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Improving Critical Thinking, Reasoning and Clinical Judgment
By Rosalinda Alfaro-LeFevre, MSN, RN, ANEF
This course is 1 contact hours
Course must be completed by August 31, 2021.
Goals and objectives: The goal of this continuing education program is to help nurses, dietitians, dietary managers, health educators, laboratory professionals, occupational therapists, physical therapists, respiratory therapists, and social workers improve their critical thinking and clinical reasoning skills. After studying the information presented here, you will be able to: • Describe critical thinking and clinical reasoning in the context of your practice • Identify characteristics and skills that demonstrate critical thinking • Use specific strategies to improve your critical thinking and clinical reasoning skills as well as those of other healthcare professionals
Nurse.com educational activities are provided by OnCourse Learning. For further information and accreditation statements, please visit Nurse.com/Accreditation. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. OnCourse Learning guarantees this educational activity is free from bias. See “How to Earn Continuing Education” to learn how to earn CE credit for this module or visit http://ce.nurse.com/instructions.aspx.
Healthcare providers have never experienced such significant changes. Each day brings new challenges, from learning to use health information technology to juggling multiple priorities for several patients. Having sound critical thinking (CT) and clinical reasoning (CR) skills makes the difference between keeping patients safe and putting them in harm’s way.
What are critical thinking and clinical reasoning?
Because thinking is a complex process that involves feelings, past experiences, and individual perceptions, there are numerous definitions of CT and CR. There’s no one right way to define either of these terms. Rather, as you’ll see in this course, there are many ways of looking at CT and CR. Looking at these concepts from different perspectives, helps you “peel the CT and CR onion” and get to the core of what’s important. Let’s begin by looking at some synonyms: • Reasoning is a commonly used synonym for thinking. • The term critical in critical thinking is synonymous with important, necessary, or required.6-8 Applying the above points, critical thinking is “important thinking (or reasoning) that needs to be done to assess and manage any problem or concern.” For example, you need to know how to assess systematically and comprehensively, how to prioritize, how to prevent and control undesirable situations, and how to evaluate progress.5,6
The terms critical thinking and clinical reasoning are often used interchangeably, but there’s a slight difference between them. CR is a specific term that usually refers to assessment and management of patient problems at the point of care (e.g., reasoning at the bedside or during clinic visits).

For reasoning about other clinical issues (e.g., teamwork, collaboration, and streamlining work flow), healthcare professionals usually use the term critical thinking. CT is a broad term that includes CR and refers to “important thinking” that must be done to assess and manage any situation (inside or outside of the clinical setting). The diagram below shows that critical thinking and clinical reasoning are the processes clinicians use to make clinical judgments (conclusions, decisions, or opinions). Notice that clinical judgments are the results or outcomes of thinking and reasoning.7
Shifting to a predictive clinical reasoning model
How to earn continuing education
THIS COURSE IS 1 CONTACT HOUR
1.
Read the Continuing Education article.
2.
This continuing education course is FREE ONLINE until May 29, 2019, courtesy of Nurse.com. To take the test for FREE, go to https://www.nurse.com/ce/improving-your-ability-to-think-critically. After that date, you can take the course for $12 at the same link. If you have a CE Direct login and password (generally provided by your employer), please login as you normally would at https://cedirect.continuingeducation.com and complete the course on that system.
3.
If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer.
4.
Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test.
5.
All users must complete the evaluation process to complete the course. You will be able to view a certificate on screen and print or save it for your records.
In support of improving patient care, OnCourse Learning is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

OnCourse Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina Board of Nursing (provider # 50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. OnCourse Learning is approved by the California Board of Registered Nursing, provider # CEP16588.

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Three stages of thinking
Because CT and CR are contextual (they change with circumstances), you should consider reasoning in three different stages or circumstances:6-8 Thinking Ahead: being proactive — anticipating what might happen and what you can do to be prepared. For new nurses, being proactive is difficult and requires expert guidance and keeping references handy. Examples: Practicing what to do if things go wrong when encountering a patient who isn’t breathing; bringing extra sterile gloves when doing sterile procedures. Thinking in Action: thinking in the moment ― rapid, dynamic reasoning includes considering several cues and priorities at once, making it difficult to describe. Thinking in action is highly influenced by previous hands-on experience. It’s more intuitive and prone to “knee-jerk” responses than the other types of reasoning listed here.

Example: An ICU nurse notices that a patient is having trouble breathing, sees a rapid heart rate and increased blood pressure on the monitor, raises the head of the bed, and asks whether there’s any pain or dizziness. Thinking back (reflecting on thinking): deconstructing and analyzing the reasoning process to identify assumptions, look for flaws and omissions, gain insight, and correct and improve thinking. Experienced clinicians reflect on their thinking during thinking-in-action, double checking themselves to make necessary corrections. However, this doesn’t replace reflective thinking that happens after the fact.

Deliberate reflective thinking that happens after the fact — for example, chart reviews, journaling, and open dialogue with others — brings new insights and greater accuracy. You can objectively identify “lessons learned” from experience.

Example: A preceptor realizes the importance of having debriefing session with a new nurse who has just had her first experience with a patient who had a cardiac arrest. During debriefing, they do a chart review and discuss what went well and what was problematic.
Today, there’s a major shift in how we manage healthcare delivery that affects how we describe critical thinking: we are more proactive. We’ve moved from a diagnose-and-treat (DT) model to a predict, prevent, manage, and promote (PPMP) model.6,7 The difference between these two models is that the PPMP model is more proactive. The DT model implies that we wait for evidence of problems before starting treatment.

For example, in the past, we monitored people with fractured hips for emboli, but we didn’t do much about preventing them. We monitored patients closely until, sure enough, they threw an embolus. Now, we apply the PPMP model and focus on preventing venous thromboembolism (VTE) by using pulsating anti-embolism stockings during and after surgery is standard practice.

Implementing a program to detect and prevent VTEs, including the use of anticoagulants, is a major concern in healthcare.9 Another example of the PPMP model is how we manage HIV exposure. In the past, we simply monitored people who were exposed to HIV until symptoms appeared (then treatment began). Today, when someone has significant exposure to HIV, we begin treatment immediately (post-exposure prophylaxis), before the virus even appears in the blood.

The DT model has a narrow approach that’s strong on treating problems but weak on preventing them and their complications. PPMP is based on evidence. We now know the typical course of most health problems. We know how to alter the course by identifying risk factors and intervening early. You may be thinking that the PPMP approach isn’t new because we’ve always focused on prevention and early intervention. But, realize that today — thanks to health information technology (HIT) and hard work on the part of many expert clinicians and researchers — we have more reliable evidence addressing how to predict, prevent, and manage problems in various situations and populations.

As a critical thinker, it’s your job to pay attention to new technology and evidence-based approaches that improve outcomes. Think about how many years we used X-rays after central venous line insertion to confirm placement. Today, with new evidence and technology, we are much more proactive, using live ultrasound to monitor how lines are inserted, thereby reducing risks of serious complications, such as a collapsed lung.

Remember the importance of the “fourth P” (promote). At every patient encounter, think about how to promote function. For example, point out the benefits of walking daily and using stress-management techniques to promote optimal physical and mental function. Keep patients active and engaged in their care as much as possible every day.
Yet, as at least one study points out, there seems to be a crisis in critical thinking: only 23% of graduate nurses entering into practice in a large hospital demonstrated critical thinking and clinical reasoning competency.1-5 New graduates find that becoming a competent, critical thinking clinician, it is intellectually, emotionally, and physically challenging, and leaves many feeling overwhelmed and underprepared.1,2 Because of these issues, retaining new nurses at a time when we really need them is becoming increasingly difficult.1-5 This module will help new and seasoned staff to develop the knowledge, skills, and attitudes needed to be competent in CT and clinical reasoning. It details the relationships among CT, CR, and clinical judgment (CJ), and gives strategies for developing the thinking skills needed to function as a 21st century healthcare provider. Let’s start by examining what CT and CR entail. Keep in mind that one of the first steps to improving your ability to think critically is gaining insight into what critical thinking entails, what factors affect reasoning, and how your thinking is affected by personal preferences and perspectives.
Critical thinking versus clinical reasoning
While problem-solving is a key part of critical thinking, some leaders believe substituting problem-solving for critical thinking is misleading. You can’t be satisfied with having just a “problem-solving mentality.” You could be demonstrating good problem-solving skills, but if you aren’t proactive — using prevention and health promotion to avoid problems and improve health — you’re not thinking critically.

If you don’t have a sincere desire to improve — to find ways to broaden your knowledge and skills and make current practices more efficient and effective — you’re not thinking critically. You may find that clients and peers, who know the value of constant improvement and professional growth, will leave you behind. A holistic way to define critical thinking is a commitment to look for the best way, based on the most current evidence. This means asking questions such as:
  • What are the outcomes?
  • How can we do this better?
  • How satisfied are our patients with their care?
  • Are we applying the most up-to-date evidence?
The following summarizes key points on CT and CR.6-8
CT and CR are outcome-focused thinking that:
  • Are guided by standards, policies, ethics codes, and laws (individual state practice acts and state boards of nursing)
  • Are based on principles of nursing process, problem-solving, and the scientific method (requires forming opinions and making decisions based on evidence)
  • Focuses on safety and quality, constantly re-evaluating, self-correcting, and striving to improve
  • Carefully identifies the key problems, issues and risks involved, including patients, families, and key stakeholders in decision making early in the process. (Stakeholders are the people who will be most affected [patients and families] or from whom requirements will be drawn [caregivers, insurance companies, third party payers, healthcare organizations])
  • Is driven by patient, family, and community needs, as well as nurses’ and other healthcare professionals’ needs to give competent, efficient care (e.g., streamlining charting to free nurses for patient care)
  • Calls for strategies that make the most of human potential and compensate for problems created by human nature (e.g., finding ways to prevent errors, using technology and overcoming the powerful influence of personal views)
Key knowledge and skills for critical thinking in nursing and healthcare.

©2017 www.AlfaroTeachSmart.com.
Problem-solving versus improvement
Thinking with electronic health records
Today’s healthcare professionals do much of their thinking with the help of electronic health records (EHR) and HIT. These systems are designed to help clinicians make critical patient care decisions in a timely way. For example, there are diagnostic generators (programs that you determine the diagnoses you should consider based on presenting signs and symptoms) and there are clinical decisions support systems that suggest specific lab studies and interventions that should be initiated as soon as possible.7 When you use well-designed EHR and HIT, two things happen that promote critical thinking:7 (1) As you use the same electronic tools repeatedly in various situations, your brain creates a mental file of what’s most important (e.g., how to prioritize your assessment); (2) The electronic documentation gives you and the rest of the team a record you can reflect on to identify patterns and pick up omissions. Because EHR and HIT often cue you to important information, interventions, or consultations that should be considered, it’s more important than ever to chart as soon as you can. Not only will your mind be fresh, but entering the data may help you set care priorities. While EHR and HIT are important in preventing errors and promoting critical thinking, remember these tools don’t think for you. Keep an open active mind, look for flaws, and decide how the information you see on your computer applies to your patients’ individual circumstances, right now.7 You — not the computer — work in “real time.”   While using EHR and HIT speeds up care management decisions, they can impede thinking in those who are task-oriented not thought-oriented. These people complete tasks in a linear way. They don’t assess, reflect, evaluate, or change approaches as needed. Sometimes we see staff who are so influenced by knowing the predicted care that they rush through assessments and make dangerous assumptions. Healthcare providers of all disciplines must realize the importance of assessing their patients directly themselves before following computer-generated plans of care. They must also remember to supervise task-oriented workers closely.
General attitudes/characteristics indicators: These are behaviors that indicate the healthcare provider possesses CT characteristics/attitudes (e.g., inquisitive, persistent, reflective, open-minded, proactive, resilient, self-aware).

Knowledge indicators: These are behaviors that indicate the healthcare provider has required knowledge (e.g., ability to discuss ethics codes and professional standards, to describe signs and symptoms of common health problems and related complications, to explain the difference between nursing and medical models, and to give key details of pharmacology, anatomy, and physiology).

Intellectual skill indicators/competencies: These are behaviors that indicate the healthcare provider has required intellectual skills/competencies (e.g., ability to assess systematically and comprehensively, distinguish relevant from irrelevant, identify missing information, recognize inconsistencies, identify assumptions, and draw valid conclusions).   Personal CTIs (see below) describe attitudes and characteristics seen in individuals who are critical thinkers. If nurses demonstrate the CTIs, it’s quite likely that they are a critical thinker and will readily gain the knowledge and skills needed to think critically in various situations and specialties.
Read the rest of the course online and take the test. OnCourse Learning guarantees this educational activity is free from bias.
Surprisingly, research shows that most critical thinkers are women between the ages of 30 and 35, fair-skinned, and have broad foreheads. However, if you aren’t questioning this statement, you’re not thinking critically about what you’re reading. When we ask, “What does a critical thinker look like?” we mean, “What characteristics do we see in someone who thinks critically?” For more than a decade, Alfaro-LeFevre has surveyed experts to determine the characteristics and behaviors of critical thinkers, updating the Evidence-Based Critical Thinking Indicators (CTI) document every three years.8 (Level C) This document and textbooks are used throughout the world to promote critical thinking in clinical practice and facilitate critical thinking research.10 (Level C),11,12 Lets look at how considering CTIs can help you decide what critical thinkers “look like.”
Critical thinking indicators
CTIs are behaviors that evidence shows promote critical thinking in nursing and healthcare. They help you know what you need to do to think critically. Think about the following summary of what critical thinking indicators entail.
CTIs are divided into three categories:6-8
What do critical thinkers look like?
Improve your critical thinking and reasoning skills
Earn 1 free credit hour with this continuing education course
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EDITOR'S NOTE: Rosalinda Alfaro-LeFevre, RN, MSN, ANEF, is the president of Teaching Smart/Learning Easy in Stuart, Fla. She’s known nationally and internationally for her writings and programs on teaching critical thinking and improving personal and professional performance
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