Improving Critical Thinking and Clinical Reasoning by Rosalinda Alfaro-LeFevre, RN, MSN, ANEF The goal of this continuing

education program is to help nurses improve their critical thinking and clinical reasoning skills. After you study the information presented here, you will be able to Describe critical thinking and clinical reasoning in the context of your practice. Identify characteristics and skills that demonstrate critical thinking. Use specific strategies to improve your critical thinking and clinical reasoning abilities. Never before have nurses experienced such significant changes. Each day brings new challenges, from adapting to health information technology to juggling multiple priorities for several patients. Having sound critical thinking and clinical reasoning skills makes the difference between keeping patients safe and putting them in harms way. This module addresses the knowledge, skills and attitudes needed for critical thinking (CT) and clinical reasoning (CR). It reviews results from key studies and gives strategies for developing the thinking skills needed to function as a 21stcentury nurse.1,2 Lets start by examining what CT and CR entail. Critical Thinking Versus Clinical Reasoning The termscritical thinking (CT)andclinical reasoning (CR)are often used interchangeably, but there is a slight difference between them. CRisa specific term that usually refers to assessment and management of patient problems at the point of care (e.g., reasoning at the bedside or during a clinic visit). For reasoning about other clinical issues (e.g., teamwork, collaboration and streamlining work flow), nurses usually use the termcritical thinking. CT is a broad term that includes CR and refers to important thinking that needs to happen to assess and manage anysituation (inside or outside of the clinical setting). Because thinking is a complex process that involves feelings, past experience, and individual tendencies, theres no one right way to define critical thinking. Many authors develop their own descriptions to complement and clarify someone elses, which is actually a good example of using this way of thinking. Critical thinking requires you to personalize information, to analyze it and draw conclusions about what it means to you, rather than simply memorizing words. Consider the following commonly seen critical thinking descriptions: -Knowing how to learn, reason, think creatively, generate and evaluate ideas, see things in the minds eye, make decisions, and solve problems -Reasonable, reflective thinking that focuses on what to believe or do -The ability to solve problems by making sense of information using creative, intuitive, logical, and analytical mental processes, and the processes are continual Its important to realize that some leaders believe substituting problem solving for critical thinking creates problems. Dont be satisfied with having just a problem-solving mentality. You could be demonstrating good problem solving, but if you arent proactive using prevention and health promotion to avoid problems youre not thinking critically. If you dont have a sincere desire to improve to find ways to broaden your knowledge and skills, and to find ways to make current practices more efficient and effective youre not thinking critically. You may find that clients and peers who know the value of constant improvement and professional growth will leave you behind. A holistic way to define critical thinking is a commitment to look for the best way, based on the most current evidence. This means asking questions such as
What are the outcomes? How can we do this better? How satisfied are our patients with their care? Are we applying the most up-to-date evidence? The box below summarizes key points on CT and CR.

CT and CR are outcome-focused thinking that Is guided by standards, policies, ethics codes and laws (individual state practice acts and state boards of nursing). Is based on principles of nursing process, problem solving and the scientific method (requires forming opinions and making decisions based on evidence). Focuses on safety and quality, constantly re-evaluating, self-correcting and striving to improve. Carefully identifies the key problems, issues and risks involved, including patients, families, and key stakeholders in decision-making early in the process. (Stakeholders) are the people who will be most affected [patients and families] or from whom requirements will be drawn [caregivers, insurance companies, third party payers, healthcare organizations]. Is driven by patient, family and community needs, as well as nurses needs to give competent, efficient care (e.g., streamlining charting to free nurses for patient care). Calls for strategies that make the most of human potential and compensate for problems created by human nature (e.g., finding ways to prevent errors, using technology and overcoming the powerful influence of personal views).

Shifting to a Predictive Clinical Reasoning Model Another consideration in todays clinical setting that affects how we describe critical thinking is that theres a shift in thinking about how to manage health problems. We have shifted from a diagnose and treat (DT) model to a predict, prevent, manage, and promote (PPMP) model. Whats the difference between a DT and a PPMP model? DT implies that we wait for evidence of problems before starting treatment. For example, in the past, we monitored people with fractured hips for emboli, but we didnt do much about preventing them. We monitored people closely until, sure enough, they threw an embolus. Today, we routinely identify those at risk and begin treatment to prevent emboli immediately. For example, we often give anticoagulants and apply pulsating antiembolic stockings. Another example of the PPMP model is how we manage exposure to HIV. In the past, we simply monitored HIV-exposed individuals for symptoms. Today, when someone has significant exposure to HIV, we begin treatment immediately, before the virus even appears in the blood. DT has a narrow approach thats strong on treating problems but weak on preventing them and their complications. PPMP is based on evidence. We now know the typical course of most health problems. We know how to alter the course by identifying risk factors and intervening early. You may be thinking that the PPMP approach isnt new because weve always focused on prevention and early intervention. But, realize that today thanks to computers, new technology, and hard work on the part of many expert clinicians and researchers we have a higher degree of reliable evidence addressing how to predict, prevent, and manage problems in various situations and populations. As a critical thinker, its your job to pay attention to new technology and evidence-based approaches that improve outcomes. Think about how many years we did X-rays after central venous line insertion to confirm placement now with new evidence and technology, we are much more proactive, using live ultrasound to monitor how lines are inserted, thereby reducing risks of serious complications, such as a collapsed lung. Remember the importance of the fourth P (promote). At every patient encounter, think about how to promote function. For example, point out the benefits of walking daily and using stress management techniques to promote optimal physical and mental function. Using Critical Pathways You may recognize critical pathways as an example of using the PPMP model. Its not unusual for patients to be placed on a critical pathway that gives the predicted care needed to meet outcomes within specific time frames. Critical pathways can either enhance or impede thinking. They enhance thinking when they help knowledgeable staff decide whats most important in care management. They can impede thinking in those who are task-oriented, not thought-oriented. These individuals complete tasks in a linear way. They dont assess, reflect, evaluate, or change approaches as needed. Sometimes we see staff who are so influenced by knowing the predicted care that they rush through assessments and make dangerous assumptions. Nurses must realize the importance of assessing their patients before implementing a critical path. They must also remember to supervise task-oriented workers closely.
The following compares what it looks like when nurses use critical pathways with and without critical thinking.

Critical Thinking

Thinking With Critical Pathways

Im familiar with this path. I wonder how this particular patient is doing in relation to the predicted care for this problem. Its going to take time to think through whats really going on with this patient, but Id better make time. Not Critical Thinking I have a path for this patient, so this should be easy and straightforward because I already know what the problems are going to be. Theres no way I have time to go through everything I need to really understand this patient. Id better just follow the path. What do Critical Thinkers Look Like? Surprisingly, research shows that most critical thinkers are women between the ages of 30 and 35, fair-skinned, and taller than 5 feet 4 inches. However, if you arent questioning this statement, youre not thinking critically about what youre reading. When we ask, What does a critical thinker look like? we mean, What characteristics do we see in someone who thinks critically? Consider this description: The ideal critical thinker is habitually inquisitive, self-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 selection of criteria, focused on inquiry, and persistent in seeking results that are as precise as the subject and the circumstances of inquiry permit.. Paul and Elder also describe key intellectual traits: Intellectual humility:Willingness to admit what you dont know Intellectual integrity:Continual evaluation of your own thinking and willingness to admit when it may be flawed Intellectual courage:Awareness of the need to face and fairly address ideas, beliefs, or viewpoints about which you have negative feelings and havent given serious hearing Intellectual empathy:A conscious effort to understand others by putting your own feelings aside and imagining yourself in their shoes.

Seven critical thinking dispositions seen in those who demonstrate critical thinking have been identified:

 Truthseeking:A courageous desire for the best knowledge, even if such knowledge fails to support or undermines ones preconceptions, beliefs, or self-interests. Open-Mindedness:Tolerance to divergent views and self-monitoring for possible bias. Analyticity:Demanding the application of reason and evidence, alert to problematic situations, inclined to anticipate consequences. Systematicity:Valuing organization, focus, and diligence to approach problems of all levels of complexity. CT Self-Confidence:Trusting ones own reasoning skills and seeing oneself as a good thinker. Inquisitiveness:Curiosity and eagerness to acquire knowledge and learn explanations even when the applications of the knowledge are not immediately apparent. Maturity:Prudence in making, suspending, or revising judgment; an awareness that multiple solutions can be acceptable; an appreciation of the need to reach closure even in the absence of complete knowledge. Scheffer and Rubenfeld performed a Delphi study to identify habits of the mind usually found in nurses who think critically. Their results identified similar traits to those listed by the authors above. They added creativity, flexibility, intuition, perseverance, and reflection as being important traits. CTIs are divided into three categories: 1. General attitudes/characteristics indicators:These are behaviors that indicate the nurse possesses CT characteristics/attitudes (e.g., inquisitive, persistent, reflective, open-minded, proactive, resilient, self-aware). 2. Knowledge indicators:These are behaviors that indicate the nurse has required knowledge (e.g., ability to discuss ethics codes and professional standards, to describe signs and symptoms of common health problems and related complications, to explain the difference between nursing and medical models, and to give key details of pharmacology, anatomy, and physiology). 3. Intellectual skill indicators/competencies:These are behaviors that indicate the nurse has required intellectual skills/competencies (e.g., ability to assess systematically and comprehensively, distinguish relevant from irrelevant, identify missing information, recognize inconsistencies, identify assumptions, and draw valid conclusions). Nursing Process American Nurses Association standards state that the nursing process serves as a critical thinking model that promotes a competent level of care.13As you work with electronic health records, remember that you must have nursing process principles assessment, diagnosis, outcome identification, planning, implementation and evaluation in yourhead. The nursing process gives you an organized way of thinking at the point of care. Also remember that when legal systems examine documentation to evaluate the standard of care, they look to see how you implemented the nursing process phases. You need a strong foundation in nursing process principles to apply evidence-based care models (e.g., case management, critical pathways) and to do the critical thinking needed to pass standard tests (e.g., National Council Licensure Examinations [NCLEX] and other certification tests). For example, you must know that the first step to CR is toassess to identify assumptions and determine whether you have all the necessary facts.If you have a test question about someone with unrelieved pain and youre asked, What would you do first? the correct response is almost always something that addresses what you would need to assess. For example, suppose a test question is about a patient who complains of unrelieved pain and youre asked, What would you do first? If you have the choice of the answers: Give pain medication, Teach pain management, Activate the Chain of Command, or Assess the pain, the correct answer is Assess the pain. Reflecting on Care Including Patients As we realize the importance of reflecting on care and including patients in decision-making, consider the importance of asking the following questions:
1. Has patient participation in the process been at an optimum level? 2. Is information accurate and complete? 3. Have assumptions been identified, and thinking tailored to the individual patient and circumstances? 4. Are conclusions based on facts (evidence), rather than guesswork? 5. Have alternate conclusions, ideas, and solutions been considered?

How to Think Critically Unlike todays youth, who are being taught very specific strategies to improve their thinking, most of us have learned how to think rather haphazardly, partially from observation and experience, and partially from school. Many adults havent learned the basic critical thinking skills that their children have. For example, think about the following discussion between two 8-year-olds:.
Chuck: Is your friend sleeping over? Chelsey: Yes, she is. Chuck: No, shes not. Chelsey: Yes, she IS! Chuck: Is NOT! Chelsey: How do you KNOW shes not? Chuck: [A bunch of contextual clues, e.g., no backpack or suitcase].

From a very early age, Chuck was taught the importance of considering the context (circumstances) of each situation. Thinking is a skill, just like tennis, skiing, or golf a skill that must be learned, adapted, and practiced to succeed in the fast-paced game of life and work. Learning how to think critically requires insight, knowledge, experience, practice, and feedback. More specifically, you need to

1. Gain insight. Develop an understanding of what critical thinking is and an awareness of how you and others think. Become familiar with common definitions and relevant critical thinking indicators. Learn how to put your thinking into words. Theres often more than one solution to a given problem. Be sure you can explain and support the thinking behind the solutions you choose. 2. Acquire specific theoretical and experiential knowledge related to diagnosis and management of patients and problems commonly seen in your particular practice setting. Classroom learning is important, but it cant take the place of experiential learning (e.g., you wont be able to recognize abnormal breath sounds until youve had practice actually hearing them). Until you have good technical skills, such as managing IVs and other equipment, most of your brainpower goes toward mastering these types of skills, leaving little energy for critical thinking. 3. Learn strategies that promote CT and CR (addressed in the next section). 4. Practice. Use it or lose it applies. Unless you practice the skills required in your particular setting, for example, assessing systematically and comprehensively, youre unlikely to gain or maintain competency. 5. Ask for feedback. Ask trusted colleagues and supervisors to tell you what they think about your CT skills. This feedback can really help you improve. Strategies Promoting CT and CR Think about the following strategies for improving CT and CR. Ask What if questions like What if something goes wrong? or What if we try? This helps you be proactive and creative. Look for flaws in your thinking. Ask questions like Whats missing? Do I recognize my biases? How could this be made better? Ask someone else to look for flaws in your thinking. Youre usually too close to your own work to be objective; others bring a fresh eye and new ideas and perspectives. Anticipate questions others might ask, such as, What will my supervisor want to know? What will the physician ask? This helps identify a wider scope of questions that must be answered to gain relevant information. Develop good habits of inquiry (habits that aid in the search for the truth, like always keeping an open mind, verifying information, and taking enough time). Develop interpersonal skills, such as conflict resolution and getting along with those who have different communication styles. If you dont have good interpersonal skills, youre unlikely to get the help or information you need to think critically. Turn errors into learning opportunities. Examining mistakes is a powerful way to learn. Evaluating CT and CR Evaluating thinking is a complex task. Its not easy to determine what goes on in someone elses head. Many factors affect how someone thinks in a given situation and no one can read someone elses mind. Observing behavior and being willing to dialogue to understand someone elses thinking is key to evaluating CT and CR. Using the evidence-based CTIs (addressed earlier) as a guide to promote discussion can be helpful because the indicators give concrete examples of CT skills. Remember that teaching and evaluation go hand in hand. Start by being very specific about what pieces of clinical reasoning you want the nurse to learn (e.g., one of the first skills nurses need to have is how to prioritize their assessments and gain accurate, relevant, complete data) Evaluation should not be a surprise. If you are a preceptor or manager, you might teach your new nurse by saying, Heres a list of behaviors (or indicators) that we look for in our nurses and here are the evaluation tools we use. If you are a new nurse, ask for competency and evaluation tools early so that you can use them as learning guides. Whatever you do, keep the lines of communication open and be sure you build positive relationships. New nurses struggle with sensory bombardment because they are in a new environment with lots of new people. They also lack confidence. Sensory bombardment and lack of confidence are brain-drains that leave very little energy for CT. Nurses need time, peer support, and good mentors to build the confidence needed to develop sound reasoning and judgment. Think about the nurses who helped or hindered your growth. Take the time and patience to mentor and support new nurses. One day theyll be the kind of nurses you need to have at your side to make things better. To gain an understanding of nurses critical thinking abilities, consider three things: 1. Patterns of verbal communication and behavior: What nurses say and do over time tells you how they think. Can you think of colleagues who are, or are not, critical thinkers, just by reflecting on how they communicate and behave? 2. Documentation and written or electronic communication: How is the nurses charting? Is it timely? Are there omissions? Does it give a good picture of the patients status? Electronic health records often dictate whats recorded. However, you should see original observations now and then. 3. Outcomes (results): This requires direct assessment of the nurses patients. How are they doing? How patients fare under a nurses care is usually a result of critical thinking. Considering patient results to evaluate thinking is helpful when working with diverse thinkers. You may have a methodical approach to care and be supervising a nurse who seems haphazard and scattered. To determine if this is simply a style difference, check on the patients. If the patients are well cared for, you may have a style difference, not a critical thinking problem. Todays workplace is challenging. The nurses who will survive, even thrive, are those who are clearly aware of how to think, how others think, and how to use strategies and tools to maximize their ability to think critically. Learn to work smarter, not harder. Make a commitment to improve thinking by engaging in open and honest dialogue, by identifying and examining assumptions behind usual practices, by looking for new approaches, and by developing the theoretical and experiential knowledge you need to think critically in your particular practice.

Imagine the following scenario.

A. IQ potential and patterns of behavior. B. Patterns of behavior and patient outcomes (results). Youre at work doing your usual job. You overhear Nancy, an experienced C. Education level and CE test results. colleague, say the following to a new nurse: The problem with you, Sarah, D. Patterns of behavior and CT instruments results. is that you just dont think.Youve got to start thinking! If I dont see improvement, this is going to be a problem! 10) Critical thinking skills, such as recognizing assumptions, knowing Later, looking very upset, Sarah comes to you and says, I dont know what whats relevant, and identifying a systematic approach to assessment, Im going to do. Im trying to do what Im supposed to do, but all Nancyare best mastered by says is that Im not thinking. Iam thinking. But, I need more guidance than A. Taking a specific course in critical thinking. shes giving me. I want to do a good job, but I need help. This is all very B. Knowing what resources can help you learn. new to me. Its not helpful to hear, Youve got to startthinking! Its vague, C. Independent learning in the clinical setting. and it wrecks my confidence. Can you please help me? D. Acquiring knowledge, experience, practice, and feedback. 11) The first step to improving your ability to think critically is to A. Become more conscious of the importance of right answers. B. Be sure youve memorized the facts needed to think critically in each specific situation. C. Gain insight into how you think and whats required to think critically. D. Take test that can give you a numerical score for your ability to think critically. 12) The PPMP model of managing health problems is A. Based on research findings. B. Less proactive than the DT model. C. Problematic because it is too predictive. D. Not applicable to nursing today. 13) Use of critical pathways A. Makes giving nursing care easier. B. Influences some staff to make assumptions. C. Is best done when computerized. D. Works better than nursing care plans.

1 ) Which of the following is the best response to Sarah? A. Nancy has always been hard on new nurses. B. Ive been new myself, and I know that its hard. C. Does Nancy write things down for you to do? D. You are putting me in a difficult position. 2 ) Sarahs lack of confidence is A. A sign that she needs leadership skills. B. Due to her lack of knowledge. C. A sign that she will struggle learning. D. Normal for a new nurse. 3 ) Lack of confidence is A. A brain-drain that leaves little energy for critical thinking. B. Innate, therefore difficult to overcome. C. Good for new nurses because it motivates them to learn. D. Usually due to previous bad experiences.

14) Mistakes in the workplace 4 ) Which of the following is MOST important in helping Sarah improve A. Should be avoided at all costs. her critical thinking skills? B. Show when knowledge is lacking. C. Can help you learn. A. Building a trusting relationship and keeping lines of communication D. Happen most often because of work pressures. open. B. Giving her a list of competencies and telling her when shell be tested. C. Helping her to realize she needs to be an independent learner. D. Asking Sarah what she learned in nursing school about critical thinking skills. 5) The terms critical thinking and clinical reasoning are A. Completely separate terms. B. New to the literature as of 2005. C. Based on evidence. D. Often used interchangeably. 6) Critical Thinking Indicators (CTIs) are A. Instruments that measure critical thinking ability. B. Graphs that plot critical thinking. C. Behaviors that promote critical thinking. D. EEG waves that indicate critical thinking. 7) Today, we see a shift in thinking about how to manage health problems, moving from a diagnose and treat model to one that focuses A. Only on outcomes achieved after health problems are treated. B. Only on the patients response to healthcare problems. C. On using critical paths as the main way to manage healthcare problems. D. On predicting, preventing, and managing health problems. 8) Having intellectual empathy means that you A. Readily recognize when others feelings may have been hurt. B. Are willing to fairly consider viewpoints different from your own. C. Are able to put yourself in other peoples shoes. D. Recognize how difficult it is for some to think critically. 9) Two ways to evaluate nurses thinking is to consider 15) Interpersonal skills are A. Essential to critical thinking. B. Difficult to evaluate objectively. C. Best learned in the practice setting. D. A separate skill from critical thinking.