nursing knowledge critical thinking

The Value of Critical Thinking in Nursing

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

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

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

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

How Do Nurses Use Critical Thinking?

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

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

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

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

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

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

Top 5 Ways Nurses Can Improve Critical Thinking Skills

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

Case-Based Approach

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

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

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

Practice Self-Reflection

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

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

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

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

Develop a Questioning Mind

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

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

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

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

Practice Self-Awareness in the Moment

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

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

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

Use a Process

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

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

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

Common Critical Thinking Pitfalls in Nursing

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

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

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

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

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

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

An Essential Skill for All Nurses

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

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

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

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

How does nursing school develop critical thinking skills?

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

Do only nurse managers use critical thinking?

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

Meet Our Contributors

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

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

Jenna Liphart Rhoads, Ph.D., RN

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

Nicholas McGowan, BSN, RN, CCRN

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

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?

Brain, Decision Making and Mental Health pp 179–189 Cite as

Critical Thinking in Nursing

• Şefika Dilek Güven 3  
• First Online: 02 January 2023

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Part of the book series: Integrated Science ((IS,volume 12))

Critical thinking is an integral part of nursing, especially in terms of professionalization and independent clinical decision-making. It is necessary to think critically to provide adequate, creative, and effective nursing care when making the right decisions for practices and care in the clinical setting and solving various ethical issues encountered. Nurses should develop their critical thinking skills so that they can analyze the problems of the current century, keep up with new developments and changes, cope with nursing problems they encounter, identify more complex patient care needs, provide more systematic care, give the most appropriate patient care in line with the education they have received, and make clinical decisions. The present chapter briefly examines critical thinking, how it relates to nursing, and which skills nurses need to develop as critical thinkers.

Graphical Abstract/Art Performance

Critical thinking in nursing.

This painting shows a nurse and how she is thinking critically. On the right side are the stages of critical thinking and on the left side, there are challenges that a nurse might face. The entire background is also painted in several colors to represent a kind of intellectual puzzle. It is made using colored pencils and markers.

(Adapted with permission from the Association of Science and Art (ASA), Universal Scientific Education and Research Network (USERN); Painting by Mahshad Naserpour).

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Güven, Ş.D. (2023). Critical Thinking in Nursing. In: Rezaei, N. (eds) Brain, Decision Making and Mental Health. Integrated Science, vol 12. Springer, Cham. https://doi.org/10.1007/978-3-031-15959-6_10

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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)

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Critical Thinking in Nursing Practice

Chapter 15 Critical Thinking in Nursing Practice Objectives •  Describe characteristics of a critical thinker. •  Discuss the nurse’s responsibility in making clinical decisions. •  Discuss how reflection improves clinical decision making. •  Describe the components of a critical thinking model for clinical decision making. •  Discuss critical thinking skills used in nursing practice. •  Explain the relationship between clinical experience and critical thinking. •  Discuss the critical thinking attitudes used in clinical decision making. •  Explain how professional standards influence a nurse’s clinical decisions. •  Discuss the relationship of the nursing process to critical thinking. Key Terms Clinical decision making, p. 196 Concept map, p. 202 Critical thinking, p. 193 Decision making, p. 195 Diagnostic reasoning, p. 196 Evidence-based knowledge, p. 193 Inference, p. 196 Nursing process, p. 197 Problem solving, p. 195 Reflection, p. 202 Scientific method, p. 195 http://evolve.elsevier.com/Potter/fundamentals/ •  Review Questions •  Case Study with Questions •  Audio Glossary •  Interactive Learning Activities •  Key Term Flashcards •  Content Updates Every day you think critically without realizing it. If it’s hot outside, you take off a sweater. If your DVD doesn’t start, you reposition the disc. If you decide to walk the dogs, you change to a pair of walking shoes. These examples involve critical thinking as you face each day and prepare for all possibilities. As a nurse, you will face many clinical situations involving patients, family members, health care staff, and peers. In each situation it is important to try to see the big picture and think smart. To think smart you have to develop critical thinking skills to face each new experience and problem involving a patient’s care with open-mindedness, creativity, confidence, and continual inquiry. When a patient develops a new set of symptoms, asks you to offer comfort, or requires a procedure, it is important to think critically and make sensible judgments so the patient receives the best nursing care possible. Critical thinking is not a simple step-by-step, linear process that you learn overnight. It is a process acquired only through experience, commitment, and an active curiosity toward learning. Clinical Decisions in Nursing Practice Nurses are responsible for making accurate and appropriate clinical decisions. Clinical decision making separates professional nurses from technical personnel. For example, a professional nurse observes for changes in patients, recognizes potential problems, identifies new problems as they arise, and takes immediate action when a patient’s clinical condition worsens. Technical personnel simply follow direction in completing aspects of care that the professional nurse has identified as necessary. A professional nurse relies on knowledge and experience when deciding if a patient is having complications that call for notification of a health care provider or decides if a teaching plan for a patient is ineffective and needs revision. Benner (1984) describes clinical decision making as judgment that includes critical and reflective thinking and action and application of scientific and practical logic. Most patients have health care problems for which there are no clear textbook solutions. Each patient’s problems are unique, a product of the patient’s physical health, lifestyle, culture, relationship with family and friends, living environment, and experiences. Thus as a nurse you do not always have a clear picture of a patient’s needs and the appropriate actions to take when first meeting a patient. Instead you must learn to question, wonder, and explore different perspectives and interpretations to find a solution that benefits the patient. Because no two patients’ health problems are the same, you always apply critical thinking differently. Observe patients closely, gather information about them, examine ideas and inferences about patient problems, recognize the problems, consider scientific principles relating to the problems, and develop an approach to nursing care. With experience you learn to creatively seek new knowledge, act quickly when events change, and make quality decisions for patients’ well-being. You will find nursing to be rewarding and fulfilling through the clinical decisions you make. Critical Thinking Defined Mr. Jacobs is a 58-year-old patient who had a radical prostatectomy for prostate cancer yesterday. His nurse, Tonya, finds the patient lying supine in bed with arms extended along his sides but tensed. When Tonya checks the patient’s surgical wound and drainage device, she notes that the patient winces when she gently places her hands to palpate around the surgical incision. She asks Mr. Jacobs when he last turned onto his side, and he responds, “Not since last night some time.” Tonya asks Mr. Jacobs if he is having incisional pain, and he nods yes, saying, “It hurts too much to move.” Tonya considers the information she has observed and learned from the patient to determine that he is in pain and has reduced mobility because of it. She decides that she needs to take action to relieve Mr. Jacobs’ pain so she can turn him more frequently and begin to get him out of bed for his recovery. In the case example the nurse observes the clinical situation, asks questions, considers what she knows about postoperative pain and risk for immobility, and takes action. The nurse applies critical thinking, a continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant ( Heffner and Rudy, 2008 ). Critical thinking involves recognizing that an issue (e.g., patient problem) exists, analyzing information about the issue (e.g., clinical data about a patient), evaluating information (reviewing assumptions and evidence) and making conclusions ( Settersten and Lauver, 2004 ). A critical thinker considers what is important in each clinical situation, imagines and explores alternatives, considers ethical principles, and makes informed decisions about the care of patients. Critical thinking is a way of thinking about a situation that always asks “Why?”, “What am I missing?”, “What do I really know about this patient’s situation?”, and “What are my options?” ( Heffner and Rudy, 2008 ; Paul and Heaslip, 1995 ). Tonya knew that pain was likely going to be a problem because the patient had extensive surgery. Her review of her observations and the patient’s report of pain confirmed her knowledge that pain was a problem. Her options include giving Mr. Jacobs an analgesic and waiting until it takes effect so she is able to reposition and make him more comfortable. Once he has less acute pain, Tonya offers to teach Mr. Jacobs some relaxation exercises. You begin to learn critical thinking early in your practice. For example, as you learn about administering baths and other hygiene measures, take time to read your textbook and the nursing literature about the concept of comfort. What are the criteria for comfort? How do patients from other cultures perceive comfort? What are the many factors that promote comfort? The use of evidence-based knowledge, or knowledge based on research or clinical expertise, makes you an informed critical thinker. Thinking critically and learning about the concept of comfort prepares you to better anticipate your patients’ needs, identify comfort problems more quickly, and offer appropriate care. Critical thinking requires cognitive skills and the habit of asking questions, remaining well informed, being honest in facing personal biases, and always being willing to reconsider and think clearly about issues ( Facione, 1990 ). When core critical thinking skills are applied to nursing, they show the complex nature of clinical decision making ( Table 15-1 ). Being able to apply all of these skills takes practice. You also need to have a sound knowledge base and thoughtfully consider what you learn when caring for patients. TABLE 15-1 Critical Thinking Skills SKILL NURSING PRACTICE APPLICATIONS Interpretation Be orderly in data collection. Look for patterns to categorize data (e.g., nursing diagnoses [see Chapter 17 ]). Clarify any data you are uncertain about. Analysis Be open-minded as you look at information about a patient. Do not make careless assumptions. Do the data reveal what you believe is true, or are there other options? Inference Look at the meaning and significance of findings. Are there relationships between findings? Do the data about the patient help you see that a problem exists? Evaluation Look at all situations objectively. Use criteria (e.g., expected outcomes, pain characteristics, learning objectives) to determine results of nursing actions. Reflect on your own behavior. Explanation Support your findings and conclusions. Use knowledge and experience to choose strategies to use in the care of patients. Self-regulation Reflect on your experiences. Identify the ways you can improve your own performance. What will make you believe that you have been successful? Modified from Facione P: Critical thinking: a statement of expert consensus for purposes of educational assessment and instruction. The Delphi report: research findings and recommendations prepared for the American Philosophical Association, ERIC Doc No. ED 315, Washington, DC, 1990, ERIC. Nurses who apply critical thinking in their work are able to see the big picture from all possible perspectives. They focus clearly on options for solving problems and making decisions rather than quickly and carelessly forming quick solutions ( Kataoka-Yahiro and Saylor, 1994 ). Nurses who work in crisis situations such as the emergency department often act quickly when patient problems develop. However, even these nurses exercise discipline in decision making to avoid premature and inappropriate decisions. Learning to think critically helps you care for patients as their advocate, or supporter, and make better-informed choices about their care. Facione and Facione (1996) identified concepts for thinking critically ( Table 15-2 ). Critical thinking is more than just problem solving. It is a continuous attempt to improve how to apply yourself when faced with problems in patient care. TABLE 15-2 Concepts for a Critical Thinker CONCEPT CRITICAL THINKING BEHAVIOR Truth seeking Seek the true meaning of a situation. Be courageous, honest, and objective about asking questions. Open-mindedness Be tolerant of different views; be sensitive to the possibility of your own prejudices; respect the right of others to have different opinions. Analyticity Analyze potentially problematic situations; anticipate possible results or consequences; value reason; use evidence-based knowledge. Systematicity Be organized, focused; work hard in any inquiry. Self-confidence Trust in your own reasoning processes. Inquisitiveness Be eager to acquire knowledge and learn explanations even when applications of the knowledge are not immediately clear. Value learning for learning’s sake. Maturity Multiple solutions are acceptable. Reflect on your own judgments; have cognitive maturity. Modified from Facione N, Facione P: Externalizing the critical thinking in knowledge development and clinical judgment, Nurs Outlook 44(3):129, 1996. Thinking and Learning Learning is a lifelong process. Your intellectual and emotional growth involves learning new knowledge and refining your ability to think, problem solve, and make judgments. To learn, you have to be flexible and always open to new information. The science of nursing is growing rapidly, and there will always be new information for you to apply in practice. As you have more clinical experiences and apply the knowledge you learn, you will become better at forming assumptions, presenting ideas, and making valid conclusions. When you care for a patient, always think ahead and ask these questions: What is the patient’s status now? How might it change and why? Which physiological and emotional responses do I anticipate? What do I know to improve the patient’s condition? In which way will specific therapies affect the patient? What should be my first action? Do not let your thinking become routine or standardized. Instead, learn to look beyond the obvious in any clinical situation, explore the patient’s unique responses to health alterations, and recognize which actions are needed to benefit the patient. With experience you are able to recognize patterns of behavior, see commonalities in signs and symptoms, and anticipate reactions to therapies. Thinking about these experiences allows you to better anticipate each new patient’s needs and recognize problems when they develop. Levels of Critical Thinking in Nursing Your ability to think critically grows as you gain new knowledge in nursing practice. Kataoka-Yahiro and Saylor (1994) developed a critical thinking model ( Fig. 15-1 ) that includes three levels: basic, complex, and commitment. An expert nurse thinks critically almost automatically. As a beginning student you make a more conscious effort to apply critical thinking because initially you are more task oriented and trying to learn how to organize nursing care activities. At first you apply the critical thinking model at the basic level. As you advance in practice, you adopt complex critical thinking and commitment. FIG. 15-1 Critical thinking model for nursing judgment. (Redrawn from Kataoka-Yahiro M, Saylor C: A critical thinking model for nursing judgment, J Nurs Educ 33(8):351, 1994. Modified from Glaser E: An experiment in the development of critical thinking, New York, 1941, Bureau of Publications, Teachers College, Columbia University; Miller M, Malcolm N: Critical thinking in the nursing curriculum, Nurs Health Care 11:67, 1990; Paul RW: The art of redesigning instruction. In Willsen J, Blinker AJA, editors: Critical thinking: how to prepare students for a rapidly changing world, Santa Rosa, Calif, 1993, Foundation for Critical Thinking; and Perry W: Forms of intellectual and ethical development in the college years: a scheme , New York, 1979, Holt, Rinehart, & Winston.) Basic Critical Thinking At the basic level of critical thinking a learner trusts that experts have the right answers for every problem. Thinking is concrete and based on a set of rules or principles. For example, as a nursing student you use a hospital procedure manual to confirm how to insert a Foley catheter. You likely follow the procedure step by step without adjusting it to meet a patient’s unique needs (e.g., positioning to minimize the patient’s pain or mobility restrictions). You do not have enough experience to anticipate how to individualize the procedure. At this level answers to complex problems are either right or wrong (e.g., when no urine drains from the catheter, the catheter tip must not be in the bladder), and one right answer usually exists for each problem. Basic critical thinking is an early step in developing reasoning ( Kataoka-Yahiro and Saylor, 1994 ). A basic critical thinker learns to accept the diverse opinions and values of experts (e.g., instructors and staff nurse role models). However, inexperience, weak competencies, and inflexible attitudes can restrict a person’s ability to move to the next level of critical thinking. Complex Critical Thinking Complex critical thinkers begin to separate themselves from experts. They analyze and examine choices more independently. The person’s thinking abilities and initiative to look beyond expert opinion begin to change. A nurse learns that alternative and perhaps conflicting solutions exist. Consider the case of Mr. Rosen, a 36-year-old man who had hip surgery. The patient is having pain but is refusing his ordered analgesic. His health care provider is concerned that the patient will not progress as planned, delaying rehabilitation. While discussing the importance of rehabilitation with Mr. Rosen, the nurse, Edwin, realizes the patient’s reason for not taking pain medication. Edwin learns that the patient practices meditation at home. As a complex critical thinker, Edwin recognizes that Mr. Rosen has options for pain relief. Edwin decides to discuss meditation and other nonpharmacological interventions with the patient as pain control options and how, when combined with analgesics, these interventions can potentially enhance pain relief. In complex critical thinking each solution has benefits and risks that you weigh before making a final decision. There are options. Thinking becomes more creative and innovative. The complex critical thinker is willing to consider different options from routine procedures when complex situations develop. You learn a variety of different approaches for the same therapy. Commitment The third level of critical thinking is commitment ( Kataoka-Yahiro and Saylor, 1994 ). At this level a person anticipates when to make choices without assistance from others and accepts accountability for decisions made. As a nurse you do more than just consider the complex alternatives that a problem poses. At the commitment level you choose an action or belief based on the available alternatives and support it. Sometimes an action is to not act or to delay an action until a later time. You choose to delay as a result of your experience and knowledge. Because you take accountability for the decision, you consider the results of the decision and determine whether it was appropriate. Critical Thinking Competencies Kataoka-Yahiro and Saylor (1994) describe critical thinking competencies as the cognitive processes a nurse uses to make judgments about the clinical care of patients. These include general critical thinking, specific critical thinking in clinical situations, and specific critical thinking in nursing. General critical thinking processes are not unique to nursing. They include the scientific method, problem solving, and decision making. Specific critical thinking competencies in clinical health care situations include diagnostic reasoning, clinical inference, and clinical decision making. The specific critical thinking competency in nursing involves use of the nursing process. Each of the competencies is discussed in the following paragraphs. General Critical Thinking Scientific Method The scientific method is a way to solve problems using reasoning. It is a systematic, ordered approach to gathering data and solving problems used by nurses, physicians, and a variety of other health care professionals. This approach looks for the truth or verifies that a set of facts agrees with reality. Nurse researchers use the scientific method when testing research questions in nursing practice situations (see Chapter 5 ). The scientific method has five steps: 1  Identifying the problem 2  Collecting data 3  Formulating a question or hypothesis 4  Testing the question or hypothesis 5  Evaluating results of the test or study Consider the following example of the scientific method in nursing practice. A nurse caring for patients who receive large doses of chemotherapy for ovarian cancer sees a pattern of patients developing severe inflammation in the mouth (mucositis) (identifies problem). The nurse reads research articles (collects data) about mucositis and learns that there is evidence to show that having patients keep ice in their mouths (cryotherapy) during the chemotherapy infusion reduces severity of mucositis after treatment. He or she asks (forms question), “Do patients with ovarian cancer who receive chemotherapy have less severe mucositis when given cryotherapy versus standard mouth rinse in the oral cavity?” The nurse then collaborates with colleagues to develop a nursing protocol for using ice with certain chemotherapy infusions. The nurses on the oncology unit collect information that allows them to compare the incidence and severity of mucositis for a group of patients who use cryotherapy versus those who use standard-practice mouth rinse (tests the question). They analyze the results of their project and find that the use of cryotherapy reduced the frequency and severity of mucositis in their patients (evaluating the results). They decide to continue the protocol for all patients with ovarian cancer. Problem Solving You face problems every day such as a computer program that doesn’t function properly or a close friend who has lost a favorite pet. When a problem arises, you obtain information and use it, plus what you already know, to find a solution. Patients routinely present problems in practice. For example, a home care nurse learns that a patient has difficulty taking her medications regularly. The patient is unable to describe what medications she has taken for the last 3 days. The medication bottles are labeled and filled. The nurse has to solve the problem of why the patient is not adhering to or following her medication schedule. The nurse knows that the patient was discharged from the hospital and had five medications ordered. The patient tells the nurse that she also takes two over-the-counter medications regularly. When the nurse asks her to show the medications that she takes in the morning, the nurse notices that she has difficulty reading the medication labels. The patient is able to describe the medications that she is to take but is uncertain about the times of administration. The nurse recommends having the patient’s pharmacy relabel the medications in larger lettering. In addition, the nurse shows the patient examples of pill organizers that will help her sort her medications by time of day for a period of 7 days. Effective problem solving also involves evaluating the solution over time to make sure that it is effective. It becomes necessary to try different options if a problem recurs. From the previous example, during a follow-up visit the nurse finds that the patient has organized her medications correctly and is able to read the labels without difficulty. The nurse obtained information that correctly clarified the cause of the patient’s problem and tested a solution that proved successful. Having solved a problem in one situation adds to a nurse’s experience in practice, and this allows the nurse to apply that knowledge in future patient situations. Decision Making When you face a problem or situation and need to choose a course of action from several options, you are making a decision. Decision making is a product of critical thinking that focuses on problem resolution. Following a set of criteria helps to make a thorough and thoughtful decision. The criteria may be personal; based on an organizational policy; or, frequently in the case of nursing, a professional standard. For example, decision making occurs when a person decides on the choice of a health care provider. To make a decision, an individual has to recognize and define the problem or situation (need for a certain type of health care provider to provide medical care) and assess all options (consider recommended health care providers or choose one whose office is close to home). The person has to weigh each option against a set of personal criteria (experience, friendliness, and reputation), test possible options (talk directly with the different health care providers), consider the consequences of the decision (examine pros and cons of selecting one health care provider over another), and make a final decision. Although the set of criteria follows a sequence of steps, decision making involves moving back and forth when considering all criteria. It leads to informed conclusions that are supported by evidence and reason. Examples of decision making in the clinical area include determining which patient care priority requires the first response, choosing a type of dressing for a patient with a surgical wound, or selecting the best teaching approach for a family caregiver who will assist a patient who is returning home after a stroke. Specific Critical Thinking Diagnostic Reasoning and Inference Once you receive information about a patient in a clinical situation, diagnostic reasoning begins. It is the analytical process for determining a patient’s health problems ( Harjai and Tiwari, 2009 ). Accurate recognition of a patient’s problems is necessary before you decide on solutions and implement action. It requires you to assign meaning to the behaviors and physical signs and symptoms presented by a patient. Diagnostic reasoning begins when you interact with a patient or make physical or behavioral observations. An expert nurse sees the context of a patient situation (e.g., a patient who is feeling light-headed with blurred vision and who has a history of diabetes is possibly experiencing a problem with blood glucose levels), observes patterns and themes (e.g., symptoms that include weakness, hunger, and visual disturbances suggest hypoglycemia), and makes decisions quickly (e.g., offers a food source containing glucose). The information a nurse collects and analyzes leads to a diagnosis of a patient’s condition. Nurses do not make medical diagnoses, but they do assess and monitor patients closely and compare the patients’ signs and symptoms with those that are common to a medical diagnosis. This type of diagnostic reasoning helps health care providers pinpoint the nature of a problem more quickly and select proper therapies. Part of diagnostic reasoning is clinical inference, the process of drawing conclusions from related pieces of evidence and previous experience with the evidence. An inference involves forming patterns of information from data before making a diagnosis. Seeing that a patient has lost appetite and experienced weight loss over the last month, the nurse infers that there is a nutritional problem. An example of diagnostic reasoning is forming a nursing diagnosis such as imbalanced nutrition: less than body requirements (see Chapter 17 ). In diagnostic reasoning use patient data that you gather or collect to logically recognize the problem. For example, after turning a patient you see an area of redness on the right hip. You palpate the area and note that it is warm to the touch and the patient complains of tenderness. You press over the area with your finger; after you release pressure, the area does not blanch or turn white. After thinking about what you know about normal skin integrity and the effects of pressure, you form the diagnostic conclusion that the patient has a pressure ulcer. As a student, confirm your judgments with experienced nurses. At times you possibly will be wrong, but consulting with nurse experts gives you feedback to build on future clinical situations. Often you cannot make a precise diagnosis during your first meeting with a patient. Sometimes you sense that a problem exists but do not have enough data to make a specific diagnosis. Some patients’ physical conditions limit their ability to tell you about symptoms. Some choose to not share sensitive and important information during your initial assessment. Some patients’ behaviors and physical responses become observable only under conditions not present during your initial assessment. When uncertain of a diagnosis, continue data collection. You have to critically analyze changing clinical situations until you are able to determine the patient’s unique situation. Diagnostic reasoning is a continuous behavior in nursing practice. Any diagnostic conclusions that you make will help the health care provider identify the nature of a problem more quickly and select appropriate medical therapies. Clinical Decision Making As in the case of general decision making, clinical decision making is a problem-solving activity that focuses on defining a problem and selecting an appropriate action. In clinical decision making a nurse identifies a patient’s problem and selects a nursing intervention. When you approach a clinical problem such as a patient who is less mobile and develops an area of redness over the hip, you make a decision that identifies the problem (impaired skin integrity in the form of a pressure ulcer) and choose the best nursing interventions (skin care and a turning schedule). Nurses make clinical decisions all the time to improve a patient’s health or maintain wellness. This means reducing the severity of the problem or resolving the problem completely. Clinical decision making requires careful reasoning (i.e., choosing the options for the best patient outcomes on the basis of the patient’s condition and the priority of the problem). Improve your clinical decision making by knowing your patients. Nurse researchers found that expert nurses develop a level of knowing that leads to pattern recognition of patient symptoms and responses ( White, 2003 ). For example, an expert nurse who has worked on a general surgery unit for many years is more likely able to detect signs of internal hemorrhage (e.g., fall in blood pressure, rapid pulse, change in consciousness) than a new nurse. Over time a combination of experience, time spent in a specific clinical area, and the quality of relationships formed with patients allow expert nurses to know clinical situations and quickly anticipate and select the right course of action. Spending more time during initial patient assessments to observe patient behavior and measure physical findings is a way to improve knowledge of your patients. In addition, consistently assessing and monitoring patients as problems occur help you to see how clinical changes develop over time. The selection of nursing therapies is built on both clinical knowledge and specific patient data, including: •  The identified status and situation you assessed about the patient, including data collected by actively listening to the patient regarding his or her health care needs. •  Knowledge about the clinical variables (e.g., age, seriousness of the problem, pathology of the problem, patient’s preexisting disease conditions) involved in the situation, and how the variables are linked together. •  A judgment about the likely course of events and outcome of the diagnosed problem, considering any health risks the patient has; includes knowledge about usual patterns of any diagnosed problem or prognosis. •  Any additional relevant data about requirements in the patient’s daily living, functional capacity, and social resources. •  Knowledge about the nursing therapy options available and the way in which specific interventions will predictably affect the patient’s situation.

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The Value of Critical Thinking in Nursing (And How to Develop It)

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In the pediatric intensive care unit, Nurse Emily faced a critical situation as eight-year-old Lily arrived with a high fever, rapid breathing, and confusion. Recognizing the signs of sepsis, Emily swiftly initiated treatment, including fluids and antibiotics. 

She ordered diagnostic tests that confirmed the diagnosis. Emily's quick thinking, timely actions, and effective communication with the medical team played a crucial role in stabilizing Lily's condition and saving her life. This fictional scenario underscores the importance of critical thinking in nursing, especially when dealing with life-threatening conditions like sepsis .

Critical thinking is an important aspect of successful nursing. We’re going to focus on why it’s important, tips for nurses to think critically, and how immersive virtual reality can help nurses develop this skill. 

What is critical thinking in nursing?

Critical thinking in nursing is the skill of analyzing information, making sound decisions, and solving healthcare problems effectively, ensuring better patient care and outcomes. 

In the above scenario, nurse Emily’s critical thinking skills could have saved 8-year-old Lily's life. 

Critical thinking, coupled with appropriate decision-making, leads to clinical judgment. Let’s explore what this means.  

Clinical judgment refers to the process by which nurses make decisions based on nursing knowledge (evidence, theories, ways/patterns of knowing), other disciplinary knowledge, critical thinking, and clinical reasoning, according to the AACN . 

There are six steps to the NCSBN Clinical Judgment Model

• 1: Recognize cues.
• 2: Analyze cues.
• 3: Prioritize hypothesis.
• 4: Generate solutions.
• 5: Take action.
• 6: Evaluate outcomes.

Strong clinical judgment skills are crucial for patient safety. In fact, studies have shown that up to 65% of adverse events in hospitals result from poor clinical decision-making and could have been prevented.

Check out our article on how UbiSim supports the six steps of clinical judgment . 

Why is critical thinking in nursing important?

In the realm of nursing, critical thinking is not merely a skill; it's the guiding light that nurses rely on to navigate the complex and ever-evolving landscape of healthcare. 

• Impacts patient care: Imagine every patient as a unique puzzle. Critical thinking is nursing’s toolkit for solving these puzzles. It enables them to analyze all the pieces of information, consider various treatment options, and make decisions that are tailor-made for each patient, leading to patient outcomes that can be life-changing.
• Helps nurses anticipate and understand patient condition changes: Sometimes, situations can evolve in the blink of an eye. Critical thinking doesn't just help nurses react; it empowers them to anticipate these changes, learning to pick up on subtle cues and signs that might signal potential issues, allowing them to act swiftly. 
• Ensures patient safety: Patient safety is a nurse’s utmost priority, and critical thinking is the compass for ensuring it. It helps them assess risks, spot potential dangers, and take preventive measures. With critical thinking, they can identify and address errors before they have a chance to escalate.
• Leads to better professional development for the nurse: A nurse’s ability to be a critical thinker doesn't just benefit patients; it also paves the way for their own growth. When they consistently demonstrate strong critical thinking skills, they earn the trust and respect of colleagues and supervisors. This opens doors to career progress and leadership roles within the healthcare system.

What are tips for nurses to improve critical thinking?

• Utilize your resources and mentors: Tap into the wealth of knowledge and experience that surrounds you. Seek guidance and advice from seasoned colleagues and mentors. They can provide valuable insights, share their experiences, and offer different perspectives on patient care. It may even be an opportunity to feel relief and validation from their experiences!
• Confront personal bias & assumptions: Bias can go undetected and can take many forms, such as size, culture, race, religion, age, sexuality, ability, socioeconomic status, gender, and more. Just being aware of these potential biases enables you to treat your patients on a level playing field. 
• Practice reflection: After a long day, the last thing a nurse wants to do is reflect, but taking a few minutes at the end of a week to consider what you did right and what could have used a different choice can contribute to better critical thinking. 
• Build confidence : Confidence plays a significant role in critical thinking. Nurses should trust in their knowledge, experience, and abilities, enabling them to approach challenges with a proactive and solution-oriented mindset. Building confidence through ongoing education, skill development, and positive reinforcement enhances critical thinking abilities in nursing practice.

Critical Thinking Using Virtual Reality

Thinking back to our situation with Nurse Emily and the eight-year-old with sepsis - imagine new nurse trainees starting on the job who have never dealt with sepsis. Do you want to wait until they experience it to have them implement what they learned in class? Or do you want to train them by enabling them to step into virtual reality and practice what it’s like to respond to a patient with sepsis? 

This is what Boston Children’s Hospital is doing - training their new nurses on how to effectively recognize and deal with sepsis using UbiSim’s immersive virtual reality platform. Read their case study to learn more!

As an integral center of UbiSim's content team, Ginelle pens stories on the rapidly changing landscape of VR in nursing simulation. Ginelle is committed to elevating the voices of practicing nurses, nurse educators, and program leaders who are making a difference.

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Clinical Reasoning In Nursing (Explained W/ Example)

Last updated on August 19th, 2023

In this article, we will cover:

What is Clinical Reasoning?

Definition of clinical reasoning in nursing.

• What is the concept of clinical reasoning?

Why is Clinical Reasoning Important in Nursing?

What are the types of clinical reasoning, what are the three elements of clinical reasoning, what are the steps of clinical reasoning, what is the importance of clinical reasoning and judgement in nursing, what is the difference between critical thinking and clinical reasoning, clinical reasoning in nursing example.

Clinical reasoning refers to the cognitive process that healthcare professionals, such as doctors, nurses, and other clinicians, use to analyze and make decisions about a patient’s condition and appropriate treatment.

It’s a complex and dynamic process that involves gathering and interpreting information from various sources, including patient history, physical examinations, laboratory tests, imaging studies, and the clinician’s own experience and knowledge.

Medicine, physical therapy, and occupational therapy were the first to introduce clinical reasoning to the healthcare disciplines. Since then, the nursing profession has used these strategies to improve patient care.

What is Clinical Reasoning in Nursing?

Clinical reasoning in nursing is dynamic and adaptive, as nurses continuously gather new information and adjust care plans based on patient responses.

It’s a crucial skill that guides nurses in providing safe, effective, and patient-centered care. Clinical reasoning involves the integration of clinical knowledge, critical thinking , and experience to address the complex and dynamic nature of patient situations.

It involves balancing medical knowledge with critical thinking , empathy, and ethical considerations to provide comprehensive and compassionate patient care.

Clinical reasoning in nursing refers to the cognitive process that nurses use to collect and assess patient information, analyze data, make informed judgments, and develop appropriate care plans.

What is the Concept of Clinical Reasoning?

Clinical reasoning is the cognitive process used by healthcare professionals to make informed decisions regarding patient care.

It encompasses tasks such as collecting information, analyzing data, identifying patterns, generating hypotheses, and making judgments for diagnosis and treatment.

Clinical reasoning blends science and intuition in medical practice. It combines evidence-based knowledge with experience-derived judgment to attain accurate diagnoses and treatments while addressing uncertainties.

As an essential component of clinical practice, clinical reasoning guides healthcare providers in delivering safe and effective patient care.

Clinical reasoning is important in nursing for several reasons. Some reasons are listed below.

Patient-Centered Care:

Clinical reasoning helps nurses tailor care plans to individual patients, considering their unique needs, preferences, and circumstances, leading to more personalized and effective care.

Safe and Effective Care:

It ensures that nurses make well-informed decisions based on thorough assessments, reducing the risk of errors and promoting patient safety.

Optimal Outcomes:

Through clinical reasoning, nurses can identify early signs of complications, make timely interventions, and contribute to better patient outcomes.

Nurtured Critical Thinking:

Clinical reasoning cultivates nurses’ critical thinking abilities, empowering them to dissect complex situations, appraise evidence, and make rational choices.

Efficient Resource Utilization:

It helps nurses prioritize care tasks, allocate resources effectively, and manage time efficiently, enhancing workflow and patient care delivery.

Evidence-Based Practice:

Nursing practice is constantly evolving with new research and evidence. Clinical reasoning involves integrating the latest evidence-based knowledge into decision-making, ensuring that care plans are aligned with the best available practices.

Complex Cases:

Nurses often encounter intricate patient cases; clinical reasoning equips them to navigate complexity, address multiple issues, and make comprehensive care plans.

Interdisciplinary Collaboration:

Effective clinical reasoning supports collaboration with other healthcare professionals, promoting well-rounded patient care.

Adaptation to Change:

In rapidly changing healthcare environments, clinical reasoning enables nurses to adapt to new information, technologies, and practices.

Critical Decision-Making:

Nurses face complex situations where quick and accurate decisions are critical. Clinical reasoning equips them with the ability to analyze data, identify patterns, and generate hypotheses. This enables nurses to make informed decisions about interventions, medications, and treatments, leading to effective care.

Early Detection and Prevention:

Through clinical reasoning, nurses can detect subtle changes in a patient’s condition that might signal complications or deterioration. This allows for early interventions, preventing potential health crises and improving patient prognosis.

Error Reduction:

Clinical reasoning encourages systematic thinking, reducing the likelihood of errors in administering medications, performing procedures, and assessing patients. This promotes patient safety and prevents adverse events.

Holistic Care:

Patient’s health is influenced by various factors beyond just medical conditions. Clinical reasoning enables nurses to consider the social, emotional, and psychological aspects of patients, promoting holistic care and overall well-being.

Ethical Dilemmas:

Nursing often involves ethical challenges. Clinical reasoning guides nurses in making ethically sound decisions by considering patients’ autonomy, values, and cultural beliefs.

Communication and Collaboration:

Clinical reasoning enhances nurses’ ability to communicate effectively with patients, families, and other healthcare professionals. It fosters collaboration by enabling nurses to articulate their assessments, interventions, and rationales clearly.

Professional Growth:

Developing strong clinical reasoning skills enhances nurses’ professional growth. It increases their confidence, competence, and ability to take on more complex patient cases and leadership roles.

In summary , clinical reasoning is an important component of nursing practice, allowing nurses to provide safe, effective, and patient-centered care.

It enables nurses to make informed decisions, improve patient outcomes, and navigate the dynamic and complex healthcare setting.

Clinical reasoning involves three key elements that healthcare professionals integrate to make informed decisions about patient care:

1. Patient Information:

This element encompasses all the relevant data about the patient’s medical history, current condition, symptoms, physical examination findings, diagnostic test results, and social and contextual factors.

Gathering comprehensive and accurate patient information is essential for forming an accurate understanding of the patient’s health status and needs.

2. Clinical Knowledge and Expertise:

Healthcare professionals draw upon their extensive medical knowledge, clinical experience, and expertise to interpret patient information.

This knowledge includes an understanding of anatomy, physiology, pathophysiology, pharmacology, and medical guidelines.

Clinical expertise is built over years of practice, exposure to a variety of cases, and ongoing learning.

3. Critical Thinking and Decision-Making Skills:

Critical thinking involves the analytical and logical thought processes that healthcare professionals use to evaluate patient information in the context of their clinical knowledge.

It includes the ability to identify patterns, assess potential diagnoses, consider alternative explanations, and weigh the pros and cons of different treatment options.

Effective decision-making is the outcome of critical thinking , as healthcare professionals choose the most appropriate course of action based on the available information.

These three elements are interdependent and work together to form the foundation of clinical reasoning.

Healthcare professionals integrate patient information with their clinical knowledge and expertise while applying critical thinking skills to reach accurate diagnoses, develop effective treatment plans, and provide high-quality patient care.

The balance between these elements varies based on the complexity of the clinical situation and the healthcare provider’s level of experience and expertise.

8 Stages of the Clinical Reasoning Cycle

Clinical reasoning involves several key steps:

1. Data Collection: Gathering relevant information about the patient’s medical history, symptoms, physical examination findings, and any diagnostic tests that have been conducted.

2. Pattern Recognition: Recognizing patterns and relationships in the collected data to identify potential diagnoses or issues. This involves comparing the patient’s presentation to previous cases and medical knowledge.

3. Hypothesis Generation: Formulating hypotheses or possible explanations for the patient’s condition based on the patterns and information observed. This step often involves generating a list of potential diagnoses that fit the available evidence.

4. Differential Diagnosis: Narrowing down the list of potential diagnoses by considering the likelihood of each condition and ruling out less likely options. This is where critical thinking and medical knowledge come into play.

5. Testing and Validation: Ordering further diagnostic tests or investigations to confirm or rule out specific diagnoses. This could include blood tests, imaging studies, biopsies, or other procedures.

6. Synthesis: Integrating the results of diagnostic tests and additional information to refine the diagnosis and treatment plan. This may involve adjusting the initial hypotheses based on new data.

7. Treatment Planning: Developing a comprehensive treatment plan that addresses the diagnosed condition, the patient’s unique circumstances, preferences, and any potential risks or benefits of various treatment options.

8. Monitoring and Adaptation: Continuously monitoring the patient’s progress and adjusting the treatment plan as needed based on how the patient responds and any new information that emerges.

Clinical reasoning requires a deep understanding of medical science, anatomy, physiology, and pathology, as well as the ability to apply this knowledge to real-world clinical scenarios.

It also involves critical thinking skills , logical reasoning, and the ability to handle uncertainty, as medical situations can be complex and patients may present with atypical symptoms.

Overall, clinical reasoning is a crucial skill for healthcare professionals, as it forms the foundation for making accurate diagnoses and providing effective patient care.

Clinical reasoning and judgment are of paramount importance in nursing for several reasons:

• Accurate Diagnosis and Treatment: Effective clinical reasoning enables nurses to accurately assess patients’ conditions, identify potential problems, and make informed decisions about appropriate interventions and treatments. Accurate diagnosis and treatment are crucial for improving patient outcomes and preventing complications.
• Patient Safety: Sound clinical judgment helps nurses recognize potential risks and make timely interventions to ensure patient safety. By identifying early signs of deterioration or complications, nurses can take appropriate actions to prevent adverse events.
• Individualized Care: Clinical reasoning allows nurses to tailor care plans to each patient’s unique needs, preferences, and circumstances. This patient-centered approach improves patient satisfaction and contributes to better treatment outcomes.
• Early Detection of Changes: Nurses often spend the most time with patients, which puts them in a prime position to notice subtle changes in a patient’s condition. Strong clinical reasoning skills enable nurses to detect these changes early and respond appropriately.
• Effective Communication: Nurses with strong clinical reasoning skills can communicate more effectively with patients, families, and interdisciplinary healthcare teams. They can convey complex medical information, treatment plans, and concerns in a clear and organized manner.
• Ethical Decision-Making: Clinical reasoning includes ethical considerations in decision-making. Nurses must weigh the ethical implications of their actions and decisions, especially when faced with complex situations that involve moral dilemmas.
• Resource Utilization: Effective clinical reasoning helps nurses allocate resources efficiently. By accurately assessing patient needs and prioritizing care, nurses can optimize the use of time, personnel, and equipment.
• Adaptation to Change: Healthcare is dynamic, and patients’ conditions can change rapidly. Nurses with strong clinical reasoning skills can adapt quickly to changing situations, making necessary adjustments to care plans and interventions.
• Continuity of Care: Nurses often play a critical role in ensuring continuity of care as patients transition between different healthcare settings. Effective clinical reasoning facilitates clear communication of patient information and ensures a smooth transition of care.
• Professional Growth: Developing clinical reasoning and judgment skills enhances a nurse’s professional growth. These skills are transferrable and applicable across various healthcare settings, allowing nurses to provide high-quality care regardless of the environment.
• Confidence and Job Satisfaction: Nurses who feel confident in their clinical reasoning abilities experience greater job satisfaction. Confidence comes from knowing that decisions are based on a solid foundation of knowledge, experience, and critical thinking.
• Advocacy: Nurses with strong clinical reasoning skills can effectively advocate for their patients, ensuring that their needs are met, their voices are heard, and their rights are respected within the healthcare system.
• Quality Improvement: Clinical reasoning plays a role in quality improvement efforts by identifying areas for improvement in patient care processes and outcomes.

In summary, clinical reasoning and judgment are essential for nurses to provide safe, effective, and patient-centered care.

These skills underpin the entire nursing process, enabling nurses to make informed decisions, communicate effectively, and positively impact patient outcomes and experiences.

Critical Thinking :

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

It is a broader skill applicable to various aspects of life and professions, encouraging logical, evidence-based thinking and minimizing biases.

Critical thinking aims to enhance problem-solving, decision-making, and analytical abilities in a wide range of contexts beyond healthcare.

Clinical Reasoning:

Clinical reasoning, on the other hand, is a specialized form of critical thinking that is primarily focused on healthcare and clinical situations.

It specifically pertains to the cognitive process healthcare professionals, especially nurses and doctors, use to collect, assess, analyze, and apply information to make informed clinical judgments and decisions.

Clinical reasoning is crucial for providing safe and effective patient care, as it integrates medical knowledge, patient assessments, ethical considerations, and treatment planning.

Critical Thinking vs. Clinical Reasoning

Clinical reasoning can be categorized into different types or approaches. Each of which represents a particular way of thinking and making decisions in clinical practice.

Some of the commonly recognized types of clinical reasoning include:

• Deductive Reasoning: This type of reasoning starts with a general principle or theory and applies it to a specific case. Healthcare professionals use deductive reasoning to make predictions or decisions based on established medical knowledge. For example, if a patient presents with a set of symptoms consistent with a well-known disease, the clinician may deduce that the patient likely has that disease.
• Inductive Reasoning: In contrast to deductive reasoning, inductive reasoning involves making generalizations or conclusions based on specific observations or cases. Clinicians use inductive reasoning to form hypotheses or theories from individual patient experiences. For instance, a nurse may notice a pattern of symptoms in several patients and develop a hypothesis about a potential new condition.
• Abductive Reasoning: Abductive reasoning combines elements of both deductive and inductive reasoning. It involves making educated guesses or hypotheses to explain observations or data that don’t fit neatly into established patterns. Clinicians use abductive reasoning when they encounter cases that don’t seem to fit existing diagnoses or models, and they generate plausible explanations to guide further investigation.
• Analytical Reasoning: This type of reasoning involves systematically breaking down a complex situation or problem into smaller parts to understand its components and relationships. Healthcare professionals use analytical reasoning to dissect complex patient cases, focusing on details and relationships to arrive at a diagnosis or treatment plan.
• Intuitive Reasoning: Intuitive reasoning relies on a healthcare professional’s experience, intuition, and gut feeling. It involves drawing on one’s own clinical experience and recognizing patterns that may not be immediately apparent. Intuitive reasoning is often employed in situations where rapid decision-making is necessary.
• Procedural Reasoning: Procedural reasoning focuses on the steps or processes needed to manage a clinical situation. It involves thinking about the sequence of actions required to address a patient’s needs. For example, a nurse may use procedural reasoning when administering medications, performing wound care, or carrying out other routine clinical procedures.
• Narrative Reasoning: Narrative reasoning involves considering the patient’s story, values, and context as essential components of clinical decision-making. It emphasizes understanding the patient’s perspective and tailoring care plans to the individual’s unique circumstances.
• Hypothetico-Deductive Reasoning: This approach involves generating and testing hypotheses systematically to arrive at a diagnosis. Healthcare professionals consider various possible diagnoses, then order specific tests to confirm or rule out each hypothesis.
• Pattern Recognition Reasoning: This type of reasoning relies on recognizing familiar patterns based on clinical experience and knowledge. Healthcare providers quickly identify common clinical presentations and apply established treatment protocols.

Emily Davis, a 68-year-old woman, is admitted to the medical unit with a diagnosis of Acute Exacerbation of COPD. She has a history of chronic obstructive pulmonary disease (COPD) and has been experiencing increased shortness of breath, cough, and decreased oxygen saturation levels.

How does your understanding of nursing fundamentals influence your clinical reasoning?

Nursing Action:

• Reflect on the nursing care provided to patients with COPD and respiratory distress.

• Review the pharmacologic treatments that will improve the patient’s COPD.

• Reflect the non-pharmacologic measures that will help to improve the patient’s respiratory distress.

• Determine the most appropriate assessments and interventions for managing respiratory distress in patients with COPD.

Implementation of Interventions:

• Assess Emily’s respiratory rate, depth, and effort, as well as oxygen saturation levels.

• Administer prescribed bronchodilators, and nebulization to improve airway patency.

• Elevate the head of the bed to promote better lung expansion.

• Encourage deep breathing exercises and effective coughing techniques.

• Consult with the physician to determine pharmacologic therapy

• Monitor Emily’s response to interventions and adjust care as needed. How does your understanding of pathophysiology guide your clinical reasoning?

• Knowledge of COPD’s pathophysiology helps anticipate complications and tailor interventions.

In this scenario, the nurse’s grasp of nursing fundamentals enables them to provide appropriate care for a patient with COPD.

By considering the patient’s history and symptoms, the nurse takes action to manage respiratory distress.

Implementing interventions such as bronchodilators and elevation of the head of the bed aligns with nursing knowledge.

Additionally, understanding the pathophysiology of COPD aids in predicting potential complications and choosing interventions to support the patient’s respiratory function.

• What is Critical Thinking in Nursing? (Explained W/ Examples)
• How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples
• What Are Socratic Questions?
• What is the “5 Whys” Technique?
• 15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)

Clinical reasoning in nursing involves the skillful integration of medical knowledge, critical thinking , and patient assessment to make informed decisions about patient care.

It enables nurses to provide safe, effective, and patient-centered interventions while considering individual needs and complex healthcare situations.

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Mastering Precepting: Core precepting concepts

"The most important practical lesson that can be given to nurses is to teach them what to observe, how to observe, what symptoms indicate improvement, what the reverse, which are of importance, which are of none, which are evidence of neglect and of what kind of neglect.”    —Florence Nightingale OBJECTIVES

• Understand development of competence
• Understand critical thinking, clinical reasoning, and clinical judgment and how to help preceptees develop each skill
• Understand the development of preceptee confidence
• Understand core concepts of nursing practice

At the heart of any precepting experience is the development of competence; the development of ability and expertise to effectively utilize that competence; and the confidence to take action when needed. Combined with other core precepting concepts, these form the foundation of effective, safe nursing practice.

• Knowledge  encompasses thinking; understanding of science and humanities; professional standards of practice; and insights gained from context, practical experiences, personal capabilities, and leadership performance.
• Skills  include psychomotor, communication, interpersonal, and diagnostic skills.
• Ability  is the capacity to act effectively. It requires listening, integrity, knowledge of one’s strengths and weaknesses, positive self-regard, emotional intelligence, and openness to feedback.
• Judgment  includes critical thinking, problem-solving, ethical reasoning, and decision-making.

Requirements for competence and competency assessment have been established by national nursing and nursing specialty organizations, state boards of nursing credentialing boards, and statutory and regulatory agencies. The presence (or absence) of competency can also be a legal issue.

• Juggling complex patients and assignments efficiently
• Intervening for subtle shifts in patients’ conditions or families’ responses
• Having interpersonal skills of calm, compassion, generosity, and authority
• Seeing the big picture and knowing how to work the system
• Possessing an attitude of dedicated curiosity and commitment to lifelong learning

Participants described how competence developed and changed over time. Also of interest was how the development of competency affected their career plans and job satisfaction. Kearny and Kenward (2010) note:

Those who continued to feel insecure in their ability to efficiently identify and respond to important downturns in patients’ conditions in a high-acuity environment, who continually felt beaten down in their attempts to get resources and help for patients from fellow nurses, and/or who believed physicians did not listen to them or respect them appeared most likely to change jobs to less complex or less acute settings or to leave nursing. (p. 13)

This study clearly has implications for preceptors. Nurses’ career decisions and job satisfaction are both affected by how well they develop competence, especially for less experienced nurses.

Unconscious incompetence —The individual seeks to solve problems intuitively with little or no insight into the principles driving the solutions. This stage is especially dangerous with novices. When NGRNs first begin professional practice or experienced nurses move into a new role, they often don’t know what they don’t know. Preceptors have to be especially vigilant with a preceptee at this level.

Conscious incompetence —The individual seeks to solve problems logically, recognizing problems with their intuitive analysis, but not yet knowing how to fix them. This awareness— of knowing what you don’t know—can affect confidence. Preceptors can help preceptees in this level understand what they are expected to know at this point vs. what they will learn in the future.

Conscious competence —As skills are acquired, individuals become more confident but need to realize that the skills have not yet become automatic. They are not yet ready to spontaneously transfer the concepts of the skill to new situations. Preceptors need to help preceptees see how the concepts transfer from one situation to another.

Unconscious competence —At this level, skills become second nature and are performed without conscious effort. Skills can be adapted creatively and spontaneously to new situations. You know it so well, you don’t think about it. The challenge in this level is to not become complacent and be closed to new ways of doing things.

A fifth level of conscious competence learning—reflective competence—has been suggested (Attri, 2017). It involves an awareness that you’ve reached unconscious competence; analyzing and being able to articulate how you got there well enough to teach someone else to reach that level and opening yourself to the need for continuous self-observation and improvement.

This concept supports adult learning theory concerning learner readiness in the assertion that individuals develop competence only after they recognize the relevance of their own incompetence. It also blends easily with the levels in Benner’s Novice to Expert model.

• What are the essential competencies and outcomes for contemporary practice? Identify the required competencies and word them as practice-based competency outcomes.
• What are the indicators that define those competencies? Only identify the behaviors, actions, and responses mandatory for the practice of each competency.
• What are the most effective ways to learn those competencies?
• What are the most effective ways to document that learners and/or practitioners have achieved the required competencies? Develop a systematic and comprehensive plan for outcomes assessment.

Eight core practice competency categories define practice in the COPA model (Lenburg, 1999):

• Assessment and intervention skills
• Communication skills
• Critical thinking skills
• Human caring and relationship skills
• Management skills
• Leadership skills
• Teaching skills
• Knowledge integration skills

Wright Competency Model The Wright Competency Assessment Model is an outcome-focused, accountability-based approach that is used in many healthcare organizations. The following principles form the foundation of the model (Wright, 2015, p. 5):

• Select competencies that matter to both the people involved and to the organization.
• Competencies should reflect the current realities of practice, be connected to quality improvement data, be dynamic, and be collaboratively selected.
• Competency selection itself involves critical thinking.
• Select the right verification methods for each competency identified.
• Clarify the roles and accountability of the manager, educator, and employee in the competency process.
• Employee-centered competency verification creates a culture of engagement and commitment.
• In ownership, competencies are collaboratively identified and are reflective of the dynamic nature of the work.
• Empowerment is achieved through employee-centered verification in which verification method choices are identified and appropriately match the competency categories.
• In accountability, leaders create a culture of success with a dual focus—focus on the organizational mission and focus on supporting positive employee behavior.

Critical Thinking Critical thinking is an essential competency for nurses to provide safe and effective care (Berkow, Virkstis, Stewart, Aronson, & Donohue, 2011). Alfaro-LeFevre (2017) says that critical thinking is “deliberate, informed thought” (p. 2) and that the difference between thinking and critical thinking is control and purpose. “Thinking refers to any mental activity. It can be ‘mindless,’ like when you’re daydreaming or doing routine tasks like brushing your teeth. Critical thinking is controlled and purposeful, using well-reasoned strategies to get the results you need” (p. 5).

Jackson (2006, p. 4) notes that three themes are found within all definitions of critical thinking: “the importance of a good foundation of knowledge, including formal and informal logic; the willingness to ask questions; and the ability to recognize new answers, even when they are not the norm and not in agreement with pre-existing attitudes.” Chan (2013), in a systematic review of critical thinking in nursing education, found that despite there being varying definitions of clinical thinking, there were some consistent components: gathering and seeking information: questioning and investigating; analysis, evaluation, and inference; and problem-solving and the application of theory. The principles of skepticism and objectivity underlie critical thinking (Chatfield, 2018). Objectivity includes recognizing and dealing with both conscious and unconscious bias.

Critical Thinking—A Philosophical Perspective In 1990, the American Philosophical Association conducted a Delphi study of an expert panel to define critical thinking and to identify and describe the core skills and dispositions of critical thinking. The expert panel, led by Peter Facione (1990), defined critical thinking to be a pervasive and deliberate human phenomenon that is the “purposeful, self-regulatory judgment which 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” (p. 2). The core skills and sub-skills identified by the expert panel are shown in Table 4.1.

According to the American Philosophical Association Delphi Study, the affective dispositions of critical thinking (approaches to life and living) include (Facione, 2011):

• Inquisitiveness with regard to a wide range of issues
• Concern to become and remain generally well informed
• Alertness to opportunities to use critical thinking
• Trust in the processes of reasoned inquiry
• Self-confidence in one’s own ability to reason
• Open-mindedness regarding divergent world views
• Flexibility in considering alternatives and opinions
• Understanding of the opinions of other people
• Fair-mindedness in appraising reasoning
• Honesty in facing one’s own biases, prejudices, stereotypes, and egocentric or sociocentric tendencies
• Prudence in suspending, making, or altering judgments
• Willingness to reconsider and revise views where honest reflection suggests that change is warranted
• Clarity in stating the question or concern
• Orderliness in working with complexity
• Diligence in seeking relevant information
• Reasonableness in selecting and applying criteria
• Care in focusing attention on the concern at hand
• Persistence though difficulties are encountered
• Precision to the degree permitted by the subject and the circumstance

Critical Thinking in Nursing Facione and Facione (1996) suggest that to observe and evaluate critical thinking in nursing knowledge development or clinical decision-making, you need to have the thinking process externalized by being spoken, written, or demonstrated. For preceptors, this means having preceptees externalize their thinking processes. Preceptors must also be able to externalize their own critical thinking to role model critical thinking for preceptees. Paul, the founder of the Foundation for Critical Thinking, and Heaslip note, “Critical thinking presupposes a certain basic level of intellectual humility (i.e., the willingness to acknowledge the extent of one’s own ignorance) and a commitment to think clearly, precisely, and accurately and, in so far as is possible, to act on the basis of genuine knowledge. Genuine knowledge is attained through intellectual effort in figuring out and reasoning about problems one finds in practice” (Paul & Heaslip, 1995, p. 41). Expert nurses, say Paul and Heaslip, “can think through a situation to determine where intuition and ignorance interface with each other” (p. 43).

Building on the work of Facione and the American Philosophical Association Delphi study, Scheffer and Rubenfeld (2000) conducted a Delphi study of international nursing experts (from 27 U.S. states and eight countries) to develop a consensus statement of critical thinking in nursing. The result of the study was a consensus statement and identification of 10 affective components (habits of the mind) and seven cognitive components (skills) of critical thinking in nursing.

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, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge (Scheffer & Rubenfeld, 2000, p. 357).

Precepting Critical Thinking Berkow and colleagues (2011) note that identifying and providing feedback on specific strengths and weaknesses is the first step to help nurses meaningfully improve their critical thinking skills. They interviewed more than 100 nurse leaders from academia, service settings, and professional associations and developed a list of core critical-thinking competencies in five broad categories: problem recognition, clinical decision-making, prioritization, clinical implementation, and reflection. Each of the categories has detailed competencies. Alfaro-LeFevre (1999) developed a list of critical-thinking key questions that can be used by a preceptor to help preceptees learn how to think critically:

• What major outcomes (observable results) do I/we hope to achieve?
• What problems or issues must be addressed to achieve the major outcomes?
• What are the circumstances (what is the context)?
• What knowledge is required?
• How much room is there for error?
• How much time do I/we have?
• What resources can help?
• Whose perspectives must be considered?
• What’s influencing my thinking?
• Be clear about the desired outcome.
• Decide what exactly the person must learn to achieve the desired outcome and decide the best way for the person to learn it.
• Reduce anxiety by offering support.
• Minimize distractions and teach at appropriate times.
• Use pictures, diagrams, and illustrations.
• Create mental images by using analogies and metaphors.
• Encourage people to remember by whatever words best trigger their mind.
• Keep it simple.
• Tune into your learners’ responses; change the pace, techniques, or content if needed.
• Summarize key points.
• Analytic processes —Breaking a situation down into its elements; generating and systematically and rationally weighing alternatives against the data and potential outcomes.
• Intuition —Immediately apprehending a situation (often using pattern recognition) as a result of experience with similar situations.
• Narrative thinking —Thinking through telling and interpreting stories.
• Recognizing a pattern or an inconsistency in the expected pattern
• Providing explanations for why they had reasoned as they had
• Forming relationships between data
• Drawing conclusions
• Noticing —“A perceptual grasp of the situation at hand” (p. 208). Noticing, Tanner says, is “a function of nurses’ expectations of the situation, whether they are explicit or not” and further that “these expectations stem from nurses’ knowledge of the particular patient and his or her patterns of responses; their clinical or practical knowledge of similar patients, drawn from experience; and their textbook knowledge” (p. 208).
• Interpreting —“Developing a sufficient understanding of the situation to respond” (p. 208). Noticing triggers reasoning patterns that help nurses interpret the data and decide on a course of action.
• Responding —“Deciding on a course of action deemed appropriate for the situation, which may include ‘no immediate action’” (p. 208).
• Reflecting —“Attending to the patients’ responses to the nursing action while in the process of acting” (reflection in action) and “reviewing the outcomes of the action, focusing on the appropriateness of all of the preceding aspects (i.e., what was noticed, how it was interpreted, and how the nurse responded)” (p. 208; reflection on action).
• Noticing —Focused observation, recognizing deviations from expected patterns, information seeking
• Interpreting —Prioritizing data, making sense of data
• Responding —Calm, confident manner; clear communication; well-planned intervention/ flexibility; being skillful
• Reflecting —Evaluation/self-analysis, commitment to improvement
• Decisions made very quickly can be every bit as good as decisions made cautiously and deliberately.
• We have to learn when we should trust our instincts and when we should be wary of them.
• Our snap judgments and first impressions can be educated and controlled.

Decision makers recognize the situation as typical and familiar . . . and proceed to take action. They understand what types of goals make sense (so priorities make sense), which cues are important (so there is not an overload of information), what to expect next (so they can prepare themselves and notice surprises, and the typical way of responding in a given situation. By recognizing a situation as typical, they also recognize a course of action likely to succeed (Klein, 1998, p. 24).

• Patterns that novices do not notice
• Anomalies, events that did not happen, and other violations of expectancies
• The big picture (situation awareness)
• The way things work
• Opportunities and improvisations
• Events that either already happened (the past) or are going to happen (the future)
• Differences that are too small for novices to notice
• Their own limitations

• critical thinking
• Beth Ulrich
• RNL Feature

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Effect of simulation on nursing knowledge and critical thinking in failure to rescue events

Affiliation.

• 1 College of Nursing, The Ohio State University, Columbus, Ohio 43210, USA. [email protected]
• PMID: 22966770
• DOI: 10.3928/00220124-20120904-27

Failure to rescue events are hospital deaths that result from human error and unsafe patient conditions. A failure to rescue event implies that the last and best chance to avoid tragedy is not acted on in time to avoid a disaster. Patient safety is often compromised by nurses who do not perform accurate assessments (vigilance), do not detect clinical changes (surveillance), or do not display critical thinking (recognition that something is wrong). This project used simulation as a teaching strategy to enhance nursing performance. Medical-surgical nurses took part in a simulated failure to rescue event in which the patient's clinical condition deteriorated rapidly. Nursing knowledge and critical thinking improved after the simulation and showed the effectiveness of simulation as a teaching strategy to address nursing knowledge and critical thinking skills.

Copyright 2012, SLACK Incorporated.

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Teaching Strategies for Developing Clinical Reasoning Skills in Nursing Students: A Systematic Review of Randomised Controlled Trials

Associated data.

Data are contained within the article.

Background: Clinical reasoning (CR) is a holistic and recursive cognitive process. It allows nursing students to accurately perceive patients’ situations and choose the best course of action among the available alternatives. This study aimed to identify the randomised controlled trials studies in the literature that concern clinical reasoning in the context of nursing students. Methods: A comprehensive search of PubMed, Scopus, Embase, and the Cochrane Controlled Register of Trials (CENTRAL) was performed to identify relevant studies published up to October 2023. The following inclusion criteria were examined: (a) clinical reasoning, clinical judgment, and critical thinking in nursing students as a primary study aim; (b) articles published for the last eleven years; (c) research conducted between January 2012 and September 2023; (d) articles published only in English and Spanish; and (e) Randomised Clinical Trials. The Critical Appraisal Skills Programme tool was utilised to appraise all included studies. Results: Fifteen papers were analysed. Based on the teaching strategies used in the articles, two groups have been identified: simulation methods and learning programs. The studies focus on comparing different teaching methodologies. Conclusions: This systematic review has detected different approaches to help nursing students improve their reasoning and decision-making skills. The use of mobile apps, digital simulations, and learning games has a positive impact on the clinical reasoning abilities of nursing students and their motivation. Incorporating new technologies into problem-solving-based learning and decision-making can also enhance nursing students’ reasoning skills. Nursing schools should evaluate their current methods and consider integrating or modifying new technologies and methodologies that can help enhance students’ learning and improve their clinical reasoning and cognitive skills.

1. Introduction

Clinical reasoning (CR) is a holistic cognitive process. It allows nursing students to accurately perceive patients’ situations and choose the best course of action among the available alternatives. This process is consistent, dynamic, and flexible, and it helps nursing students gain awareness and put their learning into perspective [ 1 ]. CR is an essential competence for nurses’ professional practice. It is considered crucial that its development begin during basic training [ 2 ]. Analysing clinical data, determining priorities, developing plans, and interpreting results are primary skills in clinical reasoning during clinical nursing practise [ 3 ]. To develop these skills, nursing students must participate in caring for patients and working in teams during clinical experiences. Among clinical reasoning skills, we can identify communication skills as necessary for connecting with patients, conducting health interviews, engaging in shared decision-making, eliciting patients’ concerns and expectations, discussing clinical cases with colleagues and supervisors, and explaining one’s reasoning to others [ 4 ].

Educating students in nursing practise to ensure high-quality learning and safe clinical practise is a constant challenge [ 5 ]. Facilitating the development of reasoning is challenging for educators due to its complexity and multifaceted nature [ 6 ], but it is necessary because clinical reasoning must be embedded throughout the nursing curriculum [ 7 ]. Such being the case, the development of clinical reasoning is encouraged, aiming to promote better performance in indispensable skills, decision-making, quality, and safety when assisting patients [ 8 ].

Nursing education is targeted at recognising clinical signs and symptoms, accurately assessing the patient, appropriately intervening, and evaluating the effectiveness of interventions. All these clinical processes require clinical reasoning, and it takes time to develop [ 9 ]. This is a significant goal of nursing education [ 10 ] in contemporary teaching and learning approaches [ 6 ].

Strategies to mitigate errors, promote knowledge acquisition, and develop clinical reasoning should be adopted in the training of health professionals. According to the literature, different methods and teaching strategies can be applied during nursing training, as well as traditional teaching through lectures. However, the literature explains that this type of methodology cannot enhance students’ clinical reasoning alone. Therefore, nursing educators are tasked with looking for other methodologies that improve students’ clinical reasoning [ 11 ], such as clinical simulation. Clinical simulation offers a secure and controlled setting to encounter and contemplate clinical scenarios, establish relationships, gather information, and exercise autonomy in decision-making and problem-solving [ 12 ]. Different teaching strategies have been developed in clinical simulation, like games or case studies. Research indicates a positive correlation between the use of simulation to improve learning outcomes and how it positively influences the development of students’ clinical reasoning skills [ 13 ].

The students of the 21st century utilise information and communication technologies. With their technological skills, organisations can enhance their productivity and achieve their goals more efficiently. Serious games are simulations that use technology to provide nursing students with a safe and realistic environment to practise clinical reasoning and decision-making skills [ 14 ] and can foster the development of clinical reasoning through an engaging and motivating experience [ 15 ].

New graduate nurses must possess the reasoning skills required to handle complex patient situations. Aware that there are different teaching methodologies, with this systematic review we intend to discover which RCTs published focus on CR in nursing students, which interventions have been developed, and their effectiveness, both at the level of knowledge and in increasing clinical reasoning skills. By identifying the different techniques used during the interventions with nursing students in recent years and their effectiveness, it will help universities decide which type of methodology to implement to improve the reasoning skills of nursing students and, therefore, obtain better healthcare results.

This study aims to identify and analyse randomised controlled trials concerning clinical reasoning in nursing students. The following questions guide this literature review:

Which randomised controlled trials have been conducted in the last eleven years regarding nursing students’ clinical reasoning? What are the purposes of the identified RCTs? Which teaching methodologies or strategies were used in the RCTs studies? What were the outcomes of the teaching strategies used in the RCTs?

2. Materials and Methods

This review follows the PRISMA 2020 model statement for systematic reviews. That comprises three documents: the 27-item checklist, the PRISMA 2020 abstract checklist, and the revised flow diagram [ 16 ].

2.1. Search Strategy

A systematic literature review was conducted on PubMed, Scopus, Embase, and the Cochrane Controlled Register of Trials (CENTRAL) up to 15th October 2023.

The PICOS methodology guided the bibliographic search [ 17 ]: “P” being the population (nursing students), “I” the intervention (clinical reasoning), “C” comparison (traditional teaching), “O” outcome (dimension, context, and attributes of clinical reasoning in the students’ competences and the results of the teaching method on nursing students), and “S” study type (RCTs).

The search strategy used in each database was the following: (“nursing students” OR “nursing students” OR “pupil nurses” OR “undergraduate nursing”) AND (“clinical reasoning” OR “critical thinking” OR “clinical judgment”). The filters applied were full text, randomised controlled trial, English, Spanish, and from 1 January 2012 to 15 October 2023. The search strategy was performed using the same process for each database. APP performed the search, and AZ supervised the process.

During the search, the terms clinical reasoning, critical thinking, and clinical judgement were used interchangeably since clinical judgement is part of clinical reasoning and is defined by the decision to act. It is influenced by an individual’s previous experiences and clinical reasoning skills [ 18 ]. Critical thinking and clinical judgement involve reflective and logical thinking skills and play a vital role in the decision-making and problem-solving processes [ 19 ].

The first search was conducted between March and September 2022, and an additional search was conducted during October 2023, adding the new articles published between September 2022 and September 2023, following the same strategy. The search strategy was developed using words from article titles, abstracts, and index terms. Parallel to this process, the PRISMA protocol was used to systematise the collection of all the information presented in each selected article. This systematic review protocol was registered in the international register PROSPERO: CRD42022372240.

2.2. Eligibility Criteria and Study Selection

The following inclusion criteria were examined: (a) clinical reasoning, clinical judgment, and critical thinking in nursing students as a primary aim; (b) articles published in the last eleven years; (c) research conducted between January 2012 and September 2023; (d) articles published only in English and Spanish; and (e) RCTs. On the other hand, the exclusion criteria were studies conducted with students from other disciplines other than nursing, not random studies or review articles.

2.3. Data Collection and Extraction

After this study selection, the following information was extracted from each article: bibliographic information, study aims, teaching methodology, sample size and characteristics, time of intervention, and conclusions.

2.4. Risk of Bias

The two reviewers, APP and AZ, worked independently to minimise bias and mistakes. The titles and abstracts of all papers were screened for inclusion. All potential articles underwent a two-stage screening process based on the inclusion criteria. All citations were screened based on title, abstract, and text. Reviewers discussed the results to resolve minor discrepancies. All uncertain citations were included for full-text review. The full text of each included citation was obtained. Each study was read thoroughly and assessed for inclusion following the inclusion and exclusion criteria explained in the methodology. The CASP tool was utilised to appraise all included studies. The CASP Randomized Controlled Trial Standard Checklist is an 11-question checklist [ 20 ], and the components assessed included the appropriateness of the objective and aims, methodology, study design, sampling method, data collection, reflexivity of the researchers, ethical considerations, data analysis, rigour of findings, and significance of this research. These items of the studies were then rated (“Yes” = with three points; “Cannot tell” = with two points; “No” = with one point). The possible rates for every article were between 0 and 39 points.

2.5. Ethical Considerations

Since this study was a comprehensive, systematic review of the existing published literature, there was no need for us to seek ethical approval.

3.1. Search Results

The initial search identified 158 articles using the above-mentioned strategy (SCOPUS ® n = 72, PUBMED ® n = 56, CENTRAL ® n = 23, and EMBASE ® n= 7), and the results are presented in Figure 1 . After retrieving the articles and excluding 111, 47 were selected for a full reading. Finally, 17 articles were selected. To comply with the methodology, the independent reviewers analysed all the selected articles one more time after the additional search, and they agreed to eliminate two of them because this study sample included nursing students as well as professional nurses. Therefore, to have a clear outcome focused on nursing students, two articles were removed, and the very final sample size was fifteen articles, following the established selection criteria ( Figure 1 ). The reasons for excluding studies from the systematic review were: nurses as targets; other design types of studies different from RCTs; focusing on other health professionals such as medical students; review studies; and being published in full text in other languages other than Spanish or English.

Flowchart of screening of clinical reasoning RCTs that underwent review.

3.2. Risk of Bias in CASP Results

All studies included in the review were screened with the CASP tool. Each study was scored out of a maximum of 39 points, showing the high quality of the randomised control trial methodology. The studies included had an average score of 33.1, ranging from 30 to 36 points. In addition, this quantitative rate of the items based on CASP, there were 13 studies that missed an item in relation to assessing/analysing outcome/s ‘blinded or not’ or not, and 11 studies that missed the item whether the benefits of the experimental intervention outweigh the harms and costs.

3.3. Data Extraction

Once the articles had undergone a full reading and the inclusion criteria were applied, data extraction was performed with a data extraction table ( Appendix A ). Their contents were summarised into six different cells: (1) CASP total points result, (2) purpose of this study, (3) teaching strategy, (4) time of intervention, (5) sample size, and (6) author and year of publication. After the review by the article’s readers, fifteen RCTs were selected. Of the fifteen, the continent with the highest number of studies was Asia, with 53.33% of the studies (n = 8) (Korea n = 4, Taiwan n = 2, and China n = 2), followed by Europe with 26.66% (n = 4) (Turkey n = 2, Paris n = 1, and Norway n = 1), and lastly South America with 20% (n = 3), all of them from Brazil.

3.4. Teaching Strategies

Different teaching strategies have been identified in the reviewed studies: simulation methods (seven articles) and learning programmes (eight articles). There are also two studies that focus on comparing different teaching methodologies.

3.4.1. Clinical Simulation

The simulation methods focused on in the studies were virtual simulation (based on mobile applications), simulation games, and high-fidelity clinical simulation. Of the total number of nursing students in the studies referring to clinical simulations, 43.85% were in their second year, while 57.1% were senior-year students. The most used method in the clinical simulation group was virtual simulation, and 57.14% of studies included only one-day teaching interventions.

Virtual simulations were used to increase knowledge about medication administration and nasotracheal suctioning in different scenarios [ 21 ], to evaluate the effect of interactive nursing skills, knowledge, and self-efficacy [ 11 ], and to detect patient deterioration in two different cases [ 22 ]. Simulation game methodology was used to improve nursing students’ cognitive and attention skills, strengthen judgment, time management, and decision-making [ 14 ].

Clinical simulation was used to develop nursing students’ clinical reasoning in evaluating wounds and their treatments [ 12 ], to evaluate and compare the perception of stressors, with the goal of determining whether simulations promote students’ self-evaluation and critical-thinking skills [ 23 ], and also to evaluate the impact of multiple simulations on students’ self-reported clinical decision-making skills and self-confidence [ 24 ].

3.4.2. Learning Programs

Different types of learning programmes have been identified in this systematic review: team-based learning, reflective training programs, person-centred educational programmes, ethical reasoning programmes, case-based learning, mapping, training problem-solving skills, and self-instructional guides. Of the total number of nursing students in the studies referring to learning programs, 57.1% were junior-year students, while 43.85% were in their senior year.

Team-based learning is a learner-centred educational strategy that promotes active learning to improve students’ problem-solving, knowledge, and practise performance. It can be implemented in small or large groups divided into teams with an instructor and reading material based on case scenarios [ 25 ]. Reflective training is based on a new mentoring practise to explore, think about, and solve problems actively during an internship. During the reflective training program, the mentors lead students to uncover clinical nursing problems through conversations with them and discussing feedback for their professional portfolios [ 26 ]. The person-centred educational programme focuses on how nursing students perceive individualised care, using design thinking to improve their perception. The use of design thinking gave the students opportunities to apply their theoretical knowledge of the person-centred program to plan innovative solutions that may effectively resolve real-life situations [ 27 ]. Another educational programme identified is the ethical reasoning program, and the aim of this is to improve nursing students’ handling of ethical decision-making situations [ 28 ], engaging the students in complex ethical clinical situations based on real cases.

Case-based learning was used to explore and demonstrate the feasibility of implementing unfolding cases in lectures to develop students’ critical-thinking abilities [ 29 ]. The web-based concept mapping of nursing students was also investigated to determine its impact on critical-thinking skills [ 30 ]. Training problem-solving skills were used to find out how it affected the rate of self-handicapping among nursing students [ 31 ]. And the last article evaluated the effect of the self-instructional guide to improve clinical reasoning skills on diagnostic accuracy in undergraduate nursing students [ 32 ].

4. Discussion

Although 158 studies were initially identified, only 15 articles were finally included in this review. The excluded articles were mainly from other disciplines other than nursing and used a less rigorous study design than RCT.

The three longest interventions were developed in Asia [ 26 , 28 , 29 ]. The longest was 300 h in duration, through one year [ 30 ]. These interventions were based on learning programs, case-based learning, person-centred care (PCC), and reflective training programs. However, it is important to take into account that Asian nursing curriculum programmes are different from European or United States curriculum because their internship is carried out only during the last academic degree year, while in Europe, following the European directive 2005/36/CE, 2013/55/UE nursing education requirements of 4600 h (2300 h of clinical practice) is carried out along the 3–4 years of the academic degree [ 33 ]. On the other hand, the intervention with the biggest sample was 419 nursing students [ 30 ], 210 in the experimental group, and 209 in the control group, and the one with the lowest sample was 51, with 24 students in the control group and 27 in the intervention group [ 32 ]. Therefore, all the included studies had a good sample size.

This systematic review has detected different methodologies to help nursing students improve their reasoning and decision-making skills. Virtual simulation was the most frequently used teaching method, both as a mobile application and as a serious game. In terms of its effectiveness in a study carried out in Taiwan, the use of a mobile application resulted in significantly higher knowledge scores, better skill performance, and higher satisfaction in students than traditional paper materials [ 21 ]. Virtual simulation [ 11 , 14 , 21 ] has also proven to be an effective tool for enhancing knowledge and confidence in recognising and responding to rapidly deteriorating patients, but studies that combined two educational strategies were more effective [ 29 ], like clinical simulation combined with another teaching strategy such as lectures or videos [ 12 ].

An interactive learner-centred nursing education mobile application with systematic contents effectively allowed students to experience positive practical nursing skills [ 11 ]. However, in a study comparing serious game simulation versus traditional teaching methods, no significant difference was found immediately or in the month following the training [ 22 ], but serious games can improve nursing students’ cognitive skills to detect patient deterioration and to make safe decisions about patient care [ 14 ]. Although the innovative teaching method was well received by the students, who expressed higher levels of satisfaction and motivation [ 22 ]. We can affirm that the development of a mobile application and its application can be effectively used by nursing students at all levels [ 11 ]. However, the performance of all these studies was measured on its short-term outcomes, only 40 min [ 21 ], 2 h [ 22 ], and 1 week [ 11 , 14 ] of intervention, and was performed with a mean sample size of 97 nursing students.

The data obtained in a study developed in Brazil [ 12 ] confirm that clinical simulation is effective for the development of nursing students’ clinical reasoning in wound evaluation and treatment and that clinical simulation in conjunction with other educational methods promotes the acquisition of knowledge by facilitating the transition from what the student knows to rational action. Moreover, the high-fidelity simulation strategy increases the perception of stressors related to a lack of competence and interpersonal relationships with patients, multidisciplinary teams, and colleagues compared with the conventional practice class in the skill laboratory. This increase was related to the students’ capacity for self-evaluation and critical reflection, concerning their learning responsibility and the need to acquire the required skills for patient care [ 23 ]. However, in the case of the effect of multiple simulations on students, there are no differences found between the double-versus single-scenario simulations [ 24 ]. The intervention time in these three studies was 30 min [ 23 ], 3.5 h [ 12 ], and 4 days [ 24 ]; then the time used to implement the intervention can determine the results obtained.

The different learning methods have an impact on various learning outcomes and students’ variables. Team-based learning [ 25 ], reflective training [ 26 ], the person-centred education programme [ 27 ], web-based concept mapping [ 30 ], and teaching cognitive-behavioural approaches [ 31 ] have proven to be effective in enhancing problem-solving abilities, knowledge, and reasoning processes and consequently improving the quality of nursing practical education. Team-based learning increased problem-solving ability scores significantly, while those in the control group decreased [ 25 ]. Reflective training, developed in China based on the new mentoring approach, was effective in encouraging nursing students to explore, think about, and solve problems actively during an internship, consequently improving their disposition for critical thinking [ 26 ]. A person-centred education programme using design thinking can effectively improve how nursing students perceive individualised care. Using design thinking allowed the students to apply their theoretical knowledge of the programme to plan innovative solutions that may effectively resolve real health problems [ 27 ]. These programmes were developed in 5 or 6 days [ 27 , 31 ], 1 week or 3 weeks [ 25 , 30 ], and 1 year [ 26 ].

The education programme focused on improving ethical decision-making had statistically significant improvements in nursing students’ self-efficacy in communication confidence, complex ethical decision-making skills, and decreased communication difficulty [ 28 ]. Case-based learning was more effective with lectures than without them in developing students’ critical thinking abilities [ 29 ]. This study was one of the longest developed with 300 h during one school year. This long-term learning intervention could have a positive impact on this study sample. Therefore, the time of the learning intervention could be a limitation in the studied RCTs. The one-time self-instruction guide was ineffective in impacting students’ diagnostic accuracy in solving case studies [ 32 ], and it is possible that only one day of intervention is not enough.

Studies have shown that problem- and team-based learning [ 25 , 31 ] are more beneficial than traditional teaching [ 29 ], as they enhance nursing skills and improve problem-solving abilities, clinical performance, communication competencies, critical thinking, and self-leadership.

Researchers generally agree that clinical reasoning is an important ability and one of the most important competencies for good nursing practise to ensure optimal patient outcomes [ 29 ] and to recognise and address patient deterioration effectively. However, effective communication is crucial in clinical reasoning. It is required to establish a rapport with patients, conduct health evaluations, make collaborative decisions, and discuss clinical cases with colleagues and supervisors. Developing clinical reasoning skills during training is essential to improving nursing professionals’ practice. To enhance clinical reasoning abilities, nursing schools should integrate simulations at every level of education to ultimately improve patient care. Improving nursing students’ preparation will impact the quality of patient care. In addition, new innovative teaching methodologies based on the use of technology could be a motivational driver in nursing clinical reasoning [ 22 ].

5. Limitations

This systematic review did not perform a search on CINAHL. Although most of the journals included in this database are included in MEDLINE, this should be addressed in the future because of the relevance of the database to nursing research. The results of the included studies could have also been influenced by the different times of the interventions and the different contexts. In addition, the reviewers have identified other studies published in languages other than those required by the inclusion criteria. It seems that many articles are published by Asian researchers, but some of them are not in English, so they cannot be analysed.

6. Conclusions

As society progresses, the new generation of nursing students poses a challenge; new technologies are ingrained in their daily lives with access to increasingly advanced technologies like artificial intelligence, and we must adapt training to capture their interest and increase their learning skills. The utilisation of mobile apps, digital simulations, and learning games has a positive impact on the clinical reasoning abilities of nursing students and their motivation. Incorporating new technologies into problem-solving-based learning and decision-making can also enhance nursing students’ reasoning skills. As a result, it is crucial to incorporate these tools into the learning process to maintain students’ interest, motivation, and satisfaction in education. Clinical simulation is particularly important in the training of students in terms of clinical performance. Still, it is necessary to add another teaching method to increase the efficacy of clinical simulations. Therefore, nursing schools should evaluate their current teaching methods and consider integrating or modifying new technologies and methodologies that can help enhance students’ learning, improve their clinical reasoning and cognitive skills, and potentially improve nursing students’ ability to affect patient care positively. By doing so, students will be better equipped to provide high-quality patient care in the future.

Funding Statement

This research received external funding from the European programme Eramus +2021-1-BE02-KA220-HED-000023194.

Author Contributions

Conceptualisation, A.P.-P. and A.Z.; methodology, A.P.-P. and A.Z.; formal analysis, A.P.-P.; writing—original draft preparation, A.P.-P.; writing—review and editing, A.Z.; visualisation, A.Z.; supervision, A.Z. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

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A Crash Course in Critical Thinking

What you need to know—and read—about one of the essential skills needed today..

Posted April 8, 2024 | Reviewed by Michelle Quirk

• In research for "A More Beautiful Question," I did a deep dive into the current crisis in critical thinking.
• Many people may think of themselves as critical thinkers, but they actually are not.
• Here is a series of questions you can ask yourself to try to ensure that you are thinking critically.

Conspiracy theories. Inability to distinguish facts from falsehoods. Widespread confusion about who and what to believe.

These are some of the hallmarks of the current crisis in critical thinking—which just might be the issue of our times. Because if people aren’t willing or able to think critically as they choose potential leaders, they’re apt to choose bad ones. And if they can’t judge whether the information they’re receiving is sound, they may follow faulty advice while ignoring recommendations that are science-based and solid (and perhaps life-saving).

Moreover, as a society, if we can’t think critically about the many serious challenges we face, it becomes more difficult to agree on what those challenges are—much less solve them.

On a personal level, critical thinking can enable you to make better everyday decisions. It can help you make sense of an increasingly complex and confusing world.

In the new expanded edition of my book A More Beautiful Question ( AMBQ ), I took a deep dive into critical thinking. Here are a few key things I learned.

First off, before you can get better at critical thinking, you should understand what it is. It’s not just about being a skeptic. When thinking critically, we are thoughtfully reasoning, evaluating, and making decisions based on evidence and logic. And—perhaps most important—while doing this, a critical thinker always strives to be open-minded and fair-minded . That’s not easy: It demands that you constantly question your assumptions and biases and that you always remain open to considering opposing views.

In today’s polarized environment, many people think of themselves as critical thinkers simply because they ask skeptical questions—often directed at, say, certain government policies or ideas espoused by those on the “other side” of the political divide. The problem is, they may not be asking these questions with an open mind or a willingness to fairly consider opposing views.

When people do this, they’re engaging in “weak-sense critical thinking”—a term popularized by the late Richard Paul, a co-founder of The Foundation for Critical Thinking . “Weak-sense critical thinking” means applying the tools and practices of critical thinking—questioning, investigating, evaluating—but with the sole purpose of confirming one’s own bias or serving an agenda.

In AMBQ , I lay out a series of questions you can ask yourself to try to ensure that you’re thinking critically. Here are some of the questions to consider:

• Why do I believe what I believe?
• Are my views based on evidence?
• Have I fairly and thoughtfully considered differing viewpoints?
• Am I truly open to changing my mind?

Of course, becoming a better critical thinker is not as simple as just asking yourself a few questions. Critical thinking is a habit of mind that must be developed and strengthened over time. In effect, you must train yourself to think in a manner that is more effortful, aware, grounded, and balanced.

For those interested in giving themselves a crash course in critical thinking—something I did myself, as I was working on my book—I thought it might be helpful to share a list of some of the books that have shaped my own thinking on this subject. As a self-interested author, I naturally would suggest that you start with the new 10th-anniversary edition of A More Beautiful Question , but beyond that, here are the top eight critical-thinking books I’d recommend.

The Demon-Haunted World: Science as a Candle in the Dark , by Carl Sagan

This book simply must top the list, because the late scientist and author Carl Sagan continues to be such a bright shining light in the critical thinking universe. Chapter 12 includes the details on Sagan’s famous “baloney detection kit,” a collection of lessons and tips on how to deal with bogus arguments and logical fallacies.

Clear Thinking: Turning Ordinary Moments Into Extraordinary Results , by Shane Parrish

The creator of the Farnham Street website and host of the “Knowledge Project” podcast explains how to contend with biases and unconscious reactions so you can make better everyday decisions. It contains insights from many of the brilliant thinkers Shane has studied.

Good Thinking: Why Flawed Logic Puts Us All at Risk and How Critical Thinking Can Save the World , by David Robert Grimes

A brilliant, comprehensive 2021 book on critical thinking that, to my mind, hasn’t received nearly enough attention . The scientist Grimes dissects bad thinking, shows why it persists, and offers the tools to defeat it.

Think Again: The Power of Knowing What You Don't Know , by Adam Grant

Intellectual humility—being willing to admit that you might be wrong—is what this book is primarily about. But Adam, the renowned Wharton psychology professor and bestselling author, takes the reader on a mind-opening journey with colorful stories and characters.

Think Like a Detective: A Kid's Guide to Critical Thinking , by David Pakman

The popular YouTuber and podcast host Pakman—normally known for talking politics —has written a terrific primer on critical thinking for children. The illustrated book presents critical thinking as a “superpower” that enables kids to unlock mysteries and dig for truth. (I also recommend Pakman’s second kids’ book called Think Like a Scientist .)

Rationality: What It Is, Why It Seems Scarce, Why It Matters , by Steven Pinker

The Harvard psychology professor Pinker tackles conspiracy theories head-on but also explores concepts involving risk/reward, probability and randomness, and correlation/causation. And if that strikes you as daunting, be assured that Pinker makes it lively and accessible.

How Minds Change: The Surprising Science of Belief, Opinion and Persuasion , by David McRaney

David is a science writer who hosts the popular podcast “You Are Not So Smart” (and his ideas are featured in A More Beautiful Question ). His well-written book looks at ways you can actually get through to people who see the world very differently than you (hint: bludgeoning them with facts definitely won’t work).

A Healthy Democracy's Best Hope: Building the Critical Thinking Habit , by M Neil Browne and Chelsea Kulhanek

Neil Browne, author of the seminal Asking the Right Questions: A Guide to Critical Thinking, has been a pioneer in presenting critical thinking as a question-based approach to making sense of the world around us. His newest book, co-authored with Chelsea Kulhanek, breaks down critical thinking into “11 explosive questions”—including the “priors question” (which challenges us to question assumptions), the “evidence question” (focusing on how to evaluate and weigh evidence), and the “humility question” (which reminds us that a critical thinker must be humble enough to consider the possibility of being wrong).

Warren Berger is a longtime journalist and author of A More Beautiful Question .

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