Critical thinking & Clinical reasoning

:I. Introduction
.The practice of nursing requires critical thinking and clinical reasoning
Critical thinking Is the process of intentional higher-level thinking of
define a clients' problem examine the evidence-based practice in caring
for the client and make choices in the delivery of care.( Critical
thinking is the ability of the nurse to think clearly, precisely,
and accurately and to act on what you know
and understand (Potter and Perry, 2012).) & (Critical thinkers in
nursing practice the cognitive skills of analyzing, applying standards,
discriminating, information seeking, logical reasoning, predicting, and
transforming knowledge6 (Scheffer & Rubenfeld, p. 357).)
Clinical reasoning: Is the cognitive process that uses thinking strategies to
gather and analyze client's information, evaluate the relevance of the
information, and decide on possible nursing to improve the clients
.physiological and psychosocial outcomes
Clinical reasoning requires the integration of critical thinking in the
identification of the most appropriate interventions that will improve
.the clients' condition

Critical thinking is an essential skill needed for the identification of client

problems and the implementation of interventions to promote effective
.care outcomes (Bittencourt & Crossetti, 2012)
The process of providing feedback and reflection is vital to the
improvement of nursing practice. A study by Asselin (2011) revealed
that students who reflected on new knowledge developed new insights
regarding practice. The insights nurses acquired led to changes in their
.approach to practice

:II. Techniques in critical thinking

1. Critical analysis: Is the application of set of questions to a particular
situation or idea to determine essential information and ideas and
discard unimportant information and ideas. The questions are not
sequential steps; rather they are a set of criteria for judging an idea.
2. Inductive and deductive reasoning:
Inductive reasoning= generalizations are formed from a set of facts or
observations.
Deductive reasoning= reasoning from the general to the specific.
 4. Evaluating the credibility of information sources: is an important step
in critical thinking. We cannot always believe what we read or are told.
The nurse must ascertain the accuracy of information by checking other
documents or with other informants. Hence, the expanding need for
evidence- based nursing practice.

5. Clarifying concepts: To comprehend a client situation clearly, the nurse

and the client must agree on the meaning of terms. For example, if the
clients say to the nurse "I think I have a tumor," the nurse needs to
clarify what the word means to the client-the medical definition of a
tumor (a solid mass) or the common lay meaning of cancer-before
responding.

6. Recognizing assumptions: People also live their lives under certain

assumptions. Some people view humans as having a basically generous
nature, whereas others believe that the human tendency is to act in
their own best interest. The nurse may believe that life should be
considered worth living no matter what the condition, whereas the
client may believe that quality of life is more important than quantity of
life. If the nurse and client recognize that they make choices based on
these assumptions, they can still work together toward an acceptable
plan of care. Difficulty arises when people do not take the time to
consider what assumptions underlie their beliefs actions.

III. Applying critical thinking to nursing practice:

Implementation of the nursing process provides nurses with a creative
approach to thinking and doing to obtain, categorize, and analyze client
data and plan actions that will meet the client's needs.

Nursing process: is a systematic, rational method of planning and

providing individualized nursing care. The phases of the nursing process
are assessing, diagnosing, planning, implementing, and evaluating.
Problem solving: Process used when a gap is perceived between an
existing state (what is occurring) & a desired state of what should be
occurring.
The nurse carefully evaluates the possible solutions and chooses the
best one to implement.
 Clinical Judgment: in nursing is a decision-making process to ascertain
the right nursing action to be implemented at the appropriate time in
the client's care. The nurse must first have the knowledge base
necessary to practice in the clinical area and then use that knowledge in
clinical practice. Clinical experience allows the nurse to recognize cues
and patterns and begin to reach correct conclusions.
Research Process: is a formalized, logical, systematic approach to
problem solving. The classic quantitative research process is most useful
when the researcher is working in a controlled situation. Therefore, it is
becoming increasingly important for nurses to identify evidence that
supports effective nursing care. One critical source of this evidence is
research.

IV. Components of clinical reasoning

Clinical reasoning is the analysis of a clinical situation as it unfolds or
develops. It requires the nurse to use:
1- Cognitive and metacognitive processes:
Cognition is the way we organize and store new information. It's how
we think and process information.
Metacognition looks at how well we understand and can control these
processes.
2- Setting Priories: The nurse must know what assessments, tasks, and
concerns need to be completed first. Priories setting flexible because
the clinical environment can change quickly, requiring changes in
priories. Beginning nursing students often view everything as being of
equal importance. They are often task oriented and focused on what
needs to be done and not necessarily on what is most important. As
they gain more clinical experience, they start to determine which data
are most relevant and important to each client's situation.
3- Developing Rationales: After assessing the data and determine what is
relevant to client's condition and concerns, the nurse identifies
interventions and sets priorities for most urgent needs. Being able to
state the rationale, based on nursing knowledge, acts as a check for
potential errors, justifies the nurse's actions, contributes to client safety,
and helps the beginning nursing student learn how a nurse thinks in
practice.
4- Learning how to act: The nurse must know how and when to respond in
a clinical situation by recognizing what is most urgent or significant. To
act, the nurse needs to understand the relevant medical and nursing
 information and translate this knowledge into a plan of care. An
example is thinking about potential complications given the client's
current problems. Applying this knowledge increases the nurse's ability
to quickly identify assessment data that indicate a potential
complication.
5- Clinical Reasoning-in-Transition: Clinical reasoning-in-transition is the
ability to recognize subtle changes in a client's condition over time. It
includes the evaluation of nursing interventions and the trending of
relevant assessment data. Nurse need develop the sense of what is the
most important in each changing clinical situation and remember that
the primary focus in on the client's well-being. Thus, the nurse can
initiate nursing interventions or actions quickly because he or she
prepared for the possibility. Avoiding potential complications promotes
client safety.
6- Reflection: is a key to success of clinical reasoning. Though reflection
the nurse identifies factors that improved client care and those the
required changing elimination. It is important to reflect on whether the
client was assessed accurately and in a timely manner. The nurse thinks
back on the interventions implemented and whether they were
effective. Most importantly, reflection includes information on the
outcome of care.
7- Responding to Changes in the Client's Condition: Nurses spend more
time with clients than do other health care providers. Clinical reasoning
involves an understanding and assessment of the client's relevant
history and current condition and how it may be changing. By closely
monitoring and comparing any changes from previous assessment data,
the nurse can recognize a change in status that may prevent an adverse
outcome.
8- Reflection: It is a key to the success of clinical reasoning. Through
reflection the nurse identifies factors that improved client care and
those that required changing or elimination. It is important to reflect on
whether the client was assessed accurately and in a timely manner. The
nurse thinks back on the interventions implemented and whether they
were effective. Most importantly, reflection includes information on the
outcome of care. The nurse also reflects on previous clinical experiences
like this one to determine if the outcomes of care improved the clients'
conditions.
V. Integration of critical thinking and clinical reasoning
Nurses use critical thinking and clinical reasoning skills when making
decisions about client care.
- The decision-making process includes prioritizing care not only with one
client but when providing care to many clients. When faced with several
client needs at the same time, the nurse must prioritize and decide
which client to assist first. Example, In the home care setting, the nurse
must decide if the client's condition can be managed in the home or
requires hospitalization.
- Logical reasoning is a critical thinking skill that closely aligns with clinical
reasoning. In the planning of care, nurses must question whether
knowledge they possess about the care of the client is consistent with
the most current evidence-based practice. The nurse must review the
most current nursing and health-related literature prior to
implementing care.

The Outcome-Present State Test Model of Clinical

Reasoning to Promote Critical Thinking in Psychiatric
Nursing Practice among Nursing Students: A Mixed
Research Study
- Goal: This study determined whether teaching intervention using the
outcome-present state test (OPT) clinical reasoning model can
effectively improve critical thinking in nursing students during a
psychiatry internship.
- Method: in this interventional study, 19 students were taught critical
thinking skills using the OPT clinical reasoning model during a psychiatry
clinical practice. Work-learning forms were used in daily 1 h individual
and group discussions with students. The critical thinking disposition
scale was completed by every student before and after the intervention.
- Result: The average critical thinking disposition pre-intervention score
was 95.21, whereas the average post-intervention score was 97.05,
indicating an increase of 1.84.
- Conclusion: Using the OPT clinical reasoning model as a teaching
strategy during a psychiatric nursing internship significantly improved
the open-mindedness dimension among the students.