Critical Thinking and Clinical Reasoning

(Christman & Ernstmeyer, 2021)

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.” 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 your ability 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.

Inductive and Deductive Reasoning and Clinical Judgment

Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process.

Inductive reasoning involves noticing cues, making generalizations, and creating hypotheses. Cues are data that fall outside of expected findings that give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A generalization is a judgment formed from a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes more clear. Based on generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. A hypothesis is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored.

No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. A nurse is similar to the detective looking for cues in Figure 4.1. Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to take action quickly, especially in emergency situations. They can see how certain objects or events form a pattern (generalization) that indicates a common problem (hypothesis).

Example: A nurse assesses a patient and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.

Figure 4.1 Inductive Reasoning Includes Looking for Cues

Deductive reasoning is another type of critical thinking that is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.

Example: Based on research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. (See Figure 4.2). The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking because the intervention is applied to all patients regardless if they have difficulty sleeping or not.

Figure 4.2 Deductive Reasoning Example: Implementing Interventions for a Quiet Zone Policy

Clinical judgment is the result of critical thinking and clinical reasoning using inductive and deductive reasoning. Clinical judgment is defined by the National Council of State Boards of Nursing (NCSBN) as, “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.” The NCSBN administers the national licensure exam (NCLEX) that measures nursing clinical judgment and decision-making ability of prospective entry-level nurses to assure safe and competent nursing care by licensed nurses.

Evidence-based practice (EBP) is defined by the American Nurses Association (ANA) as, “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.”

Methods of Documentation

This chapter contains information by Jennifer Lapum; Oona St-Amant; Charlene Ronquillo; Michelle Hughes; and Joy Garmaise-Yee’s book titled “Documentation in Nursing” and is available under CC BY-NC license. (Lapum et al., n.d.)

Several methods of documentation are used to organize a nurse’s notes, sometimes referred to as progress notes. Decisions about which method to use may depend on the organization where you work, which sometimes specify certain methods. Otherwise, it is usually a matter of personal preference.

In this section, three main documentation methods are presented: charting by exception, narrative, and nursing process. Another method that is sometimes used to inform documentation is SBAR (Situation, Background, Assessment, and Recommendation), as discussed in a previous chapter, but this was typically designed to inform verbal communication.

Charting by exception. This method is not commonly used, but some specific units find it helpful. Typically, it involves charting when a finding is not normal. A specific setting will provide a list of normal ranges or normal activities, and you will only document a note if the client’s activities or your assessment findings are outside of the norms. For example, a normal finding might be that there are no signs of infection on an incision: you would only document if the client exhibits signs of infection such as redness, swelling, or discharge.

Narrative involves chronological documentation that follows a storied format and sequential order. For example, you would document when the client’s symptoms first started, what they did to treat them, and how they responded to the treatment. A storied format involves attending to ‘what,’ ‘when,’ ‘who,’ and ‘how’ – what happened, when did it happen, who was involved, how the client responded, etc. For example: “An 8-year-old client fell off bike. Client’s mother indicated that he experienced a loss of consciousness for about 20 seconds, was confused when he awoke, and got a headache within 20 minutes. She brought him to the emergency room and arrived within 30–40 minutes of the fall.” As you can see, this documentation note is both chronological and storied.

The nursing process is used to inform documentation in which the nurse focuses on the client’s issue/concern/problem, followed by the plan and action to address the issue, and an evaluation of how the client responded. This method is also called problem-focused documentation. Several approaches are used for this kind of documentation: 

• DAR (data, action, response)
• APIE (assessment, plan, intervention, evaluation)
• SOAP (subjective, objective, assessment, plan) and its derivatives including
• SOAPIE (subjective, objective, assessment, plan, intervention, evaluation).

 These methods share commonalities; see Table 6.1.

Methods of Documentation - Examples

Examples of four methods of documentation are included in this section. In each of the examples, the following is printed at the end “Nurse’s signature, designation”, but ensure that you sign your name and insert your specific designation.

Narrative Method of Documentation – Loss of Consciousness

Case summary: A 47-year-old client, identifies as trans female with pronoun they/their, came into the emergency department after losing consciousness from being struck in the head from a boating accident. According to the client’s partner, the client regained consciousness within one minute.

DAR – Stress

Case summary: A 17-year-old client, identifies as male with pronouns he/his, came into the clinic following a high school counselor’s suggestion after sharing that he is feeling worried about going to university.

APIE – Nutrition

Case summary: A 62-year-old client, identifies as male with pronouns of he/his, who is one month post cerebrovascular accident on a rehab unit. The client is on a thickened diet as a result of dysphagia.

SOAP or SOAPIE – Elimination

Case summary: A 41-year-old client, identifies as female with pronouns she/her, on a postpartum unit 2 days after having a cesarean section (C/S). The client delivered a healthy 8 lb baby.

ADOPIE vs APIE 

In week 3 we learned about ADOPIE (assessment, diagnosis, outcome identification, planning, interventions, and evaluation). In week 6, you will see the term APIE. APIE is a shortened variation of ADOPIE and includes assessment, planning, interventions, and evaluation.