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Critical thinking in healthcare and education

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• Peer review
• Jonathan M Sharples , professor 1 ,
• Andrew D Oxman , research director 2 ,
• Kamal R Mahtani , clinical lecturer 3 ,
• Iain Chalmers , coordinator 4 ,
• Sandy Oliver , professor 1 ,
• Kevan Collins , chief executive 5 ,
• Astrid Austvoll-Dahlgren , senior researcher 2 ,
• Tammy Hoffmann , professor 6
• 1 EPPI-Centre, UCL Department of Social Science, London, UK
• 2 Global Health Unit, Norwegian Institute of Public Health, Oslo, Norway
• 3 Centre for Evidence-Based Medicine, Oxford University, Oxford, UK
• 4 James Lind Initiative, Oxford, UK
• 5 Education Endowment Foundation, London, UK
• 6 Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Australia
• Correspondence to: J M Sharples Jonathan.Sharples{at}eefoundation.org.uk

Critical thinking is just one skill crucial to evidence based practice in healthcare and education, write Jonathan Sharples and colleagues , who see exciting opportunities for cross sector collaboration

Imagine you are a primary care doctor. A patient comes into your office with acute, atypical chest pain. Immediately you consider the patient’s sex and age, and you begin to think about what questions to ask and what diagnoses and diagnostic tests to consider. You will also need to think about what treatments to consider and how to communicate with the patient and potentially with the patient’s family and other healthcare providers. Some of what you do will be done reflexively, with little explicit thought, but caring for most patients also requires you to think critically about what you are going to do.

Critical thinking, the ability to think clearly and rationally about what to do or what to believe, is essential for the practice of medicine. Few doctors are likely to argue with this. Yet, until recently, the UK regulator the General Medical Council and similar bodies in North America did not mention “critical thinking” anywhere in their standards for licensing and accreditation, 1 and critical thinking is not explicitly taught or assessed in most education programmes for health professionals. 2

Moreover, although more than 2800 articles indexed by PubMed have “critical thinking” in the title or abstract, most are about nursing. We argue that it is important for clinicians and patients to learn to think critically and that the teaching and learning of these skills should be considered explicitly. Given the shared interest in critical thinking with broader education, we also highlight why healthcare and education professionals and researchers need to work together to enable people to think critically about the health choices they make throughout life.

Essential skills for doctors and patients

Critical thinking is not a new concept in education: at the beginning of the last century the US educational reformer John Dewey identified the need to help students “to think well.” 3 Critical thinking encompasses a broad set of skills and dispositions, including cognitive skills (such as analysis, inference, and self regulation); approaches to specific questions or problems (orderliness, diligence, and reasonableness); and approaches to life in general (inquisitiveness, concern with being well informed, and open mindedness). 4

An increasing body of evidence highlights that developing critical thinking skills can benefit academic outcomes as well as wider reasoning and problem solving capabilities. 5 For example, the Thinking, Doing, Talking Science programme trains teachers in a repertoire of strategies that encourage pupils to use critical thinking skills in primary school science lessons. An independently conducted randomised trial of this approach found that it had a positive impact on pupils’ science attainment, with signs that it was particularly beneficial for pupils from poorer families. 6

In medicine, increasing attention has been paid to “critical appraisal” in the past 40 years. Critical appraisal is a subset of critical thinking that focuses on how to use research evidence to inform health decisions. 7 8 9 The need for critical appraisal in medicine was recognised at least 75 years ago, 10 and critical appraisal has been recognised for some decades as an essential competency for healthcare professionals. 11 The General Medical Council’s Good Medical Practice guidance includes the need for doctors to be able to “provide effective treatments based on the best available evidence.” 12

If patients and the public are to make well informed health choices, they must also be able to assess the reliability of health claims and information. This is something that most people struggle to do, and it is becoming increasingly important because patients are taking on a bigger role in managing their health and making healthcare decisions, 13 while needing to cope with more and more health information, much of which is not reliable. 14 15 16 17

Teaching critical thinking

Although critical thinking skills are given limited explicit attention in standards for medical education, they are included as a key competency in most frameworks for national curriculums for primary and secondary schools in many countries. 18 Nonetheless, much health and science education, and education generally, still tends towards rote learning rather than the promotion of critical thinking. 19 20 This matters because the ability to think critically is an essential life skill relevant to decision making in many circumstances. The capacity to think critically is, like a lot of learning, developed in school and the home: parental influence creates advantage for pupils who live in homes where they are encouraged to think and talk about what they are doing. This, importantly, goes beyond simply completing tasks to creating deeper understanding of learning processes. As such, the “critical thinking gap” between children from disadvantaged communities and their more advantaged peers requires attention as early as possible.

Although it is possible to teach critical thinking to adults, it is likely to be more productive if the grounds for this have been laid down in an educational environment early in life, starting in primary school. Erroneous beliefs, attitudes, and behaviours developed during childhood may be difficult to change later. 21 22 This also applies to medical education and to health professionals. It becomes increasingly difficult to teach these skills without a foundation to build on and adequate time to learn them.

Strategies for teaching students to think critically have been evaluated in health and medical education; in science, technology, engineering, and maths; and in other subjects. 23 These studies suggest that critical thinking skills can be taught and that in the absence of explicit teaching of critical thinking, important deficiencies emerge in the abilities of students to make sound judgments. In healthcare studies, many medical students score poorly on tests that measure the ability to think critically , and the ability to think critically is correlated with academic success. 24 25

Evaluations of strategies for teaching critical thinking in medicine have focused primarily on critical appraisal skills as part of evidence based healthcare. An overview of systematic reviews of these studies suggests that improving evidence based healthcare competencies is likely to require multifaceted, clinically integrated approaches that include assessment. 26

Cross sector collaboration

Informed Health Choices, an international project aiming to improve decision making, shows the opportunities and benefits of cross sector collaboration between education and health. 27 This project has brought together people working in education and healthcare to develop a curriculum and learning resources for critical thinking about any action that is claimed to improve health. It aims to develop, identify, and promote the use of effective learning resources, beginning at primary school, to help people to make well informed choices as patients and health professionals, and well informed decisions as citizens and policy makers.

The project has drawn on several approaches used in education, including the development of a “spiral curriculum,” measurement tools, and the design of learning resources. A spiral curriculum begins with determining what people should know and be able to do, and outlines where they should begin and how they should progress to reach these goals. The basic ideas are revisited repeatedly, building on them until the student has grasped a deep understanding of the concepts. 28 29 The project has also drawn on educational research and methods to develop reliable and valid tools for measuring the extent to which those goals have been achieved. 30 31 32 The development of learning resources to teach these skills has been informed by educational research, including educational psychology, motivational psychology, and research and methods for developing learning games. 33 34 35 It has also built on the traditions of clinical epidemiology and evidence based medicine to identify the key concepts required to assess health claims. 29

It is difficult to teach critical thinking abstractly, so focusing on health may have advantages beyond the public health benefits of increasing health literacy. 36 Nearly everyone is interested in health, including children, making it easy to engage learners. It is also immediately relevant to students. As reported by one 10 year old in a school that piloted primary school resources, this is about “things we might actually use instead of things we might use when we are all grown up and by then we’ll forget.” Although the current evaluation of the project is focusing on outcomes relating to appraisal of treatment claims, if the intervention shows promise the next step could be to explore how these skills translate to wider educational contexts and outcomes.

Beyond critical thinking

Exciting opportunities for cross sector collaboration are emerging between healthcare and education. Although critical thinking is a useful example of this, other themes cross the education and healthcare domains, including nutrition, exercise, educational neuroscience, learning disabilities and special education needs, and mental health.

In addition to shared topics, several common methodological and conceptual issues also provide opportunities for sharing ideas and innovations and learning from mistakes and successes. For example, the Education Endowment Foundation is the UK government’s What Works Centre for education, aiming to improve evidence based decision making. Discussions hosted by the foundation are exploring how methods to develop guidelines in healthcare can be adapted and applied in education and other sectors.

Similarly, the foundation’s universal use of independent evaluation for teaching and learning interventions is an approach that should be explored, adapted, and applied in healthcare. Since the development and evaluation of educational interventions are separated, evaluators have no vested interested in the results of the assessment, all results are published, and bias and spin in how results are analysed and presented are reduced. By contrast, industry sponsorship of drug and device studies consistently produces results that favour the manufacturer. 37

Another example of joint working between educators and health is the Best Evidence Medical Education Collaboration, an international collaboration focused on improving education of health professionals. 38 And in the UK, the Centre for Evidence Based Medicine coordinates Evidence in School Teaching (Einstein), a project that supports introducing evidence based medicine as part of wider science activities in schools. 39 It aims to engage students, teachers, and the public in evidence based medicine and develop critical thinking to assess health claims and make better choices.

Collaboration has also been important in the development of the Critical Thinking and Appraisal Resource Library (CARL), 40 a set of resources designed to help people understand fair comparisons of treatments. An important aim of CARL is to promote evaluation of these critical thinking resources and interventions, some of which are currently under way at the Education Endowment Foundation. On 22 May 2017, the foundation is also cohosting an event with the Royal College of Paediatrics and Child Health that will focus on their shared interest in critical thinking and appraisal skills.

Education and healthcare have overlapping interests. Doctors, teachers, researchers, patients, learners, and the public can all benefit from working together to help people to think critically about the choices they make. Events such as the global evidence summit in September 2017 ( https://globalevidencesummit.org ) can help bring people together and build on current international experience.

Contributors and sources: This article reflects conclusions from discussions during 2016 among education and health service researchers exploring opportunities for cross sector collaboration and learning. This group includes people with a longstanding interest in evidence informed policy and practice, with expertise in evaluation design, reviewing methodology, knowledge mobilisation, and critical thinking and appraisal.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

Provenance and peer review: Not commissioned; externally peer reviewed.

• ↵ Krupat E, Sprague JM, Wolpaw D, Haidet P, Hatem D, O’Brien B. Thinking critically about critical thinking: ability, disposition or both? Med Educ 2011 ; 357 : 625 - 35 . doi:10.1111/j.1365-2923.2010.03910.x   pmid:21564200 . OpenUrl
• ↵ Huang GC, Newman LR, Schwartzstein RM. Critical thinking in health professions education: summary and consensus statements of the millennium conference 2011. Teach Learn Med 2014 ; 357 : 95 - 102 . doi:10.1080/10401334.2013.857335   pmid:24405353 . OpenUrl
• ↵ Dewey J. How we think. D C Heath, 1910 . https://archive.org/details/howwethink000838mbp doi:10.1037/10903-000 .
• ↵ Facione PA. Critical thinking: a statement of expert consensus for purposes of educational assessment and instruction. Research findings and recommendations. American Philosophical Association, 1990 , http://files.eric.ed.gov/fulltext/ED315423.pdf .
• ↵ Higgins S, Katsipataki M, Coleman R, et al. The Sutton Trust-Education Endowment Foundation Teaching and Learning Toolkit. Education Endowment Foundation, 2015 .
• ↵ Hanley P, Slavin RE, Elliot L. Thinking, doing, talking science. Evaluation report and executive summary. Education Endowment Foundation, 2015 , https://v1.educationendowmentfoundation.org.uk/uploads/pdf/Oxford_Science.pdf .
• ↵ Sackett DL. How to read clinical journals: I. why to read them and how to start reading them critically . Can Med Assoc J 1981 ; 357 : 555 - 8 . pmid:7471000 . OpenUrl
• ↵ Guyatt G, Cairns J, Churchill D, et al. Evidence-Based Medicine Working Group. Evidence-based medicine. A new approach to teaching the practice of medicine . JAMA 1992 ; 357 : 2420 - 5 . doi:10.1001/jama.1992.03490170092032   pmid:1404801 . OpenUrl
• ↵ Oxman AD, Sackett DL, Guyatt GH. The Evidence-Based Medicine Working Group. Users’ guides to the medical literature. I. How to get started . JAMA 1993 ; 357 : 2093 - 5 . doi:10.1001/jama.1993.03510170083036   pmid:8411577 . OpenUrl
• ↵ Rynearson EH. Endocrinology: a critical appraisal . Cal West Med 1940 ; 357 : 257 - 9 . pmid:18745588 . OpenUrl
• ↵ General Medical Council. Tomorrow's doctors. General Medical Council, 1993. http://www.gmc-uk.org/10a_annex_a.pdf_25398162.pdf
• ↵ General Medical Council. Good medical practice. General Medical Council, 2013. http://www.gmc-uk.org/static/documents/content/GMP_.pdf
• ↵ Edwards A, Elwyn G. Shared decision-making in health care: achieving evidence-based patient choice. 2nd ed . Oxford University Press, 2009 .
• ↵ Sumner P, Vivian-Griffiths S, Boivin J, et al. Exaggerations and caveats in press releases and health-related science news. PLoS One 2016 ; 357 : e0168217 . doi:10.1371/journal.pone.0168217   pmid:27978540 . OpenUrl
• ↵ Schwartz LM, Woloshin S, Andrews A, Stukel TA. Influence of medical journal press releases on the quality of associated newspaper coverage: retrospective cohort study. BMJ 2012 ; 357 : d8164 . doi:10.1136/bmj.d8164 .  pmid:22286507 . OpenUrl
• ↵ Glenton C, Paulsen EJ, Oxman AD. Portals to Wonderland: health portals lead to confusing information about the effects of health care. BMC Med Inform Decis Mak 2005 ; 357 : 7 . doi:10.1186/1472-6947-5-7   pmid:15769291 . OpenUrl
• ↵ Moynihan R, Bero L, Ross-Degnan D, et al. Coverage by the news media of the benefits and risks of medications . N Engl J Med 2000 ; 357 : 1645 - 50 . doi:10.1056/NEJM200006013422206   pmid:10833211 . OpenUrl
• ↵ Voogt J, Roblin NP. A comparative analysis of international frameworks for 21st century competences: implications for national curriculum policies. J Curric Stud 2012 ; 357 : 299 - 321 doi:10.1080/00220272.2012.668938 . OpenUrl
• ↵  National Research Council. Taking science to school: learning and teaching science in grades K-8. National Academies Press, 2007 .
• ↵ Nordheim L, Pettersen KS, Flottorp S, Hjälmhult E. Critical appraisal of health claims: science teachers’ perceptions and practices . Health Educ J 2016 ; 357 : 449 - 66 doi:10.1108/HE-04-2015-0016 . OpenUrl
• ↵  Committee on Science Learning. Kindergarten through eighth grade. How children learn science. In: Duschl RA, Schweingruber A, Shouse AW, eds. Taking science to school: learning and teaching science in grades K-8. National Academies Press, 2007 .
• ↵ Vosniadou S. International handbook of research on conceptual change. 2nd ed . Routledge, 2013 .
• ↵ Abrami PC, Bernard RM, Borokhovski E, Waddington DI, Wade CA, Persson T. Strategies for teaching students to think critically a meta-analysis. Rev Educ Res 2015 ; 357 : 275 - 314 . OpenUrl
• ↵ Ross D, Schipper S, Westbury C, et al. Examining critical thinking skills in family medicine residents . Fam Med 2016 ; 357 : 121 - 6 . pmid:26950783 . OpenUrl
• ↵ Ross D, Loeffler K, Schipper S, Vandermeer B, Allan GM. Do scores on three commonly used measures of critical thinking correlate with academic success of health professions trainees? A systematic review and meta-analysis. Acad Med 2013 ; 357 : 724 - 34 . doi:10.1097/ACM.0b013e31828b0823   pmid:23524925 . OpenUrl
• ↵ Young T, Rohwer A, Volmink J, Clarke M. What are the effects of teaching evidence-based health care (EBHC)? Overview of systematic reviews. PLoS One 2014 ; 357 : e86706 . doi:10.1371/journal.pone.0086706   pmid:24489771 . OpenUrl
• ↵ Informed Health Choices Group. Informed health choices. www.informedhealthchoices.org
• ↵ Harden RM, Stamper N. What is a spiral curriculum? Med Teach 1999 ; 357 : 141 - 3 . doi:10.1080/01421599979752   pmid:21275727 . OpenUrl
• ↵ Austvoll-Dahlgren A, Oxman AD, Chalmers I, et al. Key concepts that people need to understand to assess claims about treatment effects. J Evid Based Med 2015 ; 357 : 112 - 25 . doi:10.1111/jebm.12160   pmid:26107552 . OpenUrl
• ↵ Austvoll-Dahlgren A, Nsangi A, Semakula D. Interventions and assessment tools addressing key concepts people need to know to appraise claims about treatment effects: a systematic mapping review. Syst Rev 2016 ; 357 : 215 . doi:10.1186/s13643-016-0389-z   pmid:28034307 . OpenUrl
• ↵ Austvoll-Dahlgren A, Semakula D, Nsangi A, et al. The development of the “claim evaluation tools”: assessing critical thinking about effects. BMJ Open forthcoming .
• ↵ Austvoll-Dahlgren A, Guttersrud Ø, Semakula D, Nsangi A, Oxman AD. Measuring ability to assess claims about treatment effects: a latent trait analysis of the claim evaluation tools using Rasch modelling. BMJ Open [ forthcoming ].
• ↵ Sandoval WA, Sodian B, Koerber S, Wong J. Developing children’s early competencies to engage with science . Educ Psychol 2014 ; 357 : 139 - 52 doi:10.1080/00461520.2014.917589 . OpenUrl
• ↵ Pintrich PR. A motivational science perspective on the role of student motivation in learning and teaching contexts . J Educ Psychol 2003 ; 357 : 667 - 86 doi:10.1037/0022-0663.95.4.667 . OpenUrl
• ↵ Clark DB, Tanner-Smith EE, Killingsworth SS. Digital games, design, and learning: a systematic review and meta-analysis . Rev Educ Res 2016 ; 357 : 79 - 122 . doi:10.3102/0034654315582065   pmid:26937054 . OpenUrl
• ↵ Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review . Ann Intern Med 2011 ; 357 : 97 - 107 . doi:10.7326/0003-4819-155-2-201107190-00005   pmid:21768583 . OpenUrl
• ↵ Lundh A, Sismondo S, Lexchin J, Busuioc OA, Bero L. Industry sponsorship and research outcome. Cochrane Database Syst Rev 2012 ; 357 : MR000033 . pmid:23235689 . OpenUrl
• ↵ Thistlethwaite J, Hammick M, The Best Evidence Medical Education (BEME) Collaboration: into the next decade. Med Teach 2010 ; 357 : 880 - 2 . doi:10.3109/0142159X.2010.519068   pmid:21039096 . OpenUrl
• ↵ Centre for Evidence Based Medicine. Einstein—taking EBM to schools. http://www.cebm.net/taking-ebm-schools
• ↵ Castle JC, Chalmers I, Atkinson P, et al. Establishing a library of resources to help people understand key concepts in assessing treatment claims—the Critical Thinking and Appraisal Resource Library (CARL). PLoS One forthcoming .

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• 10 October 2022

Critical Thinking In Nursing

• Laura Pueyo Band 7 Bed Manager
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Laura Pueyo, Haematology Nurse, discusses why Critical Thinking is important in Nursing and gives examples of how, when put into practice, it can improve your Nursing and reduce potential mistakes.

What is critical thinking.

Hey guys, my name is Laura.

I'm one of the Nurses from the NHS.

And today I would like to talk about critical thinking in Nursing.

I think the best way to explain this topic is with some examples.

So, let's just start picturing this.

Imagine you just started on your ward a couple of months ago and today your congestive heart failure patient is scheduled for a pacemaker implantation first thing in the morning.

So the doctor orders two units of bloods before transferring the patient to the theatre.

So you start with the first bag with no problem but at the beginning of the second bag, your patient's oxygen saturation drops from 95 to 91.

So you start to administer some oxygen but this only brings your patient's oxygen level up to 91.

So you stop and think, what could be wrong with your patient?

You'd take all of the notes and you take the charts and you notice the input and output.

So your patient has a positive fluid balance of two litres.

And you remember hearing some crackles when breathing.

So now what do you do?

It takes critical thinking to determine what could be going on with your patient and what you should do about it.

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Using Critical Thinking And Why It’s Important?

Okay, now that we have identified critical thinking, let's see what it is exactly and why it is useful for Nurses.

Critical thinking is a specific way of using your mind. It's your ability to objectively judge information rather than believing everything you are told.

It's basically to question the information that has been given to you.

Like why this patient oxygen saturation is dropping.

Not just automatically accept what you are told but instead you use your brain to analyse something before deciding whether to agree with it or not.

And by doing so, Nurses can ensure that everything possible is taken into consideration before making any final decisions about our action.

Like in this case, we take a step back and we check all of the charts to see what could be wrong with the patient.

Examples Of Critical Thinking In Practice

But let's be more visual about this.

Imagine you are about to enter into a patient room and before that you check the patient chart.

You deduce that this patient might be experiencing some pain, due to the blood results that shows high potassium levels.

So you assume that this pain may be caused by their kidney condition.

Which is supported by the patient reporting this pain when asked.

So you use your critical thinking skills to decide whether or not to order the analgesic medication before speaking with the patient that might be experiencing this pain because of the high potassium levels.

Or, another example could be for the Nurses in A&E when they make triage decisions.

With an overflow of patients and limited staff, they must evaluate which patients should be treated first.

While they rely on their training to measure the vital signs or the level of consciousness, they use their critical thinking skills to analyse the consequences of delaying treatment in each case.

No matter which department we work in, Nurses use critical thinking in our everyday routines.

When we face decisions that could ultimately mean life or death, the ability to analyse the situation and come to a solution, separates the good Nurses three ‘top’ ways.

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Improving Nursing Care Through Critical Thinking

In a clinical experience, Nurses should use a case-based approach.

This method uses an actual patient situation as a starting point and then allows you to research further by your own, by going through relevant articles on books, websites within the field.

The idea behind this approach, is that you will benefit from having more knowledge, which allows you to understand how often these cases come up and the type of concerns the patient suffers when they face them.

To get the most out of this approach, you would need to remember where did you find this information. So you can find it again when you need it.

Secondly, you can also do some critical thinking exercises.

There are many functional, critical thinking exercises that you could do on your own.

But one of the easiest ways for Nurses to test their abilities, is by looking at some examples and then working out what steps they would need to take to solve such a problem in the most effective way.

And the third technique could be to use a Nursing process.

When it comes to using critical thinking processes in Nursing, you will need to identify all of the factors that are involved in performing your task.

And then, you make sure that you are working out in the order in which they should happen.

This method help Nurses to avoid making mistakes or taking unnecessary risk, by answering that everything possible has been thought through before acting on anything.

Critical thinking in Nursing can keep Nurses at the top of their game by ensuring that they are constantly working to find out more about our profession and how we can become better at it.

By using different strategies, Nurses can make sure that any knowledge we learn is relevant and accurate for the needs of our situations.

You are now well aware of the importance of critical thinking and skills in Nursing.

Nurses who use critical thinking skills are less likely to make mistakes or take unnecessary risks because we have gone through a decision making process.

Critical Thinking Takes Practice

If you use critical thinking skills every day, you should keep working on improving them.

Because the more you practice it, the better you will come.

And the more naturally it will come to you.

I hope you like this video.

And if you want to check more videos like this, you can visit nurses.co.uk.

Have a good day.

About the author

I’m a Spanish nurse who’s been working in London for 5 years. After starting my career as a staff nurse in Spain I moved to London to specialise in Haematology, as it’s always been my passion. I’m now working as the haematology bed manager, where my job is to manage the bed capacity of the department and lead the patient flow.

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Critical thinking: what it is and why it counts. 2020. https://tinyurl.com/ybz73bnx (accessed 27 April 2021)

Faculty of Intensive Care Medicine. Curriculum for training for advanced critical care practitioners: syllabus (part III). version 1.1. 2018. https://www.ficm.ac.uk/accps/curriculum (accessed 27 April 2021)

Guerrero AP. Mechanistic case diagramming: a tool for problem-based learning. Acad Med.. 2001; 76:(4)385-9 https://doi.org/10.1097/00001888-200104000-00020

Harasym PH, Tsai TC, Hemmati P. Current trends in developing medical students' critical thinking abilities. Kaohsiung J Med Sci.. 2008; 24:(7)341-55 https://doi.org/10.1016/S1607-551X(08)70131-1

Hayes MM, Chatterjee S, Schwartzstein RM. Critical thinking in critical care: five strategies to improve teaching and learning in the intensive care unit. Ann Am Thorac Soc.. 2017; 14:(4)569-575 https://doi.org/10.1513/AnnalsATS.201612-1009AS

Health Education England. Multi-professional framework for advanced clinical practice in England. 2017. https://www.hee.nhs.uk/sites/default/files/documents/multi-professionalframeworkforadvancedclinicalpracticeinengland.pdf (accessed 27 April 2021)

Health Education England, NHS England/NHS Improvement, Skills for Health. Core capabilities framework for advanced clinical practice (nurses) working in general practice/primary care in England. 2020. https://www.skillsforhealth.org.uk/images/services/cstf/ACP%20Primary%20Care%20Nurse%20Fwk%202020.pdf (accessed 27 April 2021)

Health Education England. Advanced practice mental health curriculum and capabilities framework. 2020. https://www.hee.nhs.uk/sites/default/files/documents/AP-MH%20Curriculum%20and%20Capabilities%20Framework%201.2.pdf (accessed 27 April 2021)

Jacob E, Duffield C, Jacob D. A protocol for the development of a critical thinking assessment tool for nurses using a Delphi technique. J Adv Nurs.. 2017; 73:(8)1982-1988 https://doi.org/10.1111/jan.13306

Kohn MA. Understanding evidence-based diagnosis. Diagnosis (Berl).. 2014; 1:(1)39-42 https://doi.org/10.1515/dx-2013-0003

Clinical reasoning—a guide to improving teaching and practice. 2012. https://www.racgp.org.au/afp/201201/45593

McGee S. Evidence-based physical diagnosis, 4th edn. Philadelphia PA: Elsevier; 2018

Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking. Acad Med.. 2017; 92:(1)23-30 https://doi.org/10.1097/ACM.0000000000001421

Papp KK, Huang GC, Lauzon Clabo LM Milestones of critical thinking: a developmental model for medicine and nursing. Acad Med.. 2014; 89:(5)715-20 https://doi.org/10.1097/acm.0000000000000220

Rencic J, Lambert WT, Schuwirth L., Durning SJ. Clinical reasoning performance assessment: using situated cognition theory as a conceptual framework. Diagnosis.. 2020; 7:(3)177-179 https://doi.org/10.1515/dx-2019-0051

Examining critical thinking skills in family medicine residents. 2016. https://www.stfm.org/FamilyMedicine/Vol48Issue2/Ross121

Royal College of Emergency Medicine. Emergency care advanced clinical practitioner—curriculum and assessment, adult and paediatric. version 2.0. 2019. https://tinyurl.com/eps3p37r (accessed 27 April 2021)

Young ME, Thomas A, Lubarsky S. Mapping clinical reasoning literature across the health professions: a scoping review. BMC Med Educ.. 2020; 20 https://doi.org/10.1186/s12909-020-02012-9

Advanced practice: critical thinking and clinical reasoning

Sadie Diamond-Fox

Senior Lecturer in Advanced Critical Care Practice, Northumbria University, Advanced Critical Care Practitioner, Newcastle upon Tyne Hospitals NHS Foundation Trust, and Co-Lead, Advanced Critical/Clinical Care Practitioners Academic Network (ACCPAN)

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Advanced Critical Care Practitioner, South Tees Hospitals NHS Foundation Trust

Clinical reasoning is a multi-faceted and complex construct, the understanding of which has emerged from multiple fields outside of healthcare literature, primarily the psychological and behavioural sciences. The application of clinical reasoning is central to the advanced non-medical practitioner (ANMP) role, as complex patient caseloads with undifferentiated and undiagnosed diseases are now a regular feature in healthcare practice. This article explores some of the key concepts and terminology that have evolved over the last four decades and have led to our modern day understanding of this topic. It also considers how clinical reasoning is vital for improving evidence-based diagnosis and subsequent effective care planning. A comprehensive guide to applying diagnostic reasoning on a body systems basis will be explored later in this series.

The Multi-professional Framework for Advanced Clinical Practice highlights clinical reasoning as one of the core clinical capabilities for advanced clinical practice in England ( Health Education England (HEE), 2017 ). This is also identified in other specialist core capability frameworks and training syllabuses for advanced clinical practitioner (ACP) roles ( Faculty of Intensive Care Medicine, 2018 ; Royal College of Emergency Medicine, 2019 ; HEE, 2020 ; HEE et al, 2020 ).

Rencic et al (2020) defined clinical reasoning as ‘a complex ability, requiring both declarative and procedural knowledge, such as physical examination and communication skills’. A plethora of literature exists surrounding this topic, with a recent systematic review identifying 625 papers, spanning 47 years, across the health professions ( Young et al, 2020 ). A diverse range of terms are used to refer to clinical reasoning within the healthcare literature ( Table 1 ), which can make defining their influence on their use within the clinical practice and educational arenas somewhat challenging.

The concept of clinical reasoning has changed dramatically over the past four decades. What was once thought to be a process-dependent task is now considered to present a more dynamic state of practice, which is affected by ‘complex, non-linear interactions between the clinician, patient, and the environment’ ( Rencic et al, 2020 ).

Cognitive and meta-cognitive processes

As detailed in the table, multiple themes surrounding the cognitive and meta-cognitive processes that underpin clinical reasoning have been identified. Central to these processes is the practice of critical thinking. Much like the definition of clinical reasoning, there is also diversity with regard to definitions and conceptualisation of critical thinking in the healthcare setting. Facione (2020) described critical thinking as ‘purposeful reflective judgement’ that consists of six discrete cognitive skills: analysis, inference, interpretation, explanation, synthesis and self–regulation. Ross et al (2016) identified that critical thinking positively correlates with academic success, professionalism, clinical decision-making, wider reasoning and problem-solving capabilities. Jacob et al (2017) also identified that patient outcomes and safety are directly linked to critical thinking skills.

Harasym et al (2008) listed nine discrete cognitive steps that may be applied to the process of critical thinking, which integrates both cognitive and meta-cognitive processes:

• Gather relevant information
• Formulate clearly defined questions and problems
• Evaluate relevant information
• Utilise and interpret abstract ideas effectively
• Infer well-reasoned conclusions and solutions
• Pilot outcomes against relevant criteria and standards
• Use alternative thought processes if needed
• Consider all assumptions, implications, and practical consequences
• Communicate effectively with others to solve complex problems.

There are a number of widely used strategies to develop critical thinking and evidence-based diagnosis. These include simulated problem-based learning platforms, high-fidelity simulation scenarios, case-based discussion forums, reflective journals as part of continuing professional development (CPD) portfolios and journal clubs.

Dual process theory and cognitive bias in diagnostic reasoning

A lack of understanding of the interrelationship between critical thinking and clinical reasoning can result in cognitive bias, which can in turn lead to diagnostic errors ( Hayes et al, 2017 ). Embedded within our understanding of how diagnostic errors occur is dual process theory—system 1 and system 2 thinking. The characteristics of these are described in Table 2 . Although much of the literature in this area regards dual process theory as a valid representation of clinical reasoning, the exact causes of diagnostic errors remain unclear and require further research ( Norman et al, 2017 ). The most effective way in which to teach critical thinking skills in healthcare education also remains unclear; however, Hayes et al (2017) proposed five strategies, based on well-known educational theory and principles, that they have found to be effective for teaching and learning critical thinking within the ‘high-octane’ and ‘high-stakes’ environment of the intensive care unit ( Table 3 ). This is arguably a setting that does not always present an ideal environment for learning given its fast pace and constant sensory stimulation. However, it may be argued that if a model has proven to be effective in this setting, it could be extrapolated to other busy clinical environments and may even provide a useful aide memoire for self-assessment and reflective practices.

Integrating the clinical reasoning process into the clinical consultation

Linn et al (2012) described the clinical consultation as ‘the practical embodiment of the clinical reasoning process by which data are gathered, considered, challenged and integrated to form a diagnosis that can lead to appropriate management’. The application of the previously mentioned psychological and behavioural science theories is intertwined throughout the clinical consultation via the following discrete processes:

• The clinical history generates an initial hypothesis regarding diagnosis, and said hypothesis is then tested through skilled and specific questioning
• The clinician formulates a primary diagnosis and differential diagnoses in order of likelihood
• Physical examination is carried out, aimed at gathering further data necessary to confirm or refute the hypotheses
• A selection of appropriate investigations, using an evidence-based approach, may be ordered to gather additional data
• The clinician (in partnership with the patient) then implements a targeted and rationalised management plan, based on best-available clinical evidence.

Linn et al (2012) also provided a very useful framework of how the above methods can be applied when teaching consultation with a focus on clinical reasoning (see Table 4 ). This framework may also prove useful to those new to the process of undertaking the clinical consultation process.

Evidence-based diagnosis and diagnostic accuracy

The principles of clinical reasoning are embedded within the practices of formulating an evidence-based diagnosis (EBD). According to Kohn (2014) EBD quantifies the probability of the presence of a disease through the use of diagnostic tests. He described three pertinent questions to consider in this respect:

• ‘How likely is the patient to have a particular disease?’
• ‘How good is this test for the disease in question?’
• ‘Is the test worth performing to guide treatment?’

EBD gives a statistical discriminatory weighting to update the probability of a disease to either support or refute the working and differential diagnoses, which can then determine the appropriate course of further diagnostic testing and treatments.

Diagnostic accuracy refers to how positive or negative findings change the probability of the presence of disease. In order to understand diagnostic accuracy, we must begin to understand the underlying principles and related statistical calculations concerning sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and likelihood ratios.

The construction of a two-by-two square (2 x 2) table ( Figure 1 ) allows the calculation of several statistical weightings for pertinent points of the history-taking exercise, a finding/sign on physical examination, or a test result. From this construct we can then determine the aforementioned statistical calculations as follows ( McGee, 2018 ):

• Sensitivity , the proportion of patients with the diagnosis who have the physical sign or a positive test result = A ÷ (A + C)
• Specificity , the proportion of patients without the diagnosis who lack the physical sign or have a negative test result = D ÷ (B + D)
• Positive predictive value , the proportion of patients with disease who have a physical sign divided by the proportion of patients without disease who also have the same sign = A ÷ (A + B)
• Negative predictive value , proportion of patients with disease lacking a physical sign divided by the proportion of patients without disease also lacking the sign = D ÷ (C + D)
• Likelihood ratio , a finding/sign/test results sensitivity divided by the false-positive rate. A test of no value has an LR of 1. Therefore the test would have no impact upon the patient's odds of disease
• Positive likelihood ratio = proportion of patients with disease who have a positive finding/sign/test, divided by proportion of patients without disease who have a positive finding/sign/test OR (A ÷ N1) ÷ (B÷ N2), or sensitivity ÷ (1 – specificity) The more positive an LR (the further above 1), the more the finding/sign/test result raises a patient's probability of disease. Thresholds of ≥ 4 are often considered to be significant when focusing a clinician's interest on the most pertinent positive findings, clinical signs or tests
• Negative likelihood ratio = proportion of patients with disease who have a negative finding/sign/test result, divided by the proportion of patients without disease who have a positive finding/sign/test OR (C ÷ N1) ÷ (D÷N1) or (1 – sensitivity) ÷ specificity The more negative an LR (the closer to 0), the more the finding/sign/test result lowers a patient's probability of disease. Thresholds <0.4 are often considered to be significant when focusing clinician's interest on the most pertinent negative findings, clinical signs or tests.

There are various online statistical calculators that can aid in the above calculations, such as the BMJ Best Practice statistical calculators, which may used as a guide (https://bestpractice.bmj.com/info/toolkit/ebm-toolbox/statistics-calculators/).

Clinical scoring systems

Evidence-based literature supports the practice of determining clinical pretest probability of certain diseases prior to proceeding with a diagnostic test. There are numerous validated pretest clinical scoring systems and clinical prediction tools that can be used in this context and accessed via various online platforms such as MDCalc (https://www.mdcalc.com/#all). Such clinical prediction tools include:

• 4Ts score for heparin-induced thrombocytopenia
• ABCD² score for transient ischaemic attack (TIA)
• CHADS₂ score for atrial fibrillation stroke risk
• Aortic Dissection Detection Risk Score (ADD-RS).

Conclusions

Critical thinking and clinical reasoning are fundamental skills of the advanced non-medical practitioner (ANMP) role. They are complex processes and require an array of underpinning knowledge of not only the clinical sciences, but also psychological and behavioural science theories. There are multiple constructs to guide these processes, not all of which will be suitable for the vast array of specialist areas in which ANMPs practice. There are multiple opportunities throughout the clinical consultation process in which ANMPs can employ the principles of critical thinking and clinical reasoning in order to improve patient outcomes. There are also multiple online toolkits that may be used to guide the ANMP in this complex process.

• Much like consultation and clinical assessment, the process of the application of clinical reasoning was once seen as solely the duty of a doctor, however the advanced non-medical practitioner (ANMP) role crosses those traditional boundaries
• Critical thinking and clinical reasoning are fundamental skills of the ANMP role
• The processes underlying clinical reasoning are complex and require an array of underpinning knowledge of not only the clinical sciences, but also psychological and behavioural science theories
• Through the use of the principles underlying critical thinking and clinical reasoning, there is potential to make a significant contribution to diagnostic accuracy, treatment options and overall patient outcomes

CPD reflective questions

• What assessment instruments exist for the measurement of cognitive bias?
• Think of an example of when cognitive bias may have impacted on your own clinical reasoning and decision making
• What resources exist to aid you in developing into the ‘advanced critical thinker’?
• What resources exist to aid you in understanding the statistical terminology surrounding evidence-based diagnosis?

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Advanced practice: critical thinking and clinical reasoning

Affiliations.

• 1 Advanced Critical Care Practitioner, Newcastle upon Tyne NHS Foundation Trust / Senior Lecturer in Advanced Critical Care Practice, Department of Nursing, Midwifery and Health, Northumbria University.
• 2 Advanced Critical Care Practitioner, South Tees Hospitals NHS Foundation Trust.
• PMID: 33983801
• DOI: 10.12968/bjon.2021.30.9.526

Clinical reasoning is a multi-faceted and complex construct, the understanding of which has emerged from multiple fields outside of healthcare literature, primarily the psychological and behavioural sciences. The application of clinical reasoning is central to the advanced non-medical practitioner (ANMP) role, as complex patient caseloads with undifferentiated and undiagnosed diseases are now a regular feature in healthcare practice. This article explores some of the key concepts and terminology that have evolved over the last four decades and have led to our modern day understanding of this topic. It also considers how clinical reasoning is vital for improving evidence-based diagnosis and subsequent effective care planning. A comprehensive guide to applying diagnostic reasoning on a body systems basis will be explored later in this series.

Keywords: Advanced practice; Clinical reasoning; Consultation; Critical thinking; Diagnostic accuracy.

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Critical thinking

Advice and resources to help you develop your critical voice.

Developing critical thinking skills is essential to your success at University and beyond.  We all need to be critical thinkers to help us navigate our way through an information-rich world. 

Whatever your discipline, you will engage with a wide variety of sources of information and evidence.  You will develop the skills to make judgements about this evidence to form your own views and to present your views clearly.

One of the most common types of feedback received by students is that their work is ‘too descriptive’.  This usually means that they have just stated what others have said and have not reflected critically on the material.  They have not evaluated the evidence and constructed an argument.

What is critical thinking?

Critical thinking is the art of making clear, reasoned judgements based on interpreting, understanding, applying and synthesising evidence gathered from observation, reading and experimentation. Burns, T., & Sinfield, S. (2016)  Essential Study Skills: The Complete Guide to Success at University (4th ed.) London: SAGE, p94.

Being critical does not just mean finding fault.  It means assessing evidence from a variety of sources and making reasoned conclusions.  As a result of your analysis you may decide that a particular piece of evidence is not robust, or that you disagree with the conclusion, but you should be able to state why you have come to this view and incorporate this into a bigger picture of the literature.

Being critical goes beyond describing what you have heard in lectures or what you have read.  It involves synthesising, analysing and evaluating what you have learned to develop your own argument or position.

Critical thinking is important in all subjects and disciplines – in science and engineering, as well as the arts and humanities.  The types of evidence used to develop arguments may be very different but the processes and techniques are similar.  Critical thinking is required for both undergraduate and postgraduate levels of study.

What, where, when, who, why, how?

Purposeful reading can help with critical thinking because it encourages you to read actively rather than passively.  When you read, ask yourself questions about what you are reading and make notes to record your views.  Ask questions like:

• What is the main point of this paper/ article/ paragraph/ report/ blog?
• Who wrote it?
• Why was it written?
• When was it written?
• Has the context changed since it was written?
• Is the evidence presented robust?
• How did the authors come to their conclusions?
• Do you agree with the conclusions?
• What does this add to our knowledge?
• Why is it useful?

Our web page covering Reading at university includes a handout to help you develop your own critical reading form and a suggested reading notes record sheet.  These resources will help you record your thoughts after you read, which will help you to construct your argument. 

Reading at university

Developing an argument

Being a university student is about learning how to think, not what to think.  Critical thinking shapes your own values and attitudes through a process of deliberating, debating and persuasion.   Through developing your critical thinking you can move on from simply disagreeing to constructively assessing alternatives by building on doubts.

There are several key stages involved in developing your ideas and constructing an argument.  You might like to use a form to help you think about the features of critical thinking and to break down the stages of developing your argument.

Features of critical thinking (pdf)

Features of critical thinking (Word rtf)

Our webpage on Academic writing includes a useful handout ‘Building an argument as you go’.

Academic writing

You should also consider the language you will use to introduce a range of viewpoints and to evaluate the various sources of evidence.  This will help your reader to follow your argument.  To get you started, the University of Manchester's Academic Phrasebank has a useful section on Being Critical. 

Academic Phrasebank

Developing your critical thinking

Set yourself some tasks to help develop your critical thinking skills.  Discuss material presented in lectures or from resource lists with your peers.  Set up a critical reading group or use an online discussion forum.  Think about a point you would like to make during discussions in tutorials and be prepared to back up your argument with evidence.

For more suggestions:

Developing your critical thinking - ideas (pdf)

Developing your critical thinking - ideas (Word rtf)

Published guides

For further advice and more detailed resources please see the Critical Thinking section of our list of published Study skills guides.

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This is what we expect line managers to do. But, what influences the decisions we make, and what practices help us do this well?

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

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

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

Patricia Benner ; Ronda G. Hughes ; Molly Sutphen .

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

• Critical Thinking

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Critical Reflection, Critical Reasoning, and Judgment

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

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

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

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

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

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

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

Techne and Phronesis

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

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

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

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

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

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

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

Thinking Critically

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Intuition and Perception

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

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

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

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

• Applying Practice Evidence

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

Evaluating Evidence

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

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

Sources of Evidence

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

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

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

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

Evidence-Based Practice

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

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

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

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

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

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

When Evidence Is Missing

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

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

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

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

The Three Apprenticeships of Professional Education

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

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

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

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

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

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

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

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

Clinical Grasp *

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

Making Qualitative Distinctions

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

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

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

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

Recognizing Changing Clinical Relevance

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

Developing Clinical Knowledge in Specific Patient Populations

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

Clinical Forethought

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

Future think

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

Clinical forethought about specific diagnoses and injuries

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

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

Anticipation of crises, risks, and vulnerabilities for particular patients

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

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

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

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

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

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

Seeing the unexpected

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

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

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

• Cite this Page Benner P, Hughes RG, Sutphen M. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 6.
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Abrami PC, Bernard RM, Borokhovski E, Waddington DI, Anne Wade C, Persson T. Strategies for teaching students to think critically: a meta-analysis. Rev Educ Res. 2015; 85:(2)275-314

Carter AG, Creedy DK, Sidebotham M. Critical thinking in midwifery practice: a conceptual model. Nurse Educ Pract. 2018; 33:114-120

Chatfield T. Critical thinking: your guide to effective argument, successful analysis and independent study.London: Sage Publications; 2017

Elstein A, Bordage G. Psychology of clinical reasoning. In: Dowie J, Elstein A (eds). Cambridge: Cambridge University Press; 1988

Critical thinking and clinical judgment. 2008. https://bit.ly/3I5WRsn (accessed 20 February 2022)

Fontein-Kuipers Y, Romejin E, Zwijnenberg A ‘I SeeYou’: A woman-centred care education and research project in Dutch bachelor midwifery education. Health Educ J. 2018; 77:(8)899-914

Jefford E, Fahy K, Sundin D. Decision-making theories and their usefulness to the midwifery profession both in terms of midwifery practice and the education of midwives. Int J Nurs Pract. 2011; 17:246-253

Learn Higher. Critical thinking and reflection - resources for staff. 2021. https://bit.ly/33B1ifI (accessed 18 February 2022)

Mok H, Stevens P. Models of decision-making. In: Raynor M, Marshall J, Sullivan A (eds). Edinburgh: Churchill Livingstone Elsevier; 2005

Newell A, Simon HA. Human problem-solving.New Jersey: Prentice-Hall; 1972

NHS England. A-EQUIP a model of clinical midwifery supervision. 2017. https://bit.ly/3vr2nT5 (accessed 20 February 2022)

Nursing and Midwifery Council. The code. 2018. https://bit.ly/3h0jLFt (accessed 20 February 2022)

Nursing and Midwifery Council. Standards of proficiency for midwives. 2019. https://bit.ly/35fNjfW (accessed 20 February 2022)

Renfrew MJ, McFadden A, Bastos MH Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet. 2014; 384:(9948)1129-1145

Schon DA. The reflective practitioner.Farnham, England: Ashgate Publishing; 1991

Thoresen A, Norbye B. Reflective writing followed by dialogue improves supervision practices and cooperation in midwifery education. Educ Action Res. 2021; 29:149-164

Critical thinking

Senior lecturer (midwifery), University of West London

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Debra Sloam

Lecturer, University of West London

Kate Nash and Debra Sloam explore the benefits of critical thinking and the A-EQUIP model for student midwives

Midwifery practice involves making clinical judgements that influence midwives' decision-making and the subsequent safe care of women and babies. Clinical judgements are shaped by midwives' knowledge and experiences, and form part of decision-making. Understanding how practitioners formulate decisions is an important aspect of both pre- and post-registration midwifery training, as midwives must be accountable and justify care decisions while working in partnership with women and their families ( Nursing and Midwifery Council (NMC), 2018 ).

Clinical reasoning describes the cognitive processes underpinning decision-making and forms part of the broader philosophical domain of hypothetico-deductive theory ( Newell and Simon, 1972 ; Jefford et al, 2011 ). This describes how the brain receives, stores and processes information from the environment ( Elstein and Bordage, 1988 ; Mok and Stevens, 2005 ). Such models are rooted in rational and logical analysis of a situation where knowledge and judgement are made explicit.

Critical thinking is an essential requirement for effectual clinical reasoning and decision making, and a fundamental component of safe and effective midwifery practice ( NMC, 2019 ). However, the concept of critical thinking is not always well understood. Students require strategies to understand and develop critical thinking skills to enhance decision-making within practice. The integration of the A-EQUIP model and restorative clinical supervision within pre-registration midwifery programmes is a means of supporting students to develop critical thinking skills.

What is critical thinking?

Critical thinking is the ability to engage in purposeful self-regulatory thinking and provides the impetus for knowledge development and clinical judgment ( Facione and Facione, 2008 ; Abrami et al, 2015 ). Developing critical thinking skills can assist students with learning to be autonomous reflective practitioners as they embark upon a pathway of lifelong learning. Critical thinking can encourage insight and understanding and enhance engagement with professional behaviours necessary within practice. Through the development of critical thinking, students learn how to process, assess and assimilate information, developing clinical reasoning while reflecting upon thinking processes.

Carter et al (2018) have significantly contributed to the knowledge base for critical thinking in midwifery practice, including a literature review and the development of a conceptual model of critical thinking in midwifery practice. The model demonstrates a new understanding of critical thinking in midwifery practice that is embedded within a woman-centred philosophy of care that aligns well with the standards of midwifery ( NMC, 2019 ) and framework for quality maternal and newborn care ( Renfrew et al, 2014 ).

Thinking about what constitutes critical thinking can be helpful when exploring critical thinking ( Box 1 ). Not thinking critically means automatically accepting what one is told or has read without asking whether it is accurate, true or reasonable ( Chatfield, 2017 ). Asking meaningful questions is central to critical thinking.

Box 1.Overview of critical thinkingWhat it is:

• Enables analysis of all possibilities and reviews strengths and weaknesses
• Facilitates collection of appropriate information to inform analysis and consider possible solutions/alternatives
• Interprets information from a variety of sources and considers all viewpoints
• Is insightful and reflective, open to learning and improvement

What it is not:

• Being critical
• Making irrational judgements
• ‘Knee jerking’ when things go wrong or being so focused on a solution that you fail to see the bigger picture
• Refusing to accept criticism or that you may have made the wrong judgement

The ability to question and learn with an open mind involves considering various perspectives and the ability to explore beneath the surface of what is presented to identify the facts of a situation. Asking questions ( Box 2 ) helps to break an issue or dilemma into parts to consider the relationship between each part and each part to the whole. This process helps develop more analytical answers and deeper thinking.

Box 2.Critical thinking questionsDescribe: what happened, when, where and why?

• What is this problem about?
• Who does it involve and affect?
• When and where is this happening?

Analysis: how, why and what if?

• What are the contributing factors?
• How might one factor impact another?
• What if one factor is removed or altered?
• Are there alternative options or factors to consider?

Evaluating: so what and what next?

• What does this mean?
• What actions do I need to take?
• How will I know that this is right?

Adapted from Learn Higher, 2021

Integral to critical thinking is the ability to analyse, evaluate and make judgements based on the outcomes of the evaluations. Reflection is important and closely intertwined with critical thinking, especially when used within a coaching framework ( Fontien-Kuipers et al, 2018 ; Thoresen and Norbye, 2021 ). Reflective practice has been widely discussed within healthcare literature and encompasses the ability to reflect upon one's actions to engage in a process of continuous learning ( Schon, 1991 ). Reflecting on practice supports the ability to self-regulate thoughts and behaviours as one considers their own judgements and beliefs while assessing them against the backdrop of new knowledge and skills development.

Within practice, critical thinking can improve the ability to recognise and adapt to changing situations, enhancing situational awareness and emotional intelligence when considering how a judgement might influence and be influenced by the presenting clinical picture. Rather than becoming fixated upon immediate assumptions, critical thinking encourages clinicians to actively seek to understand what is happening, evaluate the evidence and think carefully about the process of thinking itself ( Chatfield, 2017 ).

The skills required for critical thinking are implicitly integrated into midwifery pre-registration programmes where students are required to use specific information with sufficient understanding and knowledge to explain the conceptual, contextual or methodological principles within practical situations ( Abrami et al, 2015 ). Introducing students to skills of research appraisal develops critical thinking, confidence and self-efficacy. With motivation and effort, students can be encouraged to understand the multiple perspectives that may shape how information is presented and be able to negotiate information to draw conclusions, justify and articulate reasoning and advocate for women to promote informed choices.

The deployment of the A-EQUIP model ( NHS England, 2017 ) and implementation of opportunities for restorative clinical supervision within pre-registration midwifery programmes can help students explicitly develop their critical thinking skills. As part of restorative clinical supervision, students can be supported to reflect upon practice experiences and examine their reactions and responses with a view to reviewing their knowledge, behaviour and learning.

Restorative clinical supervision provides opportunities for students to consider their motivation, check for possible bias or prejudice that may influence their clinical judgement and offers opportunities for self-development or improvement. Transparency is promoted, as students can be supported to reflect on errors or omissions that occurred and consider steps to address these. Restorative clinical supervision can be used to develop critical thinking and support effective clinical practice ( Box 3 ).

Box 3.Restorative clinical supervision and critical thinkingDevelops analysis skills:Through sensitive prompting, facilitator can encourage students to identify actual/inferred meaning and impact of beliefs, judgements and opinions on a woman's experience or multi-professional working, eg verbal and non-verbal communicationAbility to classify information and make sense of its significance:By describing the incident, students can be supported to classify and clarify information, assisting with clear presentation of information in practice, eg use of situation, background, assessment, recommendationDevelops interpretational skills:Students can be supported to understand components of professional practice and meaningfully link them, eg physiological and clinical context for cardiotocography assessmentSupports practical application of midwifery skills:Midwifery skills include recognising and responding to physiological changes and providing information through effective communication to facilitate informed choiceSupports development of ideas:Supports development of blue sky thinking and ideas/innovation for improvement

Critical thinking skills are enhanced by the regular provision of constructive feedback and opportunities for supportive self-reflection, which can encourage self-regulation and reframing issues or difficulties experienced through critical thinking. The A-EQUIP model provides an excellent framework for supporting developing critical thinking as students are introduced to the benefits of critically thinking through restorative clinical supervision.

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How soft skills propel career readiness

Teaching critical thinking, effective communication skills and intercultural understanding will produce a better workforce in texas..

By Iris Lazarus

1:30 AM on Mar 20, 2024 CDT

Schools in Texas face an uphill battle with statewide budgets and school choice debates. But when it comes to giving students a bright future, the state is at the top of its game. From record-breaking job creation to year-over-year economic growth, Texas is a state where students see prosperity and possibility.

Helping young learners access that future, however, means ensuring that we, as educators, equip them with future-ready skills needed to flourish.

This is the one thing we as parents, educators and lawmakers can all agree on. The challenges of 21st-century life place complex demands on graduates as they take their next steps into higher education or a career. Students need to begin early to develop the leadership qualities and work ethic needed to be career-ready. If young learners are to flourish in Texas after grade 12, school communities and educators must give them every provision available to succeed.

A report by the Organization for Economic Cooperation and Development identified indicators of career readiness, noting that students thrive when discussing career objectives as part of classroom pedagogy. While academic pursuits must involve rigorous assessments, they must also be balanced by a more holistic approach to learning.

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We saw in 2020 how traditional education systems were not prepared for the unknown future. The pandemic was just one curveball among many experienced by students and educators alike.

Preparing students for the future means doing more than memorizing facts and figures, or learning how to take a particular examination. Nurturing future-ready students means considering soft skills like critical thinking, effective communication and intercultural understanding that they will need to confront the many challenges the world will serve them.

As companies increasingly rely on skills-based hiring practices, traditional academic credentials alone no longer guarantee students’ success in their chosen career path.

Being “career-ready” means more than just learning a skill or understanding an industry.

Taking a holistic approach to K-12 education is the first step to nurturing tomorrow’s leaders. Textbooks and assessments are just one component. Learning to collaborate with others, to ask questions through inquiry-based learning and prioritize wellness all contribute to career-readiness. And these soft skills are exactly what employers are looking for in job candidates.

The LinkedIn 2024 Most In-Demand Skills report cited communication as the most important skill among employers. Other soft skills like leadership, problem-solving and teamwork topped the list, substantiating calls for more focus on future-ready education. These qualities exemplify what a holistic approach to education provides to young learners, preparing them for whatever their next step may be.

We’re living in a globalized world, even in Texas. By imbuing learners’ curriculums with an international angle, we create compassionate leaders who will guide the growing and diversifying industries that make Texas such a prosperous state.

Part of being career-ready means being prepared to communicate with and understand — both linguistically and culturally — those around us. As Texas grows and attracts even more residents from around the world, having cross-cultural communication skills will be advantageous to job seekers and aspiring leaders.

Through educational coursework such as the Career-related Programme at the International Baccalaureate, educational leaders are able to provide the kind of career readiness that young learners need to thrive in Texas.

Career-readiness needs to be at the top of our priority list for students. While every student may not pursue higher education, almost every student will need to work eventually. Taking a career-ready approach ensures that educational systems set all students up for success, regardless of their goals.

If Texas aims to continue topping the charts of economic achievement and prosperity, it needs homegrown leaders who are ready and willing to take the reins. Leaders might consider what is most needed to prepare future-ready students to move forward and build momentum for Texas’ economic excellence.

Increased access to career-preparedness programs will pave the way for the future leaders of Texas.

Iris Lazarus is the Senior IB World Schools manager at the International Baccalaureate Organization.

We welcome your thoughts in a letter to the editor. See the guidelines and submit your letter here . If you have problems with the form, you can submit via email at [email protected]

Iris Lazarus

Dallas police chief says he’s working out how to enforce SB 4 amid community concerns

Opal lee’s homecoming: grandmother of juneteenth reclaims her family home, douglas restaurant to close in university park, after parking woes in snider plaza, dallas’ shingle mountain rezoning vote delayed again, storms pass through dallas-fort worth; flood warnings linger in rockwall, hunt counties.

@grassyass__/TikTok Steve Cukrov/ShutterStock (Licensed)

‘You’re wasting so much money’: Woman says you should stop buying White Claws and High Noons, shares alternative

'let's use our critical thinking skills.'.

Stacy Fernandez

Posted on Mar 21, 2024   Updated on Mar 21, 2024, 11:45 am CDT

Watch out, hard seltzer brands; this woman is coming for you.

Hard seltzers, like White Claws, Truly, and High Noons, have grown in popularity over the last decade. It started in 2016 when White Claw first entered the market with the Natural Lime, Black Cherry, Ruby Grapefruit, Raspberry, and Mango flavors, per Thrillist . While Truly followed right behind them, White Claw remains the more popular brand.

It was the perfect time to launch. At the time, regular seltzer water was becoming popular (remember when everyone wanted a SodaStream in their home?), and this was its boozy counterpart.

They also piqued the interest of health-conscious and sober curious people because of the combination of lower calories and sugar, plus the lower alcohol content compared to beers and cocktails.

Plus, many people love how portable and convenient hard seltzers are. You can easily take the can with you to the pool, a beach day, a picnic, or even a boozy hike.

But people don’t always love how pricey they can be. A six-pack can easily run $10 to $15, depending on where you buy it, and one 24-oz can cost $3.50 to $4.50.

Instead of buying cans, TikTok user Grace (@grassyass__) has a cost-saving solution.

“This is your sign to stop buying High Noons and White Claws. Take it from me. You’re wasting so much money,” Grace says.

“What, you spend $12 on a 4-pack of High Noons to drink them within literally an hour? No. We have High Noons at home,” she adds.

In the viral video that has nearly 750,000 views, Grace explains how she recreates the drink at home. She pulls out a liter of Tito’s Vodka, pours a shot into a glass, and tops it off with a flavored seltzer water.

“This is so cost-effective,” Grace points out.

She adds that the liter of vodka only cost her $30, so she’d be able to make her own drinks at a fraction of the cost.

“Let’s use our critical thinking skills,” Grace says.

Commenters quickly burst her bubble, pointing out that what she made is just a classic vodka soda, which people have been making at home and ordering at bars for decades.

“How did you ever think to put vodka and soda together? What’s next? Gin and tonic? Maybe rum with coke,” a top comment read.

“HAHAHAHAH PLZ I REALIZED HOW STUPID THIS WAS LIKE 2 MIN AFTER POSTING,” Grace replied.

@grassyass__ i can’t believe i discovered the vodka soda 😍 #fyp #fypシ #hack #highnoon #whiteclaw #xyzabc #yw ♬ original sound – grass

Others shared their tips to make the drink even better.

“Mio water enhancer and Tito’s,” a person recommended.

“You need a more robust juice. Needs a splash of grapefruit not just seltzer,” another added.

The Daily Dot reached out to Grace for comment via direct message from Instagram.

The internet is chaotic—but we’ll break it down for you in one daily email. Sign up for the Daily Dot’s web_crawlr newsletter  here  to get the best (and worst) of the internet straight into your inbox.

Stacy Fernández is a freelance writer, project manager and communications specialist. She’s worked at The Texas Tribune, The Dallas Morning News and run social for The Education Trust New York. Her favorite hobby is finding hidden gems at the thrift store, she loves a good audio book and is a chocolate enthusiast.

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3 advisories in effect for 29 regions in the area

Northside isd students participate in outdoor challenge testing teamwork, critical thinking skills, event taking place at eisenhower park march 19-20, april 2-4.

Tiffany Huertas , Reporter

Azian Bermea , Photojournalist

SAN ANTONIO – This week over 2,600 Northside ISD students in the gifted and talented program are competing in an outdoor challenge that will test them in many ways.

Third, fourth and fifth grade students from across the district must work together in the “Challenge Survivor GT”.

The event is taking place at Eisenhower Park March 19-21 and again April 2-4.

“We really just wanted to create an equitable experience for our students,” said Katie Hitchman, GT instructional support teacher at Northside ISD.

Students go through 17 different stations, testing their teamwork and critical thinking skills.

“Some of the different activities they will participate in today include puzzles. There is a human system where they actually have to use their bodies to create a pathway,” Hitchman said.

Just like the television show “Survivor”, students will also collect items along the way to build a shelter at the end.

Survivor GT aims to encourage students to explore, discover and deepen their connection to the complexities within the environment.

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About the Authors:

Tiffany huertas.

Tiffany Huertas is a reporter for KSAT 12 known for her in-depth storytelling and her involvement with the community.

Azian Bermea

Azian Bermea is a photojournalist at KSAT.

Good Morning San Antonio 5 a.m. : Mar 22, 2024

Ksat 12 nightbeat : mar 21, 2024, records: wren collective behind controversial portland protest policy, time to scrap caps on san antonio city manager pay & tenure, full episode: know my neighborhood: northern hills/valencia, getting involved.