critical thinking in health assessment

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Improving Physical Assessment and Clinical Judgment Skills without Increasing Content in a Prelicensure Nursing Health Assessment Course

One hundred twenty-six assessment skills are taught in prelicensure nursing health assessment courses, yet 30 skills are used on a routine basis in practice. New nurses struggle to apply their acquired knowledge in clinical settings. Method: A literature review was completed. Based on the results, a first semester health assessment course in a southeastern accelerated baccalaureate nursing program was redesigned. Lectures and skills labs were adjusted to focus on the most critical assessment skills. To foster critical thinking and clinical judgement, a health assessment post conference was added where students completed concept maps, system specific case studies, nursing priority setting, and patient teaching plans. Results: Outcome surveys were completed by second semester faculty. Prior to course adjustments, 33 percent of students did not meet the benchmark. Following course changes, all students met or exceeded the benchmark. Conclusion: Focusing on critical assessment skills will increase student nurses’ ability to deliver safe patient care.

1. Introduction

Patients depend on a nurse’s ability to recognize and respond quickly to changes in their condition. Clinical judgement involves the process of clinical thinking, clinical reasoning leading to a clinical judgement. This process requires a nurse to recognize patient cues, and critically analyze the data. This is followed by making appropriate decisions to optimize patient outcomes [ 1 , 2 , 3 , 4 ]. Yet, studies document that new nurses struggle to apply their recently acquired knowledge in the rapid-paced, ever-changing clinical setting [ 5 ]. In one survey, 77 percent of new nurse graduates failed to demonstrate clinical competency [ 1 ]. In another study, 65 to 76 percent of inexperienced RNs were unable to meet entry level clinical judgment skills, and the majority had difficulty translating knowledge and theory into practice [ 6 ]. This should not be surprising as new graduate nurses are likely to have theoretical competence but lack practical proficiency. In addition, new nurses often use concrete thinking and depend on technology to evaluate a patient’s condition, thus missing the clues which highlight a bigger picture [ 5 ]. The implementing of clinical judgement is made more difficult due to the ever-increasing amount of information nurses must absorb. It has been estimated that nursing knowledge doubles every six years [ 1 ]. The purpose of this paper is to present how a Bachelor of Science Nursing Health assessment course was redesigned to improve health assessment skills competencies without increasing course content.

In a National Council of State Boards of Nursing survey, employers reported concern regarding new graduate nurses’ readiness to enter practice. Fewer than 50 percent of employers reported “yes definitely” when asked if new graduates were ready to provide safe and effective care [ 7 ]. Other studies supported this assessment, indicating that only 23 percent of novice nurses were well prepared for clinical practice [ 8 ]. Supporting the concern for nursing preparedness, the World Health Organization stated that medication errors were the 14th leading cause of death globally and the 3rd leading cause of death in the United States [ 7 ]. Lack of readiness can significantly contribute to preventable errors [ 9 ].

The foundation for developing nursing interventions starts with clinical competency. However, it has been argued that the comprehensive physical exam has become a “sacred cow” in nursing education [ 8 ]. Some have asked, are we trying to teach too much. To answer this question, Giddens and Eddy (2009) [ 10 ] conducted a survey which found that more than 50 percent of nursing schools taught 122 specific physical assessment skills. Other researchers who surveyed baccalaureate nursing programs found that over 126 physical assessment skills were being taught [ 6 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ].

In 2007, Giddens [ 16 ] published a landmark study to determine the physical assessment skills routinely used by the bedside nurse. It was found that of the 126 physical exam techniques taught, only 30 were used either daily or weekly in the nurses’ clinical practice. Additional studies replicating Giddens’ work, comparing the number of critical nursing assessment skills being taught to what practicing nurses routinely preform, found that out of 126 assessment skills taught, only about 30 were used on a daily or weekly basis [ 6 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. Giddens (2007) [ 16 ] concluded that nurse educators should reconsider which assessment skills are needed for entry into practice.

In 2017, Kohtz, et al. [ 12 ] published a study which replicated Giddens’ original 2007 study by surveying fourth semester students. The results determined the frequency of physical exam skills used in the students’ clinical care. Of the 126 physical assessment skills surveyed, only 21 skills were used each time the student was in clinical practice. An additional nine physical exam skills were performed two to five times per week. In another study evaluating final semester nursing students, researchers found that of 126 skills taught, 53 skills were never performed during the students’ clinical practice [ 10 ]. Perceived barriers to utilizing more advanced assessment skills included a lack of confidence, doubt on the impact on patient care, and lack of nursing role models [ 10 ]. Anderson, et al. (2014) [ 11 ] surveyed 900 nurses using Gidden’s 126 skills and asked the nurses to report the frequency of use. Based on survey, only 37 competencies were felt to be essential components of the physical assessment [ 11 ].

As new prelicensure nursing health assessment faculty and experienced nurse practitioners, course faculty wondered why we were teaching advanced practice physical assessment skills to first semester nursing students. These skills are rarely, if ever, used in general practice by a registered nurse. Examples of rarely used physical assessment skills included: diaphragmatic excursion, liver span, chest percussion and assessment of cardiac borders. In addition, course faculty were hearing from second semester medical/surgical clinical faculty that students lacked confident in the basic patient physical assessment skills. Clinical faculty noted that students were struggling to apply physical exam findings in a meaningful way.

Poje (2020) [ 20 ] wrote of a similar experience when discussing a patient’s exam findings with a student. The student had been taught many exam techniques but had difficulty determining the importance of each finding. Just teaching assessment skills alone does not teach a nurse how to analyze the exam findings. This lack of clinical judgement application can increase the risk of missing the signs of patient deterioration [ 19 ]. To graduate students who can apply clinical judgement to provide safe, effective care, faculty must discern the “need to know” from the “nice to know”.

Given the need to improve clinical judgement while not increasing content, it is time to reexamine teaching assessment skills which are infrequently or rarely used by a registered nurse [ 10 ]. Faculty must look for ways to improve student preparation for practice. However, increasing the content-laden curriculum will only exacerbate information overload. This leaves faculty struggling to balance what is critical to know without overwhelming their students.

With the emphasis on clinical reasoning and clinical judgement, it was time to rethink how health assessment was being taught. Since there was going to be a change in textbooks, it seemed the perfect time to redesign the course. The purpose of this paper is to present how a Bachelor of Science Nursing Health assessment course was redesigned to improve health assessment skills competencies without increasing course content.

2. Materials and Methods

The Medical University of South Carolina Institutional Review Board (MUSC-IRB) determined this project a quality improvement/program evaluation project, thus MUSC-IRB review was not required. Patient consent was waived due to the project being deemed a quality improvement/program evaluation project. A comprehensive literature review was completed. Key search words used in the literature search were physical exam, nursing assessment, prelicensure nurse, health assessment, physical assessment, and undergraduate nursing education. In December of 2019, Scopus, CINHAL Complete, and PubMed databases were searched for research published in the previous five years. Inclusion criteria included: prelicensure nursing program, health assessment curriculum with a focus on a comprehensive list of health assessment skills, nursing skills actively used in clinical care, and English speaking. Exclusion criteria included: non-health assessment curriculum, advanced nursing programs, no data on nursing health assessment skills taught or no data on nursing health assessment skills used in a clinical setting, and non-English speaking programs. Initial results yielded 179 articles. However, several landmark studies were outside the timeline but were included in the final screening. Twenty-seven articles were screened with seven meeting inclusion criteria ( Figure 1 ).

Literature Review.

The articles which met inclusion criteria were reviewed and data highlighting critical nursing assessment skills summarized ( Table 1 ). Data were then assessed to determine if there was consensus among the research on critical physical assessment skills. Based on the review, consensus across studies was found as to which assessment skills were critical for a nurse to perform competently upon entry into practice.

Essential Skills Summary Table.

Course faculty met to review the literature results and to compare skills currently being taught with the critical competency skills. Prior to the curriculum redesign, students were required to learn 195 assessment techniques. Required skills were decreased from 195 to 75 (a decrease of 62 percent). Areas which saw the greatest reduction in required skills were: head, eyes, ears, and neck and throat (HEENT), decreasing from 47 separate skills to 11 and neurological exam from 57 skills to 24 ( Table 2 ). Specific examples of skills eliminated included: chest percussion, chest excursion, JVP measurement, liver hooking, percussing liver borders, thyroid exam, and otoscopic exam.

Physical Assessment Skills Percent Reduction.

Faculty redesigned the health assessment lab and final physical assessment check-off to focus on the identified critical skills necessary to complete a head-to-toe assessment competently. Lectures were adjusted to focus on the critical assessment skills. A one-hour post-lab conference was initiated to introduce the use of clinical judgement when completing a health assessment. During the post-conference, students completed a concept map on a disease appropriate to the system being studied and then applied the information to an original case study. The case study required students to identify cues in the patient health history. Students then determined what type of physical exam techniques should be applied when examining the patient. Finally, students were asked to determine the patient’s first, second, and third nursing priorities and develop a teaching plan.

Prior to redesigning the course, students were only tested on two systems which were randomly assigned. In the redesigned course, students were required to complete a full head-to-toe assessment to demonstrate competencies in all the critical assessment skills.

The initial pre-course change surveys were sent out to the medical/surgical clinical faculty at the start of spring semester in January of 2020. Clinical faculty were asked to evaluate second semester students who had just completed the health assessment course. Students were evaluated on their ability to perform a comprehensive physical assessment based on the criteria of “does not meet expectations”, “meets expectation”, or “exceeds expectation”.

The health assessment curriculum changes were implemented at the beginning of the spring semester in January of 2020. In March of 2020, due to COVID-19, students were no longer allowed on campus, and all course and skills labs were moved online. Due to COVID-19 restrictions, students submitted a video of themselves completing a comprehensive physical exam, and the videos were reviewed and graded by their lab faculty. Due to the abrupt change to online learning, a post-curriculum change survey was not sent out after the spring semester.

In the fall of 2020, face-to-face skills labs were restarted. At the end of the fall semester, students demonstrated their ability to complete a comprehensive physical exam competently with faculty present in real time. Post-curriculum change surveys were sent out to the clinical faculty in January of 2021. In December of 2021, the first cohort who completed the revised health assessment curriculum will graduate and take their licensing exam.

The results of the pre- and post-course change surveys showed significant improvement in student outcomes. Prior to course revisions, 30 percent of students did not meet expectations followed by 50 percent meeting expectations and 20 percent exceeding expectations. Post-course redesign surveys demonstrated a shift to 50 percent meeting expectations and 50 percent exceeding expectations.

By decreasing the number of skills students were required to be proficient in, students were able to hone their skills on the important techniques and learn to apply clinical judgement to exam findings. This positive result was supported by clinical faculty who noted improvement in the students’ ability to assess their findings and begin to apply the critical thinking necessary implement nursing care plans. Students voiced increased confidence in their ability to perform a head-to-toe assessment on the end of course evaluation surveys.

4. Discussion

The COVID-19 pandemic created changes in our healthcare delivery models through the increased use of telehealth and expansion of the nurses’ scope of practice. However, the complexity of patient care has only increased and thus increased the risk for adverse outcomes. Studies indicate novice nurses tend to think in a concrete/linear process. They struggle to process large amounts of complex information and anticipate changes in a patient’s situation [ 15 ]. This leads to difficulty determining which clinical situations need immediate attention and which are less acute.

To intervene quickly and prevent poor patient outcomes, nurses must be able to recognize both the overt and subtle cues when performing a patient assessment [ 13 ]. If one lacks the ability to apply clinical judgement, there is an increased risk of missing the signs of patient deterioration [ 10 ]. Student nurses need to start shifting from concrete thinking to an analytical approach to patient care and assessment. They need to recognize a situation in which a particular aspect of theoretical knowledge applies and begin to develop practical knowledge that allows refinement, extension, and adjustment of textbook knowledge [ 6 ]. This can be accomplished by developing confidence in performing basic assessment skills and becoming competent in translating the findings into appropriate nursing actions [ 8 ].

Our revised approach to a nursing health assessment course is unique given the strong emphasis on critical thinking and clinical judgement without an increase in content. Sound clinical judgment includes multiple components all intertwined together. The nurse must understand the pathophysiology and diagnostic aspects of a patient’s clinical signs/symptoms and disease process. The nurse must be able to assess the illness experience for both the patient and family and evaluate their physical, social, emotional strengths and coping resources [ 11 ]. With the reduction in required skills for which a student must demonstrate competency, students had time to focus on the clinical aspects of the exam and correlate it to the patient disease process. Using a nursing concept map to focus on a specific disease process enabled students to synthesize and apply the information to specific health assessment skills. Scaffold learning occurs as students begin to understand basic disease processes and then apply the information to patient case students. Finally, utilizing this process helps students begin to practice the implementation of patient-centered care.

It is time to re-examine those skills that are used infrequently or rarely and to discuss with our colleagues the usefulness of teaching these skills. This is not to advocate that all skills used infrequently or rarely should be abandoned, only that each skill should be thoughtfully considered and discussed. Douglas et al., (2016) [ 17 ] proposed a “Core + Cluster” approach to nursing physical assessment. This approach would include the 37 essential skills routinely performed with the addition of cluster skills for specialized areas. This approach defines how our faculty determined the critical skills students needed to learn. Students were still required to learn all four components of a physical exam (inspection, palpation, percussion, and auscultation). However, additional skills were added based on their importance in determining changes in a patient’s health status. Thus, certain neurological and respiratory assessment skills were still included in the final assessment even though they were not part of the 37 essential skills.

Evaluation of this quality improvement project is ongoing. In December of 2021, the first cohort will complete the program under the revised curriculum. Adjustments may be made after the licensure board results are reviewed. Based on the previous semester experiences, several revisions will be implemented in the Fall 2021 semester which will include completion of an empathy concept map which focuses on skills to improve wholistic care and gender inclusive interview skills, and enhanced role playing to improve comprehensive interview skills.

5. Conclusions

The Institute of Medicine recommended transforming nursing education to close the practice-education gap [ 11 ]. Given the increased emphasis on improving graduate nurses’ readiness to enter practice, everything should be on the table for review and revision including physical assessment skills. Faculty must look for ways to improve student preparation for practice. However, increasing the content-laden curriculum will only exacerbate information overload. This leaves faculty struggling to balance what is critical to know without overwhelming their students. One option is to re-examine closely which assessment skills are being taught and consider eliminating skills which are infrequently or rarely used by a registered nurse [ 10 ]. Focusing on critical physical assessment skills, which include application of clinical judgement skills in real-life scenarios, will increase student nurses’ ability to observe, assess, and prioritize patient concerns, leading to an improved ability to deliver safe client care.

Author Contributions

Conceptualization, K.K. and K.P.; methodology, K.K. and S.N.; validation, K.K., S.D. and S.N.; formal analysis, K.K., K.P. and S.D.; data curation, K.K.; writing—original draft preparation, K.K.; writing—review and editing, K.K., K.P., S.D. and S.N. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

Ethical review and approval were waived for this study. This study was deemed a quality improvement.

Informed Consent Statement

Patient consent was waived due to the project being deemed a quality improvement/program evaluation project.

Conflicts of Interest

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Critical thinking in healthcare and education

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• 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.

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1.3: Critical Thinking and Clinical Reasoning

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• Ernstmeyer & Christman (Eds.)
• Chippewa Valley Technical College via OpenRN

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Before learning how to use the nursing process, it is important to understand some basic concepts related to critical thinking and nursing practice. Let’s take a deeper look at how nurses think.

Critical Thinking and Clinical Reasoning

Nurses make decisions while providing patient care by using critical thinking and clinical reasoning. Critical thinking is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” [1] Using critical thinking means that nurses take extra steps to maintain patient safety and don’t just “follow orders.” It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research.

“Critical thinkers” possess certain attitudes that foster rational thinking. These attitudes are as follows:

• Independence of thought: Thinking on your own
• Fair-mindedness: Treating every viewpoint in an unbiased, unprejudiced way
• Insight into egocentricity and sociocentricity: Thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
• Intellectual humility: Recognizing your intellectual limitations and abilities
• Nonjudgmental: Using professional ethical standards and not basing your judgments on your own personal or moral standards
• Integrity: Being honest and demonstrating strong moral principles
• Perseverance: Persisting in doing something despite it being difficult
• Confidence: Believing in yourself to complete a task or activity
• Interest in exploring thoughts and feelings: Wanting to explore different ways of knowing
• Curiosity: Asking “why” and wanting to know more

Clinical reasoning is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.” To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. [3]

The ANA’s Standards of Professional Nursing Practice associated with each component of the nursing process are described below.

Assessment is the first step of the nursing process. The American Nurses Association (ANA) “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.”    This includes collecting “pertinent data related to the health and quality of life in a systematic, ongoing manner, with compassion and respect for the wholeness, inherent dignity, worth, and unique attributes of every person, including but not limited to, demographics, environmental and occupational exposures, social determinants of health, health disparities, physical, functional, psychosocial, emotional, cognitive, spiritual/transpersonal, sexual, sociocultural, age-related, environmental, and lifestyle/economic assessments.” [1]

A registered nurse uses a systematic method to collect and analyze patient data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. For example, a nurse’s assessment of a hospitalized patient in pain includes the patient’s response to pain, such as the inability to get out of bed, refusal to eat, withdrawal from family members, or anger directed at hospital staff. Nurses assess patients to gather clues, make generalizations, and diagnose human responses to health conditions and life processes. Patient data is considered either subjective or objective, and it can be collected from multiple sources.

The “Diagnosis” Standard of Practice is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.” [13] A nursing diagnosis is the nurse’s clinical judgment about the client's response to actual or potential health conditions or needs. Nursing diagnoses are the bases for the nurse’s care plan and are different than medical diagnoses.

Outcomes Identification

The “Outcomes Identification” Standard of Practice is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the patient based on their assessment data and nursing diagnoses.

The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” [16] Assessment data, diagnoses, and goals are used to select evidence-based nursing interventions customized to each patient’s needs and concerns. Goals, expected outcomes, and nursing interventions are documented in the patient’s nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care. [17]

Nursing Care Plans

Creating nursing care plans is a part of the “Planning” step of the nursing process. A nursing care plan is a type of documentation that demonstrates the individualized planning and delivery of nursing care for each specific patient using the nursing process. Registered nurses (RNs) create nursing care plans so that the care provided to the patient across shifts is consistent among health care personnel. 

Implementation

The “Implementation” Standard of Practice is defined as, “The nurse implements the identified plan.” Nursing interventions are implemented or delegated with supervision according to the care plan to assure continuity of care across multiple nurses and health professionals caring for the patient. Interventions are also documented in the patient’s electronic medical record as they are completed.

The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” During evaluation, nurses assess the patient and compare the findings against the initial assessment to determine the effectiveness of the interventions and overall nursing care plan. Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated and modified as needed.

Benefits of Using the Nursing Process

Using the nursing process has many benefits for nurses, patients, and other members of the health care team. The benefits of using the nursing process include the following:

• Promotes quality patient care
• Decreases omissions and duplications
• Provides a guide for all staff involved to provide consistent and responsive care
• Encourages collaborative management of a patient’s health care problems
• Improves patient safety
• Improves patient satisfaction
• Identifies a patient’s goals and strategies to attain them
• Increases the likelihood of achieving positive patient outcomes
• Saves time, energy, and frustration by creating a care plan or path to follow

By using these components of the nursing process as a critical thinking model, nurses plan interventions customized to the patient’s needs, plan outcomes and interventions, and determine whether those actions are effective in meeting the patient’s needs. In the remaining sections of this chapter, we will take an in-depth look at each of these components of the nursing process. Using the nursing process and implementing evidence-based practices are referred to as the “science of nursing.” Let’s review concepts related to the “art of nursing” while providing holistic care in a caring manner using the nursing process.

Holistic Nursing Care

The American Nurses Association (ANA) recently updated the definition of nursing as, “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.”

The ANA further describes nursing is a learned profession built on a core body of knowledge that integrates both the art and science of nursing. The art of nursing is defined as, “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.”

Nurses care for individuals holistically, including their emotional, spiritual, psychosocial, cultural, and physical needs. They consider problems, issues, and needs that the person experiences as a part of a family and a community as they use the nursing process. 

Caring and the Nursing Process

The American Nurses Association (ANA) states, “The act of caring is foundational to the practice of nursing.” Successful use of the nursing process requires the development of a care relationship with the patient. A care relationship is a mutual relationship that requires the development of trust between both parties. This trust is often referred to as the development of rapport and underlies the art of nursing. While establishing a caring relationship, the whole person is assessed, including the individual’s beliefs, values, and attitudes, while also acknowledging the vulnerability and dignity of the patient and family. Assessing and caring for the whole person takes into account the physical, mental, emotional, and spiritual aspects of being a human being.   Caring interventions can be demonstrated in simple gestures such as active listening, making eye contact, touching, and verbal reassurances while also respecting and being sensitive to the care recipient’s cultural beliefs and meanings associated with caring behaviors. 

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