Running head: AGAINST ERROR

Against Error:
Critical Thinking and Clinical Reasoning
Jack L. Kaczmarczyk
Baker College

Against Error:
Critical Thinking and Clinical Reasoning
Thomas H. Huxley (1880), when writing about crayfish at the turn of the nineteenth
century, managed not only to produce a zoological classic, but interestingly also provided us with
three cardinal signs of critical thinking. Science is simply common sense at its best; that is,
rigidly accurate in observation, and merciless to fallacy in logic, he writes (p. 2). Critical
thinking is defined by common sense, accurate observation, and logic. It is a fundamental skill
for any practitioner of science since its application reduces the manifestation of fallacy and the
frequency of error. In the field of medicine, where fallacy leads to misdiagnosis and error kills,
its value is literally life-changing. A nurse who thinks critically protects patients, protects
themselves, and protects the profession. A nurse who thinks critically achieves the goal of
clinical reasoning, which is the accurate diagnosis of patient problems in response to their
disease processes or the care provided.

AGAINST ERROR

Common sense, writes Voltaire, is not so common. Unfortunately, research about

clinical reasoning shows that common sense is not very prevalent among novice nurses, either.
While novices readily retrieve patient data, Simmons writes, important cues are often
overlooked as the degree of uncertainty or decision complexity increases, (2010, p. 1154). If our
registered nurses are generally so abject, how much more the nursing student. In lab, it quickly
dawns upon the student nurse that it less necessary to possess a textbook knowledgesurely, it
will come in handy sometimethan it is to possess a foundation of common sense. For example,
one cannot expect a bedpan to be effective if it is placed underneath a patient backwards; or, that
a swab culture must be done on a wound between dressings, and not after. These profundities and
a host of other problems are handled by the experienced nurse, continues Simmons, by
employing heuristics, a sort of ingrained pattern-recognition that compares the circumstances
of the present with a mental archetype (2010). This frees up processing speed, let us say, in order
that the nurse might concentrate processors on higher priorities.
Accurate observation has to have the highest priority. Miss a detail or fudge a reading,
lose a life. At least, this morbid outlook is unavoidable for the nursing student who seriously
apprehends their future career. Anything less than Sherlockian powers of deduction, we feel, will
be too little to win the day. The truth, again as evidenced by Simmons study, is a lot more
homely. Heuristics come into play again. Discordant pieces of patient data that do not gel are
quickly identified by their fitting with, or not fitting with, a pattern. The rapidity with which
heuristics works is its greatest strength. It is also its greatest weakness. While it takes less energy,
is quicker than active reasoning, and is the preferred method of physicians to rely on, this tactic
can be the cause of error when bias has affected the process, (Crampton, 2013, p. 21).
Logic, especially the cold, hard sort as described by Huxley, defends against bias. The
etymology of bias is telling; it comes to us from the French biais which means slant,

AGAINST ERROR

oblique, (Online Etymology Dictionary). If we are not strictly logical, we come to situations at
an angle of our own. Personal opinions about a patients lifestyle, beliefs, or values, should never
enter into nursing practice. If that happens, the objectivity which proper assessment demands is
lost, and, professionally, so is the nurse. Anchoring bias is another type of error that can
jeopardize patient care, especially when determining if a nursing intervention has been effective.
This bias is typified by an unwillingness to haul up the anchor of our first diagnosis
(Crampton, 2013). Subsequent data gets tethered there whether it belongs or not, leading to
misdiagnosis of future complications.
In summary, clinical reasoning is the machine used to diagnose and treat a patient in the
scope of nursing practice. Critical thinking is the power source; one without the other cuts the
effectiveness of a nurse in half. Perhaps that definition has not the pithiness of Huxleys that
opened this essay, but at the time of writing The Crayfish he was at the height of his powers and,
at the time of writing the present work, the author is only a nursing student.

References
Andersson, N., Klang, B., & Petersson, G. (2012). Differences in clinical reasoning among
nurses working in highly specialised paediatric care. Journal Of Clinical Nursing,
21(5/6), 870-879. doi:10.1111/j.1365-2702.2011.03935.x
Adibi, P., Ashoorion, V., & Liaghatdar, M. J. (2012). What variables can influence clinical
reasoning? Journal of Research in Medical Sciences.
bias. (n.d.). Online Etymology Dictionary. Retrieved October 13, 2013, from Dictionary.com
website: http://dictionary.reference.com/browse/bias
Crampton, J. (2013). Why nurses should use clinical reasoning to diagnose a cough. Primary
Health Care, 23(7), 18-24.
Huxley, T. H. (1880). The Crayfish: An Introduction to the Study of Zoology. London: C. Kegan

AGAINST ERROR
Paul & Co.
Simmons, B. (2010). Clinical reasoning: concept analysis. Journal Of Advanced Nursing, 66(5),
1151-1158. doi:10.1111/j.1365-2648.2010.05262.x