that when knowledge is underdetermined, changeable, and particular, it cannot be turned into the universal or standardized. It must be perceived, discerned, and judged, all of which require experiential learning. In nursing and medicine, perceptual acuity in physical assessment and clinical judgment (i.e., reasoning across time about changes in the particular patient or the clinician’s understanding of the patient’s condition) fall into the Greek Aristotelian category of phronesis. Dewey 32 sought to rescue knowledge gained by practical activity in the world. He identified three flaws in the understanding of experience in Greek philosophy: (1) empirical knowing is the opposite of experience with science; (2) practice is reduced to techne or the application of rational thought or technique; and (3) action and skilled know-how are considered temporary and capricious as compared to reason, which the Greeks considered as ultimate reality.

In practice, nursing and medicine require both techne and phronesis. The clinician standardizes and routinizes what can be standardized and routinized, as exemplified by standardized blood pressure measurements, diagnoses, and even charting about the patient’s condition and treatment. 27 Procedural and scientific knowledge can often be formalized and standardized (e.g., practice guidelines), or at least made explicit and certain in practice, except for the necessary timing and adjustments made for particular patients. 11 , 22

Rational calculations available to techne—population trends and statistics, algorithms—are created as decision support structures and can improve accuracy when used as a stance of inquiry in making clinical judgments about particular patients. Aggregated evidence from clinical trials and ongoing working knowledge of pathophysiology, biochemistry, and genomics are essential. In addition, the skills of phronesis (clinical judgment that reasons across time, taking into account the transitions of the particular patient/family/community and transitions in the clinician’s understanding of the clinical situation) will be required for nursing, medicine, or any helping profession.

Thinking Critically

Being able to think critically enables nurses to meet the needs of patients within their context and considering their preferences; meet the needs of patients within the context of uncertainty; consider alternatives, resulting in higher-quality care; 33 and think reflectively, rather than simply accepting statements and performing tasks without significant understanding and evaluation. 34 Skillful practitioners can think critically because they have the following cognitive skills: information seeking, discriminating, analyzing, transforming knowledge, predicating, applying standards, and logical reasoning. 5 One’s ability to think critically can be affected by age, length of education (e.g., an associate vs. a baccalaureate decree in nursing), and completion of philosophy or logic subjects. 35–37 The skillful practitioner can think critically because of having the following characteristics: motivation, perseverance, fair-mindedness, and deliberate and careful attention to thinking. 5 , 9

Thinking critically implies that one has a knowledge base from which to reason and the ability to analyze and evaluate evidence. 38 Knowledge can be manifest by the logic and rational implications of decisionmaking. Clinical decisionmaking is particularly influenced by interpersonal relationships with colleagues, 39 patient conditions, availability of resources, 40 knowledge, and experience. 41 Of these, experience has been shown to enhance nurses’ abilities to make quick decisions 42 and fewer decision errors, 43 support the identification of salient cues, and foster the recognition and action on patterns of information. 44 , 45

Clinicians must develop the character and relational skills that enable them to perceive and understand their patient’s needs and concerns. This requires accurate interpretation of patient data that is relevant to the specific patient and situation. In nursing, this formation of moral agency focuses on learning to be responsible in particular ways demanded by the practice, and to pay attention and intelligently discern changes in patients’ concerns and/or clinical condition that require action on the part of the nurse or other health care workers to avert potential compromises to quality care.

Formation of the clinician’s character, skills, and habits are developed in schools and particular practice communities within a larger practice tradition. As Dunne notes,

A practice is not just a surface on which one can display instant virtuosity. It grounds one in a tradition that has been formed through an elaborate development and that exists at any juncture only in the dispositions (slowly and perhaps painfully acquired) of its recognized practitioners. The question may of course be asked whether there are any such practices in the contemporary world, whether the wholesale encroachment of Technique has not obliterated them—and whether this is not the whole point of MacIntyre’s recipe of withdrawal, as well as of the post-modern story of dispossession 11 (p. 378).

Clearly Dunne is engaging in critical reflection about the conditions for developing character, skills, and habits for skillful and ethical comportment of practitioners, as well as to act as moral agents for patients so that they and their families receive safe, effective, and compassionate care.

Professional socialization or professional values, while necessary, do not adequately address character and skill formation that transform the way the practitioner exists in his or her world, what the practitioner is capable of noticing and responding to, based upon well-established patterns of emotional responses, skills, dispositions to act, and the skills to respond, decide, and act. 46 The need for character and skill formation of the clinician is what makes a practice stand out from a mere technical, repetitious manufacturing process. 11 , 30 , 47

In nursing and medicine, many have questioned whether current health care institutions are designed to promote or hinder enlightened, compassionate practice, or whether they have deteriorated into commercial institutional models that focus primarily on efficiency and profit. MacIntyre points out the links between the ongoing development and improvement of practice traditions and the institutions that house them:

Lack of justice, lack of truthfulness, lack of courage, lack of the relevant intellectual virtues—these corrupt traditions, just as they do those institutions and practices which derive their life from the traditions of which they are the contemporary embodiments. To recognize this is of course also to recognize the existence of an additional virtue, one whose importance is perhaps most obvious when it is least present, the virtue of having an adequate sense of the traditions to which one belongs or which confront one. This virtue is not to be confused with any form of conservative antiquarianism; I am not praising those who choose the conventional conservative role of laudator temporis acti. It is rather the case that an adequate sense of tradition manifests itself in a grasp of those future possibilities which the past has made available to the present. Living traditions, just because they continue a not-yet-completed narrative, confront a future whose determinate and determinable character, so far as it possesses any, derives from the past 30 (p. 207).

It would be impossible to capture all the situated and distributed knowledge outside of actual practice situations and particular patients. Simulations are powerful as teaching tools to enable nurses’ ability to think critically because they give students the opportunity to practice in a simplified environment. However, students can be limited in their inability to convey underdetermined situations where much of the information is based on perceptions of many aspects of the patient and changes that have occurred over time. Simulations cannot have the sub-cultures formed in practice settings that set the social mood of trust, distrust, competency, limited resources, or other forms of situated possibilities.

One of the hallmark studies in nursing providing keen insight into understanding the influence of experience was a qualitative study of adult, pediatric, and neonatal intensive care unit (ICU) nurses, where the nurses were clustered into advanced beginner, intermediate, and expert level of practice categories. The advanced beginner (having up to 6 months of work experience) used procedures and protocols to determine which clinical actions were needed. When confronted with a complex patient situation, the advanced beginner felt their practice was unsafe because of a knowledge deficit or because of a knowledge application confusion. The transition from advanced beginners to competent practitioners began when they first had experience with actual clinical situations and could benefit from the knowledge gained from the mistakes of their colleagues. Competent nurses continuously questioned what they saw and heard, feeling an obligation to know more about clinical situations. In doing do, they moved from only using care plans and following the physicians’ orders to analyzing and interpreting patient situations. Beyond that, the proficient nurse acknowledged the changing relevance of clinical situations requiring action beyond what was planned or anticipated. The proficient nurse learned to acknowledge the changing needs of patient care and situation, and could organize interventions “by the situation as it unfolds rather than by preset goals 48 (p. 24). Both competent and proficient nurses (that is, intermediate level of practice) had at least two years of ICU experience. 48 Finally, the expert nurse had a more fully developed grasp of a clinical situation, a sense of confidence in what is known about the situation, and could differentiate the precise clinical problem in little time. 48

Expertise is acquired through professional experience and is indicative of a nurse who has moved beyond mere proficiency. As Gadamer 29 points out, experience involves a turning around of preconceived notions, preunderstandings, and extends or adds nuances to understanding. Dewey 49 notes that experience requires a prepared “creature” and an enriched environment. The opportunity to reflect and narrate one’s experiential learning can clarify, extend, or even refute experiential learning.

Experiential learning requires time and nurturing, but time alone does not ensure experiential learning. Aristotle linked experiential learning to the development of character and moral sensitivities of a person learning a practice. 50 New nurses/new graduates have limited work experience and must experience continuing learning until they have reached an acceptable level of performance. 51 After that, further improvements are not predictable, and years of experience are an inadequate predictor of expertise. 52

The most effective knower and developer of practical knowledge creates an ongoing dialogue and connection between lessons of the day and experiential learning over time. Gadamer, in a late life interview, highlighted the open-endedness and ongoing nature of experiential learning in the following interview response:

Being experienced does not mean that one now knows something once and for all and becomes rigid in this knowledge; rather, one becomes more open to new experiences. A person who is experienced is undogmatic. Experience has the effect of freeing one to be open to new experience … In our experience we bring nothing to a close; we are constantly learning new things from our experience … this I call the interminability of all experience 32 (p. 403).

Practical endeavor, supported by scientific knowledge, requires experiential learning, the development of skilled know-how, and perceptual acuity in order to make the scientific knowledge relevant to the situation. Clinical perceptual and skilled know-how helps the practitioner discern when particular scientific findings might be relevant. 53

Often experience and knowledge, confirmed by experimentation, are treated as oppositions, an either-or choice. However, in practice it is readily acknowledged that experiential knowledge fuels scientific investigation, and scientific investigation fuels further experiential learning. Experiential learning from particular clinical cases can help the clinician recognize future similar cases and fuel new scientific questions and study. For example, less experienced nurses—and it could be argued experienced as well—can use nursing diagnoses practice guidelines as part of their professional advancement. Guidelines are used to reflect their interpretation of patients’ needs, responses, and situation, 54 a process that requires critical thinking and decisionmaking. 55 , 56 Using guidelines also reflects one’s problem identification and problem-solving abilities. 56 Conversely, the ability to proficiently conduct a series of tasks without nursing diagnoses is the hallmark of expertise. 39 , 57

Experience precedes expertise. As expertise develops from experience and gaining knowledge and transitions to the proficiency stage, the nurses’ thinking moves from steps and procedures (i.e., task-oriented care) toward “chunks” or patterns 39 (i.e., patient-specific care). In doing so, the nurse thinks reflectively, rather than merely accepting statements and performing procedures without significant understanding and evaluation. 34 Expert nurses do not rely on rules and logical thought processes in problem-solving and decisionmaking. 39 Instead, they use abstract principles, can see the situation as a complex whole, perceive situations comprehensively, and can be fully involved in the situation. 48 Expert nurses can perform high-level care without conscious awareness of the knowledge they are using, 39 , 58 and they are able to provide that care with flexibility and speed. Through a combination of knowledge and skills gained from a range of theoretical and experiential sources, expert nurses also provide holistic care. 39 Thus, the best care comes from the combination of theoretical, tacit, and experiential knowledge. 59 , 60

Experts are thought to eventually develop the ability to intuitively know what to do and to quickly recognize critical aspects of the situation. 22 Some have proposed that expert nurses provide high-quality patient care, 61 , 62 but that is not consistently documented—particularly in consideration of patient outcomes—and a full understanding between the differential impact of care rendered by an “expert” nurse is not fully understood. In fact, several studies have found that length of professional experience is often unrelated and even negatively related to performance measures and outcomes. 63 , 64

In a review of the literature on expertise in nursing, Ericsson and colleagues 65 found that focusing on challenging, less-frequent situations would reveal individual performance differences on tasks that require speed and flexibility, such as that experienced during a code or an adverse event. Superior performance was associated with extensive training and immediate feedback about outcomes, which can be obtained through continual training, simulation, and processes such as root-cause analysis following an adverse event. Therefore, efforts to improve performance benefited from continual monitoring, planning, and retrospective evaluation. Even then, the nurse’s ability to perform as an expert is dependent upon their ability to use intuition or insights gained through interactions with patients. 39

Intuition and Perception

Intuition is the instant understanding of knowledge without evidence of sensible thought. 66 According to Young, 67 intuition in clinical practice is a process whereby the nurse recognizes something about a patient that is difficult to verbalize. Intuition is characterized by factual knowledge, “immediate possession of knowledge, and knowledge independent of the linear reasoning process” 68 (p. 23). When intuition is used, one filters information initially triggered by the imagination, leading to the integration of all knowledge and information to problem solve. 69 Clinicians use their interactions with patients and intuition, drawing on tacit or experiential knowledge, 70 , 71 to apply the correct knowledge to make the correct decisions to address patient needs. Yet there is a “conflated belief in the nurses’ ability to know what is best for the patient” 72 (p. 251) because the nurses’ and patients’ identification of the patients’ needs can vary. 73

A review of research and rhetoric involving intuition by King and Appleton 62 found that all nurses, including students, used intuition (i.e., gut feelings). They found evidence, predominately in critical care units, that intuition was triggered in response to knowledge and as a trigger for action and/or reflection with a direct bearing on the analytical process involved in patient care. The challenge for nurses was that rigid adherence to checklists, guidelines, and standardized documentation, 62 ignored the benefits of intuition. This view was furthered by Rew and Barrow 68 , 74 in their reviews of the literature, where they found that intuition was imperative to complex decisionmaking, 68 difficult to measure and assess in a quantitative manner, and was not linked to physiologic measures. 74

Intuition is a way of explaining professional expertise. 75 Expert nurses rely on their intuitive judgment that has been developed over time. 39 , 76 Intuition is an informal, nonanalytically based, unstructured, deliberate calculation that facilitates problem solving, 77 a process of arriving at salient conclusions based on relatively small amounts of knowledge and/or information. 78 Experts can have rapid insight into a situation by using intuition to recognize patterns and similarities, achieve commonsense understanding, and sense the salient information combined with deliberative rationality. 10 Intuitive recognition of similarities and commonalities between patients are often the first diagnostic clue or early warning, which must then be followed up with critical evaluation of evidence among the competing conditions. This situation calls for intuitive judgment that can distinguish “expert human judgment from the decisions” made by a novice 79 (p. 23).

Shaw 80 equates intuition with direct perception. Direct perception is dependent upon being able to detect complex patterns and relationships that one has learned through experience are important. Recognizing these patterns and relationships generally occurs rapidly and is complex, making it difficult to articulate or describe. Perceptual skills, like those of the expert nurse, are essential to recognizing current and changing clinical conditions. Perception requires attentiveness and the development of a sense of what is salient. Often in nursing and medicine, means and ends are fused, as is the case for a “good enough” birth experience and a peaceful death.

• Applying Practice Evidence

Research continues to find that using evidence-based guidelines in practice, informed through research evidence, improves patients’ outcomes. 81–83 Research-based guidelines are intended to provide guidance for specific areas of health care delivery. 84 The clinician—both the novice and expert—is expected to use the best available evidence for the most efficacious therapies and interventions in particular instances, to ensure the highest-quality care, especially when deviations from the evidence-based norm may heighten risks to patient safety. Otherwise, if nursing and medicine were exact sciences, or consisted only of techne, then a 1:1 relationship could be established between results of aggregated evidence-based research and the best path for all patients.

Evaluating Evidence

Before research should be used in practice, it must be evaluated. There are many complexities and nuances in evaluating the research evidence for clinical practice. Evaluation of research behind evidence-based medicine requires critical thinking and good clinical judgment. Sometimes the research findings are mixed or even conflicting. As such, the validity, reliability, and generalizability of available research are fundamental to evaluating whether evidence can be applied in practice. To do so, clinicians must select the best scientific evidence relevant to particular patients—a complex process that involves intuition to apply the evidence. Critical thinking is required for evaluating the best available scientific evidence for the treatment and care of a particular patient.

Good clinical judgment is required to select the most relevant research evidence. The best clinical judgment, that is, reasoning across time about the particular patient through changes in the patient’s concerns and condition and/or the clinician’s understanding, are also required. This type of judgment requires clinicians to make careful observations and evaluations of the patient over time, as well as know the patient’s concerns and social circumstances. To evolve to this level of judgment, additional education beyond clinical preparation if often required.

Sources of Evidence

Evidence that can be used in clinical practice has different sources and can be derived from research, patient’s preferences, and work-related experience. 85 , 86 Nurses have been found to obtain evidence from experienced colleagues believed to have clinical expertise and research-based knowledge 87 as well as other sources.

For many years now, randomized controlled trials (RCTs) have often been considered the best standard for evaluating clinical practice. Yet, unless the common threats to the validity (e.g., representativeness of the study population) and reliability (e.g., consistency in interventions and responses of study participants) of RCTs are addressed, the meaningfulness and generalizability of the study outcomes are very limited. Relevant patient populations may be excluded, such as women, children, minorities, the elderly, and patients with multiple chronic illnesses. The dropout rate of the trial may confound the results. And it is easier to get positive results published than it is to get negative results published. Thus, RCTs are generalizable (i.e., applicable) only to the population studied—which may not reflect the needs of the patient under the clinicians care. In instances such as these, clinicians need to also consider applied research using prospective or retrospective populations with case control to guide decisionmaking, yet this too requires critical thinking and good clinical judgment.

Another source of available evidence may come from the gold standard of aggregated systematic evaluation of clinical trial outcomes for the therapy and clinical condition in question, be generated by basic and clinical science relevant to the patient’s particular pathophysiology or care need situation, or stem from personal clinical experience. The clinician then takes all of the available evidence and considers the particular patient’s known clinical responses to past therapies, their clinical condition and history, the progression or stages of the patient’s illness and recovery, and available resources.

In clinical practice, the particular is examined in relation to the established generalizations of science. With readily available summaries of scientific evidence (e.g., systematic reviews and practice guidelines) available to nurses and physicians, one might wonder whether deep background understanding is still advantageous. Might it not be expendable, since it is likely to be out of date given the current scientific evidence? But this assumption is a false opposition and false choice because without a deep background understanding, the clinician does not know how to best find and evaluate scientific evidence for the particular case in hand. The clinician’s sense of salience in any given situation depends on past clinical experience and current scientific evidence.

Evidence-Based Practice

The concept of evidence-based practice is dependent upon synthesizing evidence from the variety of sources and applying it appropriately to the care needs of populations and individuals. This implies that evidence-based practice, indicative of expertise in practice, appropriately applies evidence to the specific situations and unique needs of patients. 88 , 89 Unfortunately, even though providing evidence-based care is an essential component of health care quality, it is well known that evidence-based practices are not used consistently.

Conceptually, evidence used in practice advances clinical knowledge, and that knowledge supports independent clinical decisions in the best interest of the patient. 90 , 91 Decisions must prudently consider the factors not necessarily addressed in the guideline, such as the patient’s lifestyle, drug sensitivities and allergies, and comorbidities. Nurses who want to improve the quality and safety of care can do so though improving the consistency of data and information interpretation inherent in evidence-based practice.

Initially, before evidence-based practice can begin, there needs to be an accurate clinical judgment of patient responses and needs. In the course of providing care, with careful consideration of patient safety and quality care, clinicians must give attention to the patient’s condition, their responses to health care interventions, and potential adverse reactions or events that could harm the patient. Nonetheless, there is wide variation in the ability of nurses to accurately interpret patient responses 92 and their risks. 93 Even though variance in interpretation is expected, nurses are obligated to continually improve their skills to ensure that patients receive quality care safely. 94 Patients are vulnerable to the actions and experience of their clinicians, which are inextricably linked to the quality of care patients have access to and subsequently receive.

The judgment of the patient’s condition determines subsequent interventions and patient outcomes. Attaining accurate and consistent interpretations of patient data and information is difficult because each piece can have different meanings, and interpretations are influenced by previous experiences. 95 Nurses use knowledge from clinical experience 96 , 97 and—although infrequently—research. 98–100

Once a problem has been identified, using a process that utilizes critical thinking to recognize the problem, the clinician then searches for and evaluates the research evidence 101 and evaluates potential discrepancies. The process of using evidence in practice involves “a problem-solving approach that incorporates the best available scientific evidence, clinicians’ expertise, and patient’s preferences and values” 102 (p. 28). Yet many nurses do not perceive that they have the education, tools, or resources to use evidence appropriately in practice. 103

Reported barriers to using research in practice have included difficulty in understanding the applicability and the complexity of research findings, failure of researchers to put findings into the clinical context, lack of skills in how to use research in practice, 104 , 105 amount of time required to access information and determine practice implications, 105–107 lack of organizational support to make changes and/or use in practice, 104 , 97 , 105 , 107 and lack of confidence in one’s ability to critically evaluate clinical evidence. 108

When Evidence Is Missing

In many clinical situations, there may be no clear guidelines and few or even no relevant clinical trials to guide decisionmaking. In these cases, the latest basic science about cellular and genomic functioning may be the most relevant science, or by default, guestimation. Consequently, good patient care requires more than a straightforward, unequivocal application of scientific evidence. The clinician must be able to draw on a good understanding of basic sciences, as well as guidelines derived from aggregated data and information from research investigations.

Practical knowledge is shaped by one’s practice discipline and the science and technology relevant to the situation at hand. But scientific, formal, discipline-specific knowledge are not sufficient for good clinical practice, whether the discipline be law, medicine, nursing, teaching, or social work. Practitioners still have to learn how to discern generalizable scientific knowledge, know how to use scientific knowledge in practical situations, discern what scientific evidence/knowledge is relevant, assess how the particular patient’s situation differs from the general scientific understanding, and recognize the complexity of care delivery—a process that is complex, ongoing, and changing, as new evidence can overturn old.

Practice communities like individual practitioners may also be mistaken, as is illustrated by variability in practice styles and practice outcomes across hospitals and regions in the United States. This variability in practice is why practitioners must learn to critically evaluate their practice and continually improve their practice over time. The goal is to create a living self-improving tradition.

Within health care, students, scientists, and practitioners are challenged to learn and use different modes of thinking when they are conflated under one term or rubric, using the best-suited thinking strategies for taking into consideration the purposes and the ends of the reasoning. Learning to be an effective, safe nurse or physician requires not only technical expertise, but also the ability to form helping relationships and engage in practical ethical and clinical reasoning. 50 Good ethical comportment requires that both the clinician and the scientist take into account the notions of good inherent in clinical and scientific practices. The notions of good clinical practice must include the relevant significance and the human concerns involved in decisionmaking in particular situations, centered on clinical grasp and clinical forethought.

The Three Apprenticeships of Professional Education

We have much to learn in comparing the pedagogies of formation across the professions, such as is being done currently by the Carnegie Foundation for the Advancement of Teaching. The Carnegie Foundation’s broad research program on the educational preparation of the profession focuses on three essential apprenticeships:

To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: (1) intellectual training to learn the academic knowledge base and the capacity to think in ways important to the profession; (2) a skill-based apprenticeship of practice; and (3) an apprenticeship to the ethical standards, social roles, and responsibilities of the profession, through which the novice is introduced to the meaning of an integrated practice of all dimensions of the profession, grounded in the profession’s fundamental purposes. 109

This framework has allowed the investigators to describe tensions and shortfalls as well as strengths of widespread teaching practices, especially at articulation points among these dimensions of professional training.

Research has demonstrated that these three apprenticeships are taught best when they are integrated so that the intellectual training includes skilled know-how, clinical judgment, and ethical comportment. In the study of nursing, exemplary classroom and clinical teachers were found who do integrate the three apprenticeships in all of their teaching, as exemplified by the following anonymous student’s comments:

With that as well, I enjoyed the class just because I do have clinical experience in my background and I enjoyed it because it took those practical applications and the knowledge from pathophysiology and pharmacology, and all the other classes, and it tied it into the actual aspects of like what is going to happen at work. For example, I work in the emergency room and question: Why am I doing this procedure for this particular patient? Beforehand, when I was just a tech and I wasn’t going to school, I’d be doing it because I was told to be doing it—or I’d be doing CPR because, you know, the doc said, start CPR. I really enjoy the Care and Illness because now I know the process, the pathophysiological process of why I’m doing it and the clinical reasons of why they’re making the decisions, and the prioritization that goes on behind it. I think that’s the biggest point. Clinical experience is good, but not everybody has it. Yet when these students transition from school and clinicals to their job as a nurse, they will understand what’s going on and why.

The three apprenticeships are equally relevant and intertwined. In the Carnegie National Study of Nursing Education and the companion study on medical education as well as in cross-professional comparisons, teaching that gives an integrated access to professional practice is being examined. Once the three apprenticeships are separated, it is difficult to reintegrate them. The investigators are encouraged by teaching strategies that integrate the latest scientific knowledge and relevant clinical evidence with clinical reasoning about particular patients in unfolding rather than static cases, while keeping the patient and family experience and concerns relevant to clinical concerns and reasoning.

Clinical judgment or phronesis is required to evaluate and integrate techne and scientific evidence.

Within nursing, professional practice is wise and effective usually to the extent that the professional creates relational and communication contexts where clients/patients can be open and trusting. Effectiveness depends upon mutual influence between patient and practitioner, student and learner. This is another way in which clinical knowledge is dialogical and socially distributed. The following articulation of practical reasoning in nursing illustrates the social, dialogical nature of clinical reasoning and addresses the centrality of perception and understanding to good clinical reasoning, judgment and intervention.

Clinical Grasp *

Clinical grasp describes clinical inquiry in action. Clinical grasp begins with perception and includes problem identification and clinical judgment across time about the particular transitions of particular patients. Garrett Chan 20 described the clinician’s attempt at finding an “optimal grasp” or vantage point of understanding. Four aspects of clinical grasp, which are described in the following paragraphs, include (1) making qualitative distinctions, (2) engaging in detective work, (3) recognizing changing relevance, and (4) developing clinical knowledge in specific patient populations.

Making Qualitative Distinctions

Qualitative distinctions refer to those distinctions that can be made only in a particular contextual or historical situation. The context and sequence of events are essential for making qualitative distinctions; therefore, the clinician must pay attention to transitions in the situation and judgment. Many qualitative distinctions can be made only by observing differences through touch, sound, or sight, such as the qualities of a wound, skin turgor, color, capillary refill, or the engagement and energy level of the patient. Another example is assessing whether the patient was more fatigued after ambulating to the bathroom or from lack of sleep. Likewise the quality of the clinician’s touch is distinct as in offering reassurance, putting pressure on a bleeding wound, and so on. 110

Engaging in Detective Work, Modus Operandi Thinking, and Clinical Puzzle Solving

Clinical situations are open ended and underdetermined. Modus operandi thinking keeps track of the particular patient, the way the illness unfolds, the meanings of the patient’s responses as they have occurred in the particular time sequence. Modus operandi thinking requires keeping track of what has been tried and what has or has not worked with the patient. In this kind of reasoning-in-transition, gains and losses of understanding are noticed and adjustments in the problem approach are made.

We found that teachers in a medical surgical unit at the University of Washington deliberately teach their students to engage in “detective work.” Students are given the daily clinical assignment of “sleuthing” for undetected drug incompatibilities, questionable drug dosages, and unnoticed signs and symptoms. For example, one student noted that an unusual dosage of a heart medication was being given to a patient who did not have heart disease. The student first asked her teacher about the unusually high dosage. The teacher, in turn, asked the student whether she had asked the nurse or the patient about the dosage. Upon the student’s questioning, the nurse did not know why the patient was receiving the high dosage and assumed the drug was for heart disease. The patient’s staff nurse had not questioned the order. When the student asked the patient, the student found that the medication was being given for tremors and that the patient and the doctor had titrated the dosage for control of the tremors. This deliberate approach to teaching detective work, or modus operandi thinking, has characteristics of “critical reflection,” but stays situated and engaged, ferreting out the immediate history and unfolding of events.

Recognizing Changing Clinical Relevance

The meanings of signs and symptoms are changed by sequencing and history. The patient’s mental status, color, or pain level may continue to deteriorate or get better. The direction, implication, and consequences for the changes alter the relevance of the particular facts in the situation. The changing relevance entailed in a patient transitioning from primarily curative care to primarily palliative care is a dramatic example, where symptoms literally take on new meanings and require new treatments.

Developing Clinical Knowledge in Specific Patient Populations

Extensive experience with a specific patient population or patients with particular injuries or diseases allows the clinician to develop comparisons, distinctions, and nuanced differences within the population. The comparisons between many specific patients create a matrix of comparisons for clinicians, as well as a tacit, background set of expectations that create population- and patient-specific detective work if a patient does not meet the usual, predictable transitions in recovery. What is in the background and foreground of the clinician’s attention shifts as predictable changes in the patient’s condition occurs, such as is seen in recovering from heart surgery or progressing through the predictable stages of labor and delivery. Over time, the clinician develops a deep background understanding that allows for expert diagnostic and interventions skills.

Clinical Forethought

Clinical forethought is intertwined with clinical grasp, but it is much more deliberate and even routinized than clinical grasp. Clinical forethought is a pervasive habit of thought and action in nursing practice, and also in medicine, as clinicians think about disease and recovery trajectories and the implications of these changes for treatment. Clinical forethought plays a role in clinical grasp because it structures the practical logic of clinicians. At least four habits of thought and action are evident in what we are calling clinical forethought: (1) future think, (2) clinical forethought about specific patient populations, (3) anticipation of risks for particular patients, and (4) seeing the unexpected.

Future think

Future think is the broadest category of this logic of practice. Anticipating likely immediate futures helps the clinician make good plans and decisions about preparing the environment so that responding rapidly to changes in the patient is possible. Without a sense of salience about anticipated signs and symptoms and preparing the environment, essential clinical judgments and timely interventions would be impossible in the typically fast pace of acute and intensive patient care. Future think governs the style and content of the nurse’s attentiveness to the patient. Whether in a fast-paced care environment or a slower-paced rehabilitation setting, thinking and acting with anticipated futures guide clinical thinking and judgment. Future think captures the way judgment is suspended in a predictive net of anticipation and preparing oneself and the environment for a range of potential events.

Clinical forethought about specific diagnoses and injuries

This habit of thought and action is so second nature to the experienced nurse that the new or inexperienced nurse may have difficulty finding out about what seems to other colleagues as “obvious” preparation for particular patients and situations. Clinical forethought involves much local specific knowledge about who is a good resource and how to marshal support services and equipment for particular patients.

Examples of preparing for specific patient populations are pervasive, such as anticipating the need for a pacemaker during surgery and having the equipment assembled ready for use to save essential time. Another example includes forecasting an accident victim’s potential injuries, and recognizing that intubation might be needed.

Anticipation of crises, risks, and vulnerabilities for particular patients

This aspect of clinical forethought is central to knowing the particular patient, family, or community. Nurses situate the patient’s problems almost like a topography of possibilities. This vital clinical knowledge needs to be communicated to other caregivers and across care borders. Clinical teaching could be improved by enriching curricula with narrative examples from actual practice, and by helping students recognize commonly occurring clinical situations in the simulation and clinical setting. For example, if a patient is hemodynamically unstable, then managing life-sustaining physiologic functions will be a main orienting goal. If the patient is agitated and uncomfortable, then attending to comfort needs in relation to hemodynamics will be a priority. Providing comfort measures turns out to be a central background practice for making clinical judgments and contains within it much judgment and experiential learning.

When clinical teaching is too removed from typical contingencies and strong clinical situations in practice, students will lack practice in active thinking-in-action in ambiguous clinical situations. In the following example, an anonymous student recounted her experiences of meeting a patient:

I was used to different equipment and didn’t know how things went, didn’t know their routine, really. You can explain all you want in class, this is how it’s going to be, but when you get there … . Kim was my first instructor and my patient that she assigned me to—I walked into the room and he had every tube imaginable. And so I was a little overwhelmed. It’s not necessarily even that he was that critical … . She asked what tubes here have you seen? Well, I know peripheral lines. You taught me PICC [peripherally inserted central catheter] lines, and we just had that, but I don’t really feel comfortable doing it by myself, without you watching to make sure that I’m flushing it right and how to assess it. He had a chest tube and I had seen chest tubes, but never really knew the depth of what you had to assess and how you make sure that it’s all kosher and whatever. So she went through the chest tube and explained, it’s just bubbling a little bit and that’s okay. The site, check the site. The site looked okay and that she’d say if it wasn’t okay, this is what it might look like … . He had a feeding tube. I had done feeding tubes but that was like a long time ago in my LPN experiences schooling. So I hadn’t really done too much with the feeding stuff either … . He had a [nasogastric] tube, and knew pretty much about that and I think at the time it was clamped. So there were no issues with the suction or whatever. He had a Foley catheter. He had a feeding tube, a chest tube. I can’t even remember but there were a lot.

As noted earlier, a central characteristic of a practice discipline is that a self-improving practice requires ongoing experiential learning. One way nurse educators can enhance clinical inquiry is by increasing pedagogies of experiential learning. Current pedagogies for experiential learning in nursing include extensive preclinical study, care planning, and shared postclinical debriefings where students share their experiential learning with their classmates. Experiential learning requires open learning climates where students can discuss and examine transitions in understanding, including their false starts, or their misconceptions in actual clinical situations. Nursing educators typically develop open and interactive clinical learning communities, so that students seem committed to helping their classmates learn from their experiences that may have been difficult or even unsafe. One anonymous nurse educator described how students extend their experiential learning to their classmates during a postclinical conference:

So for example, the patient had difficulty breathing and the student wanted to give the meds instead of addressing the difficulty of breathing. Well, while we were sharing information about their patients, what they did that day, I didn’t tell the student to say this, but she said, ‘I just want to tell you what I did today in clinical so you don’t do the same thing, and here’s what happened.’ Everybody’s listening very attentively and they were asking her some questions. But she shared that. She didn’t have to. I didn’t tell her, you must share that in postconference or anything like that, but she just went ahead and shared that, I guess, to reinforce what she had learned that day but also to benefit her fellow students in case that thing comes up with them.

The teacher’s response to this student’s honesty and generosity exemplifies her own approach to developing an open community of learning. Focusing only on performance and on “being correct” prevents learning from breakdown or error and can dampen students’ curiosity and courage to learn experientially.

Seeing the unexpected

One of the keys to becoming an expert practitioner lies in how the person holds past experiential learning and background habitual skills and practices. This is a skill of foregrounding attention accurately and effectively in response to the nature of situational demands. Bourdieu 29 calls the recognition of the situation central to practical reasoning. If nothing is routinized as a habitual response pattern, then practitioners will not function effectively in emergencies. Unexpected occurrences may be overlooked. However, if expectations are held rigidly, then subtle changes from the usual will be missed, and habitual, rote responses will inappropriately rule. The clinician must be flexible in shifting between what is in background and foreground. This is accomplished by staying curious and open. The clinical “certainty” associated with perceptual grasp is distinct from the kind of “certainty” achievable in scientific experiments and through measurements. Recognition of similar or paradigmatic clinical situations is similar to “face recognition” or recognition of “family resemblances.” This concept is subject to faulty memory, false associative memories, and mistaken identities; therefore, such perceptual grasp is the beginning of curiosity and inquiry and not the end. Assessment and validation are required. In rapidly moving clinical situations, perceptual grasp is the starting point for clarification, confirmation, and action. Having the clinician say out loud how he or she is understanding the situation gives an opportunity for confirmation and disconfirmation from other clinicians present. 111 The relationship between foreground and background of attention needs to be fluid, so that missed expectations allow the nurse to see the unexpected. For example, when the background rhythm of a cardiac monitor changes, the nurse notices, and what had been background tacit awareness becomes the foreground of attention. A hallmark of expertise is the ability to notice the unexpected. 20 Background expectations of usual patient trajectories form with experience. Tacit expectations for patient trajectories form that enable the nurse to notice subtle failed expectations and pay attention to early signs of unexpected changes in the patient's condition. Clinical expectations gained from caring for similar patient populations form a tacit clinical forethought that enable the experienced clinician to notice missed expectations. Alterations from implicit or explicit expectations set the stage for experiential learning, depending on the openness of the learner.

Learning to provide safe and quality health care requires technical expertise, the ability to think critically, experience, and clinical judgment. The high-performance expectation of nurses is dependent upon the nurses’ continual learning, professional accountability, independent and interdependent decisionmaking, and creative problem-solving abilities.

This section of the paper was condensed and paraphrased from Benner, Hooper-Kyriakidis, and Stannard. 23 Patricia Hooper-Kyriakidis wrote the section on clinical grasp, and Patricia Benner wrote the section on clinical forethought.

• Cite this Page Benner P, Hughes RG, Sutphen M. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 6.
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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?

What is Critical Thinking in Nursing? (Explained W/ Examples)

Last updated on August 23rd, 2023

Critical thinking is a foundational skill applicable across various domains, including education, problem-solving, decision-making, and professional fields such as science, business, healthcare, and more.

It plays a crucial role in promoting logical and rational thinking, fostering informed decision-making, and enabling individuals to navigate complex and rapidly changing environments.

In this article, we will look at what is critical thinking in nursing practice, its importance, and how it enables nurses to excel in their roles while also positively impacting patient outcomes.

What is Critical Thinking?

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

It’s a mental activity that goes beyond simple memorization or acceptance of information at face value.

Critical thinking involves careful, reflective, and logical thinking to understand complex problems, consider various perspectives, and arrive at well-reasoned conclusions or solutions.

Key aspects of critical thinking include:

• Analysis: Critical thinking begins with the thorough examination of information, ideas, or situations. It involves breaking down complex concepts into smaller parts to better understand their components and relationships.
• Evaluation: Critical thinkers assess the quality and reliability of information or arguments. They weigh evidence, identify strengths and weaknesses, and determine the credibility of sources.
• Synthesis: Critical thinking involves combining different pieces of information or ideas to create a new understanding or perspective. This involves connecting the dots between various sources and integrating them into a coherent whole.
• Inference: Critical thinkers draw logical and well-supported conclusions based on the information and evidence available. They use reasoning to make educated guesses about situations where complete information might be lacking.
• Problem-Solving: Critical thinking is essential in solving complex problems. It allows individuals to identify and define problems, generate potential solutions, evaluate the pros and cons of each solution, and choose the most appropriate course of action.
• Creativity: Critical thinking involves thinking outside the box and considering alternative viewpoints or approaches. It encourages the exploration of new ideas and solutions beyond conventional thinking.
• Reflection: Critical thinkers engage in self-assessment and reflection on their thought processes. They consider their own biases, assumptions, and potential errors in reasoning, aiming to improve their thinking skills over time.
• Open-Mindedness: Critical thinkers approach ideas and information with an open mind, willing to consider different viewpoints and perspectives even if they challenge their own beliefs.
• Effective Communication: Critical thinkers can articulate their thoughts and reasoning clearly and persuasively to others. They can express complex ideas in a coherent and understandable manner.
• Continuous Learning: Critical thinking encourages a commitment to ongoing learning and intellectual growth. It involves seeking out new knowledge, refining thinking skills, and staying receptive to new information.

Definition of Critical Thinking

Critical thinking is an intellectual process of analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

What is Critical Thinking in Nursing?

Critical thinking in nursing is a vital cognitive skill that involves analyzing, evaluating, and making reasoned decisions about patient care.

It’s an essential aspect of a nurse’s professional practice as it enables them to provide safe and effective care to patients.

Critical thinking involves a careful and deliberate thought process to gather and assess information, consider alternative solutions, and make informed decisions based on evidence and sound judgment.

This skill helps nurses to:

• Assess Information: Critical thinking allows nurses to thoroughly assess patient information, including medical history, symptoms, and test results. By analyzing this data, nurses can identify patterns, discrepancies, and potential issues that may require further investigation.
• Diagnose: Nurses use critical thinking to analyze patient data and collaboratively work with other healthcare professionals to formulate accurate nursing diagnoses. This is crucial for developing appropriate care plans that address the unique needs of each patient.
• Plan and Implement Care: Once a nursing diagnosis is established, critical thinking helps nurses develop effective care plans. They consider various interventions and treatment options, considering the patient’s preferences, medical history, and evidence-based practices.
• Evaluate Outcomes: After implementing interventions, critical thinking enables nurses to evaluate the outcomes of their actions. If the desired outcomes are not achieved, nurses can adapt their approach and make necessary changes to the care plan.
• Prioritize Care: In busy healthcare environments, nurses often face situations where they must prioritize patient care. Critical thinking helps them determine which patients require immediate attention and which interventions are most essential.
• Communicate Effectively: Critical thinking skills allow nurses to communicate clearly and confidently with patients, their families, and other members of the healthcare team. They can explain complex medical information and treatment plans in a way that is easily understood by all parties involved.
• Identify Problems: Nurses use critical thinking to identify potential complications or problems in a patient’s condition. This early recognition can lead to timely interventions and prevent further deterioration.
• Collaborate: Healthcare is a collaborative effort involving various professionals. Critical thinking enables nurses to actively participate in interdisciplinary discussions, share their insights, and contribute to holistic patient care.
• Ethical Decision-Making: Critical thinking helps nurses navigate ethical dilemmas that can arise in patient care. They can analyze different perspectives, consider ethical principles, and make morally sound decisions.
• Continual Learning: Critical thinking encourages nurses to seek out new knowledge, stay up-to-date with the latest research and medical advancements, and incorporate evidence-based practices into their care.

In summary, critical thinking is an integral skill for nurses, allowing them to provide high-quality, patient-centered care by analyzing information, making informed decisions, and adapting their approaches as needed.

It’s a dynamic process that enhances clinical reasoning , problem-solving, and overall patient outcomes.

What are the Levels of Critical Thinking in Nursing?

The development of critical thinking in nursing practice involves progressing through three levels: basic, complex, and commitment.

The Kataoka-Yahiro and Saylor model outlines this progression.

1. Basic Critical Thinking:

At this level, learners trust experts for solutions. Thinking is based on rules and principles. For instance, nursing students may strictly follow a procedure manual without personalization, as they lack experience. Answers are seen as right or wrong, and the opinions of experts are accepted.

2. Complex Critical Thinking:

Learners start to analyze choices independently and think creatively. They recognize conflicting solutions and weigh benefits and risks. Thinking becomes innovative, with a willingness to consider various approaches in complex situations.

3. Commitment:

At this level, individuals anticipate decision points without external help and take responsibility for their choices. They choose actions or beliefs based on available alternatives, considering consequences and accountability.

As nurses gain knowledge and experience, their critical thinking evolves from relying on experts to independent analysis and decision-making, ultimately leading to committed and accountable choices in patient care.

Why Critical Thinking is Important in Nursing?

Critical thinking is important in nursing for several crucial reasons:

Patient Safety:

Nursing decisions directly impact patient well-being. Critical thinking helps nurses identify potential risks, make informed choices, and prevent errors.

Clinical Judgment:

Nursing decisions often involve evaluating information from various sources, such as patient history, lab results, and medical literature.

Critical thinking assists nurses in critically appraising this information, distinguishing credible sources, and making rational judgments that align with evidence-based practices.

Enhances Decision-Making:

In nursing, critical thinking allows nurses to gather relevant patient information, assess it objectively, and weigh different options based on evidence and analysis.

This process empowers them to make informed decisions about patient care, treatment plans, and interventions, ultimately leading to better outcomes.

Promotes Problem-Solving:

Nurses encounter complex patient issues that require effective problem-solving.

Critical thinking equips them to break down problems into manageable parts, analyze root causes, and explore creative solutions that consider the unique needs of each patient.

Drives Creativity:

Nursing care is not always straightforward. Critical thinking encourages nurses to think creatively and explore innovative approaches to challenges, especially when standard protocols might not suffice for unique patient situations.

Fosters Effective Communication:

Communication is central to nursing. Critical thinking enables nurses to clearly express their thoughts, provide logical explanations for their decisions, and engage in meaningful dialogues with patients, families, and other healthcare professionals.

Aids Learning:

Nursing is a field of continuous learning. Critical thinking encourages nurses to engage in ongoing self-directed education, seeking out new knowledge, embracing new techniques, and staying current with the latest research and developments.

Improves Relationships:

Open-mindedness and empathy are essential in nursing relationships.

Critical thinking encourages nurses to consider diverse viewpoints, understand patients’ perspectives, and communicate compassionately, leading to stronger therapeutic relationships.

Empowers Independence:

Nursing often requires autonomous decision-making. Critical thinking empowers nurses to analyze situations independently, make judgments without undue influence, and take responsibility for their actions.

Facilitates Adaptability:

Healthcare environments are ever-changing. Critical thinking equips nurses with the ability to quickly assess new information, adjust care plans, and navigate unexpected situations while maintaining patient safety and well-being.

Strengthens Critical Analysis:

In the era of vast information, nurses must discern reliable data from misinformation.

Critical thinking helps them scrutinize sources, question assumptions, and make well-founded choices based on credible information.

How to Apply Critical Thinking in Nursing? (With Examples)

Here are some examples of how nurses can apply critical thinking.

Assess Patient Data:

Critical Thinking Action: Carefully review patient history, symptoms, and test results.

Example: A nurse notices a change in a diabetic patient’s blood sugar levels. Instead of just administering insulin, the nurse considers recent dietary changes, activity levels, and possible medication interactions before adjusting the treatment plan.

Diagnose Patient Needs:

Critical Thinking Action: Analyze patient data to identify potential nursing diagnoses.

Example: After reviewing a patient’s lab results, vital signs, and observations, a nurse identifies “ Risk for Impaired Skin Integrity ” due to the patient’s limited mobility.

Plan and Implement Care:

Critical Thinking Action: Develop a care plan based on patient needs and evidence-based practices.

Example: For a patient at risk of falls, the nurse plans interventions such as hourly rounding, non-slip footwear, and bed alarms to ensure patient safety.

Evaluate Interventions:

Critical Thinking Action: Assess the effectiveness of interventions and modify the care plan as needed.

Example: After administering pain medication, the nurse evaluates its impact on the patient’s comfort level and considers adjusting the dosage or trying an alternative pain management approach.

Prioritize Care:

Critical Thinking Action: Determine the order of interventions based on patient acuity and needs.

Example: In a busy emergency department, the nurse triages patients by considering the severity of their conditions, ensuring that critical cases receive immediate attention.

Collaborate with the Healthcare Team:

Critical Thinking Action: Participate in interdisciplinary discussions and share insights.

Example: During rounds, a nurse provides input on a patient’s response to treatment, which prompts the team to adjust the care plan for better outcomes.

Ethical Decision-Making:

Critical Thinking Action: Analyze ethical dilemmas and make morally sound choices.

Example: When a terminally ill patient expresses a desire to stop treatment, the nurse engages in ethical discussions, respecting the patient’s autonomy and ensuring proper end-of-life care.

Patient Education:

Critical Thinking Action: Tailor patient education to individual needs and comprehension levels.

Example: A nurse uses visual aids and simplified language to explain medication administration to a patient with limited literacy skills.

Adapt to Changes:

Critical Thinking Action: Quickly adjust care plans when patient conditions change.

Example: During post-operative recovery, a nurse notices signs of infection and promptly informs the healthcare team to initiate appropriate treatment adjustments.

Critical Analysis of Information:

Critical Thinking Action: Evaluate information sources for reliability and relevance.

Example: When presented with conflicting research studies, a nurse critically examines the methodologies and sample sizes to determine which study is more credible.

Making Sense of Critical Thinking Skills

What is the purpose of critical thinking in nursing.

The purpose of critical thinking in nursing is to enable nurses to effectively analyze, interpret, and evaluate patient information, make informed clinical judgments, develop appropriate care plans, prioritize interventions, and adapt their approaches as needed, thereby ensuring safe, evidence-based, and patient-centered care.

Why critical thinking is important in nursing?

Critical thinking is important in nursing because it promotes safe decision-making, accurate clinical judgment, problem-solving, evidence-based practice, holistic patient care, ethical reasoning, collaboration, and adapting to dynamic healthcare environments.

Critical thinking skill also enhances patient safety, improves outcomes, and supports nurses’ professional growth.

How is critical thinking used in the nursing process?

Critical thinking is integral to the nursing process as it guides nurses through the systematic approach of assessing, diagnosing, planning, implementing, and evaluating patient care. It involves:

• Assessment: Critical thinking enables nurses to gather and interpret patient data accurately, recognizing relevant patterns and cues.
• Diagnosis: Nurses use critical thinking to analyze patient data, identify nursing diagnoses, and differentiate actual issues from potential complications.
• Planning: Critical thinking helps nurses develop tailored care plans, selecting appropriate interventions based on patient needs and evidence.
• Implementation: Nurses make informed decisions during interventions, considering patient responses and adjusting plans as needed.
• Evaluation: Critical thinking supports the assessment of patient outcomes, determining the effectiveness of intervention, and adapting care accordingly.

Throughout the nursing process , critical thinking ensures comprehensive, patient-centered care and fosters continuous improvement in clinical judgment and decision-making.

What is an example of the critical thinking attitude of independent thinking in nursing practice?

An example of the critical thinking attitude of independent thinking in nursing practice could be:

A nurse is caring for a patient with a complex medical history who is experiencing a new set of symptoms. The nurse carefully reviews the patient’s history, recent test results, and medication list.

While discussing the case with the healthcare team, the nurse realizes that the current treatment plan might not be addressing all aspects of the patient’s condition.

Instead of simply following the established protocol, the nurse independently considers alternative approaches based on their assessment.

The nurse proposes a modification to the treatment plan, citing the rationale and evidence supporting the change.

This demonstrates independent thinking by critically evaluating the situation, challenging assumptions, and advocating for a more personalized and effective patient care approach.

How to use Costa’s level of questioning for critical thinking in nursing?

Costa’s levels of questioning can be applied in nursing to facilitate critical thinking and stimulate a deeper understanding of patient situations. The levels of questioning are as follows:

• 15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)
• Nursing Concept Map (FREE Template)
• Clinical Reasoning In Nursing (Explained W/ Example)
• 8 Stages Of The Clinical Reasoning Cycle
• How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples
• What is the “5 Whys” Technique?
• What Are Socratic Questions?

Critical thinking in nursing is the foundation that underpins safe, effective, and patient-centered care.

Critical thinking skills empower nurses to navigate the complexities of their profession while consistently providing high-quality care to diverse patient populations.

Reading Recommendation

Potter, P.A., Perry, A.G., Stockert, P. and Hall, A. (2013) Fundamentals of Nursing

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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

Critical thinking, Nursing Process, and Clinical Judgement

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• Current affairs

Kazakh as an Unwritten Language: The Case of Astrakhan Oblast

• September 28, 2023
• 12 minute read

An ethnically diverse region that abuts the Caspian Sea in southwestern Russia, Astrakhan Oblast is home to the country’s largest Kazakh community. Almost 150,000 people, or 18 percent of the oblast’s population, identify as ethnic Kazakhs. Although Astrakhan does border Kazakhstan, most of them are not recent immigrants from the neighboring country. Their families have been living in what is now Astrakhan since long before the current national borders were drawn.

Dor Shabashewitz

Dor Shabashewitz is a Russia-born Israeli journalist and political analyst with a background in anthropology and sociolinguistics. He worked as a junior researcher at the RAS Institute for Linguistic Studies and conducted extensive fieldwork in Astrakhan’s Kazakh and Nogai rural communities as a part of his Master’s studies at the European University at St. Petersburg. In 2021, the Russian Federal Security Service forced him to leave the country following politically motivated accusations of “extremism” and “separatism.” These days, he covers ethnic minority rights and regional politics in the Lower Volga and Central Asia for RFE/RL ’s Tatar-Bashkir Service.

* The article that follows provides a brief overview of the sociolinguistic situation among those Kazakhs living in the Russian part of the Volga River delta. It is based on field research conducted by the author during his master’s studies between 2019 and 2021.

In the Middle Ages, Astrakhan was part of the Golden Horde and, later, an independent khanate. In 1556, it was conquered by the Russians and eventually incorporated into the Russian Empire as a governorate. The first major wave of Kazakh migration to Astrakhan Governorate began between 1799 and 1801, when Bökey Khan, son of the Junior jüz leader Nuraly, led several thousand nomadic families from across the Ural River to a more fertile area in the Volga River delta. A steady influx of Kazakh settlers continued well into the mid-nineteenth century. The new Astrakhan Kazakh community led by Bökey enjoyed the status of a semi-independent vassal state for several decades before gradually ceding most of its autonomy under pressure from the Russian authorities.

The early Soviet years revived the idea of a Kazakh autonomous area in Astrakhan. In 1919, some of the Kazakh districts of Astrakhan Governorate were grouped together under the name Volga-Caspian Kirghizia and transferred to what later became the Kazakh SSR. Most of them stayed and became part of Kazakhstan upon its independence, but some of the transfers were reversed in the 1920s. Thus, the Volodarsky and Krasny Yar districts ended up in Russia’s Astrakhan Oblast despite 70 percent and 50 percent of their inhabitants, respectively, being ethnic Kazakhs.

Notwithstanding the omnipresent linguistic Russification of the Soviet era, Kazakh enjoyed certain formal privileges in the Kazakh SSR as a co-official language that was used in many schools, especially in rural areas. State-funded magazines, newspapers, books, and movies were produced in the language. Government support for the national language and its social prestige only increased after Kazakhstan became a sovereign country in 1991. This was not the case in Astrakhan Oblast—the region’s Kazakh community had no linguistic autonomy or representation under the Soviets, and this did not change when the USSR fell apart.

Vitality Factors

In what state, then, is the Kazakh language among Astrakhan’s Kazakhs after decades without formal recognition? In what domains is it still spoken? What do the Astrakhan Kazakhs think of their ethnic language, and what role does it play in their identity? These were the questions I hoped to answer when I set off on a fieldwork trip to my home region’s Volodarsky district as a master’s student in social anthropology back in 2019.

During my fieldwork, I visited numerous rural settlements of varying sizes, ethnic compositions, locations, histories, and economic conditions. It became evident that all of these factors played a significant role in the vitality of Kazakh in any given village, but the relative weight of each factor was rather unexpected. My analysis showed that the share of ethnic Kazakhs in a village did not correlate strongly with how much they used the language in their daily lives. I have been to monoethnic Kazakh villages that spoke almost exclusively Russian, as well as mixed ones where Kazakh was still maintained by some members of the younger generations.

Geography and the perceived history of a settlement turned out to be the two most defining factors. Inhabitants of villages that are close to Astrakhan City and have a stable public transport connection to the city tend to switch to Russian more quickly than residents of more remote ones. Career opportunities in rural areas are scarce, prompting villagers to look for jobs in the urban center. When logistically possible, many opt to continue living in their villages and commute to work several times a week instead of moving to the city. Despite its impressive ethnic diversity, Astrakhan City is overwhelmingly Russian-speaking. Kazakh rural commuters tend to integrate into this environment and “bring it home” after work, influencing the linguistic landscape of their communities.

“Perceived history” deserves an anthropological study of its own. Many of the Astrakhan Kazakhs I interviewed explained that their villages were originally founded by Russian peasants or created by the Soviets in a centralized way and populated by collective farm workers of diverse origins. Many settlements with such histories gradually became majority-Kazakh, but most locals believed they were “not really Kazakh villages” and thus considered Kazakh a rather inappropriate language to use in public spaces. In settlements such as Vinny, this mentality led to Kazakh becoming a family language only, with Russian as the sole means of communication in all other domains—even between Kazakhs.

This stands in stark contrast to the village of Altynzhar, which was founded by Kazakh settlers and has a long tradition of local pride. The renowned nineteenth-century Kazakh composer Qurmangazy is buried in Altynzhar; the village hosts a museum dedicated to his life and to the culture of the region’s Kazakh community more generally. Altynzhar was also home to the Kazakh poet and language activist Mäjilis Ötejanov. Due to its history and cultural significance, Altynzhar is often viewed as the informal capital of the Astrakhan Kazakhs. This status, combined with the lack of reliable public transportation, helps the local population to maintain their language and identity better than elsewhere.

Language Use

Despite the differences between individual settlements, home is by far the most common domain of use for the Kazakh language across Astrakhan Oblast. For most of my respondents, constant code-switching between Russian and Kazakh is the default register when they talk to their relatives. The ratio of elements from the two languages, however, varies widely. Kazakh may dominate or it may only be represented by several words—but, as my experience shows, it is never fully absent.

In Vinny, I interviewed a young Kazakh man who was born and raised in the village but went to an urban high school and later moved to a different part of Russia for university. These days, he lives and works in Astrakhan City. At the time I met him, he was visiting Vinny to see his parents, who still lived there permanently. During the interview, he said he spoke no Kazakh at all: “I do not speak Kazakh… Never wanted to learn it, thought it was useless. Grandma would talk to me in Kazakh, and I am like… I do not understand everything, but I can get the general idea.”

Just an hour later, I overheard him using numerous Kazakh words in a Russian-language conversation with his mother. Answering my ensuing question, the young man explained: “There are still some words that are easier for me to say in Kazakh. Like ‘scoop’ or ‘ladle’—I just say ojaw .” Later, I discovered other Kazakh words in the speech register he used at home. They were terms related to farming, as well as the names of certain traditional foods and houseware items.

This case is by no means unique—in fact, it is very typical. Lexical domains related to rural ways of life and things you find in a traditional household seem to be the least likely to be forgotten by young and predominantly Russian-speaking Astrakhan Kazakhs. This may be because they lack any similar rural experience gained in a non-Kazakh context.

Leaving the “Kazakh” village for the “Russian” city, one practically replaces one’s entire vocabulary—but with exceptions. The array of subjects discussed in urban settings is at least as wide as that in rural areas, but the two sets of lexical domains do not always coincide. Traditional ethnic cuisine, cattle farming, agriculture, and culturally specific rural household items are not things that city dwellers usually speak of, hence the words for them are not as easily replaced with Russian equivalents in the speech of first-generation urbanites. Sometimes, the Kazakh words remain the only ones they know. The lack of need or even opportunity to talk about these things in Russian makes this set of Kazakh vocabulary more resistant to attrition. It is only natural for urban Kazakhs to use these terms when they go to a rural area to visit their family. This may be viewed as a “light version” of cue-dependent language retrieval .

Equally, even among those Astrakhan Kazakhs who live in rural settlements and use Kazakh-Russian code-mixing as their default home register, one can point to specific domains that almost universally trigger the use of a much higher share of Russian-language elements. This includes all of the “complicated” domains, as the respondents call them. For example, a middle-aged man from the village of Novy Rychan said: “When fixing a TV set, we are most definitely talking in Russian.” In a different settlement, I witnessed four men talking in almost “pure” Kazakh—that is, using few Russian elements. Then one of them mentioned the COVID-19 pandemic, and this change of subject, combined with “complex” vocabulary related to healthcare and government policies, triggered an instant switch to almost equally “pure” Russian.

As is evident from these situations, Kazakh is often regarded and used as a rural and “simplistic” language, fitting for discussions of farming but not technology or anything modern. This set of associations speaks to its low social prestige—but may also be viewed positively by some. Many heritage speakers of Astrakhan Kazakh associate the language with a sense of home and strong family ties. “Kazakh is… It is something about your home, you know, where you feel most comfortable and secure. It is the mother language, after all. Whenever I hear it, I think of those evenings I spent in the village of Multanovo with my parents and grandma as a kid. I miss this feeling now that I live in the city,” said one of my respondents.

Two other important domains associated with Kazakh, which are intertwined with each other, are religion and ethnic celebrations. While overwhelmingly secular in daily life, most Astrakhan Kazakhs identify as Muslim. Many hardly ever go to mosques—in fact, there are large, exclusively Kazakh villages with no mosques at all. Moreover, the minority that does adhere to a strictly Islamic way of life is viewed as odd and even suspicious by the more secular majority.

Still, events such as weddings and funerals almost universally have an Islamic element to them. Interestingly enough, many of my respondents think of Islam as inseparable from the Kazakh language. “When the Quran is being recited, you are supposed to talk in Kazakh,” said a middle-aged man from Novy Rychan. Obviously, the recitation itself happens in Arabic, and one is supposed to listen to it rather than talk simultaneously. What this respondent meant was that the “religious” and “traditional” atmosphere of such events triggered increased use of Kazakh before and after the recitation and other rituals.

Kazakh as an Unwritten Language

While still widely spoken in some of the more remote villages, Astrakhan Kazakh remains a practically unwritten language. In the early Soviet years, Kazakh was used at numerous village schools as the primary language of instruction, but it was quickly downgraded to being taught as a subject only. By 1966, it had disappeared from the region’s school system entirely.

The perestroika era brought a surge in ethnic activism, with Kazakh language lessons being reintroduced in almost a hundred village schools in the late 1980s and 1990s. Unfortunately, this did not last long: Vladimir Putin’s rule brought another wave of linguistic Russification as part of his “unity through uniformity” policy. Kazakh was soon downgraded to an optional, once-a-week class. Today, fewer than 20 Astrakhan Oblast schools offer it in any form, even though over 140 of the region’s rural localities have a Kazakh majority or plurality.

This lack of Kazakh at school has resulted in entire generations having little exposure to written Kazakh and being functionally illiterate in it, even when perfectly literate in Russian. This can be seen from the way the names of many Astrakhan Kazakhs are written in their Russian IDs and passports. When giving their children legal names, many parents opt for naive phonetic approximations that do not match the way a name is normally spelled in Kazakhstan (eg., Kuvanshkirey rather than the more typical Qwanışkereý in Kazakh or Kuanyshkerey in Russian). Many of my respondents said they had trouble understanding and distinguishing the “weird letters” used in Standard Kazakh, referring to the additional and modified Cyrillic characters that are absent from the Russian alphabet.

Russian dominates all of the “formal” domains in Astrakhan Oblast, from education to technology and interactions with the government

Lack of language-specific literacy is not the only linguistic barrier between Kazakh-speakers in Astrakhan and those in Kazakhstan. As explained above, Russian dominates all of the “formal” domains in Astrakhan Oblast, from education to technology and interactions with the government. This means that most Astrakhan Kazakhs never discuss these topics in Kazakh and may be unfamiliar with the more “complex” vocabulary in that language, even when fully proficient in the registers related to home, family, traditions, and rural lifestyle.

“The Kazakh word for ‘proof’ is dälel , which I only know because I looked it up. My neighbor grew up speaking Kazakh, but she would not understand me if I used it when talking to her. She just uses the Russian word, dokazatelstvo ,” said a respondent from Multanovo. This is a perfect example of a term perceived as “complex” and thus unknown to many Astrakhan Kazakhs.

Most Astrakhan Kazakhs are well aware of the differences between their ethnic language and the Kazakh of Kazakhstan. A middle-aged, native Kazakh-speaking respondent from Novy Rychan talked about his trip to Atyrau, Kazakhstan, saying that he felt insecure about his Kazakh skills while there. He opted to talk to locals in Russian because he feared they would mock his “incorrect” Kazakh. This perception of Astrakhan Kazakh as “simplified” and “Russified” is fairly common among its speakers. While somewhat negative, it may also serve as a marker of the community’s identity, helping to distinguish between “us” (Astrakhan Kazakhs) and “them” (Kazakhstan Kazakhs).

Future of Kazakh in Astrakhan

The case of an Astrakhan Kazakh person looking up and memorizing a “complex” word associated with the Kazakh language of Kazakhstan illustrates a small but important tendency. A growing number of young, native Russian-speaking Astrakhan Kazakhs are deliberately immersing themselves in Kazakhstani media, explaining that they want to learn the “proper” way to speak their language and reconnect with their culture, which has been partially lost to colonization and assimilation.

While most young Astrakhan Kazakhs seem to have no interest in using their ethnic language in any form, this minority tendency offers hope that Kazakh will live on in Astrakhan Oblast. If the language policy does not change in the decades to come, the local dialect may eventually die out as a natural form of communication in rural communities, but Standard Kazakh is likely to be maintained by the conscious activist minority.

That being said, the continuity of the language policy is a big “if.” Russia’s government has been increasingly unstable since the beginning of the war in Ukraine. In many regions, ethnic minorities feel that they are unfairly overrepresented among those sent to fight in Ukraine, and this is especially true for Astrakhan Kazakhs. At the same time, the federal government is cracking down on indigenous activism more heavily than ever.

The growing dissent among minorities has led to the emergence of numerous secessionist organizations. An overview of pro-independence movements that view Astrakhan as a part of their hypothetical states can be found in my recent article for New Eastern Europe . It is hard to make predictions about the success of these movements, but in the event that they succeed, language policy and power dynamics between the region’s ethnic groups are more than likely to change.

All photos by

Dor Shabashewitz and Valery Maslov

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