Critical Thinking, Clinical Judgment, and the Nursing Process

Critical Thinking, Clinical Judgment, and the Nursing Process

Brenda Morris, EdD, RN, CNE


Critical thinking: it’s recognizable when someone does it well and certainly evident when it is not happening. During the past 20 years we have talked increasingly about critical thinking in nursing, but that wasn’t always the case. In the early 1960s, when I was entering the profession, serious efforts to change the “handmaiden” image of nursing were only just beginning. Clearly, if one’s role is defined as handmaiden, rather than as colleague or independent decision maker, critical thinking is not deemed particularly important or even desirable. Rather, blind, noncritical obedience is the order of the day. Fortunately, as nursing has become more truly professional and nurses have functioned with increasing autonomy in increasingly complex situations, critical thinking has become a most important and valued competency.

What elements converge to produce a good critical thinker? It seems to me that there are several requisites, not the least of which is intelligence. However, even though intelligence is a necessary condition, critical thinking is not guaranteed to occur without training and a nourishing environment as well. We assume that critical thinking is something that can be learned; hence we address it at all levels of nursing curricula.

Based on my experience, I believe that two essential types of learning provide the basis for critical thinking. The first is substantive. It is impossible to think truly critically about something you do not understand or about which you possess only partial information. Mastery of the theory and research findings that relate to the problem or issue to be addressed is critical, but this is not something that nurses always take time to achieve. Unfortunately, we have been less successful than other professions (namely, medicine) in socializing our practitioners to value learning as a career-long pursuit; yet pursuit of the most state-of-the-science information is an essential ingredient of critical thinking.

The second type of learning involves the process of critical thinking itself. The skills of raising questions, using logic, and comprehensively considering alternative perspectives, explanations, and courses of action can often best be learned experientially within a structure that encourages and, in fact, mandates that kind of thoughtful consideration. The model that comes to mind is the daily medical rounds in which physicians-in-training are challenged to present cases and to lay out their diagnostic reasoning clearly for others to critique. Equally valid as an environment for cultivating critical thinking is that found in many of the social sciences and humanities, where freewheeling debate and open challenge of ideas are encouraged. At first frightened by that kind of candor during my doctoral studies in sociology, I later came to value greatly the critical input of my peers. More of that kind of willingness to challenge one another’s assumptions and ideas within an atmosphere of mutual respect would benefit our profession.

For me, the groundwork for critical thinking was laid early in my education. Fortunately, the faculty responsible for the BSN program I attended were forward-thinking and highly committed to the emerging definition of nursing as a true profession, with the requisite obligation to base action on scientific knowledge and clear and logical thinking. Without labeling the goal as such, we were consistently encouraged, groomed, and enabled to be critical thinkers. We were continually challenged by being asked to provide rationales for our decisions, to make explicit all of the alternative approaches and explanations we had considered and rejected, and to explain why. Not inconsequentially, the school was in a small liberal arts institution, where we were exposed on a daily basis to a wide range of points of view and disciplinary perspectives and assumptions. If anything, the nursing students were the “oddballs” whose pragmatism and goal-directedness seemed strange to the arts, sciences, and music majors. I wrestled more than once with how in the world assignments such as dissecting the symbolism in Moby Dick might be relevant to my career in nursing, but I now appreciate the mind-expanding contribution that such activities made to my ability to think critically.

The base hopefully having been laid during one’s professional education, critical thinking depends not only on training but also on an environment or context that enables, encourages, and rewards it. Regretfully, today’s employment picture in nursing is typically one with precious little time for contemplation. Downsizing, high proportions of nonprofessional personnel, high levels of acuity, and high productivity requirements may discourage critical thinking. That means every effort must be made to counter the tendency to let critical thinking slide and, instead, to encourage, nurture, and reward it, even if that means bucking the tide and incurring some additional short-term costs.

The “community of scholars” type of environment to which top educational institutions aspire should, by definition, be conducive to critical thinking. Nevertheless, even in those settings, time and energy to engage in deliberation, to exchange ideas, and to critique those ideas openly are scarce, and the kind of culture that encourages such scholarly dialogue is relatively rare. When it is in place, it is wonderful. One of my most exciting opportunities to engage in intense and prolonged critical thinking occurred when a group of four colleagues and I were “freed up” from many of our routine responsibilities to plan a doctoral program “from scratch.” In weekly full-day sessions we argued, debated, challenged, cajoled, compromised, and created. We drew on what we knew substantively about nursing, science, philosophy, and the disciplines of our respective doctoral degrees (none of which were in nursing). It was hard work, but invigorating. The ground rules were that no idea was to be belittled or rejected out of hand; all perspectives were heard and considered. We were given time to think with minimal interruption and maximal flexibility; accordingly, the end product was excellent and the process truly energizing. Such time away from the routine is rarely available in today’s environment, but the model is certainly not without merit. Essential are a culture and leadership that permit and encourage critique without recrimination.

In clinical settings, time to engage in deliberative critical thinking is even more difficult to attain. Rather, critical thinking seems to be expected to occur routinely without much cultivation. Benner’s model of progression from novice to expert suggests that excellent clinical experience fosters critical thinking that eventually becomes almost automatic and intuitive. However, I assert that the level of critical thinking displayed by clinical experts needs to be developed deliberately and strategically. The clinical environment in which I have seen critical thinking encouraged most effectively was one in which the expectations were explicit, critical thinking was measured routinely in the practice context, relevant learning and growth opportunities were provided, and critical thinking was taken into account in performance evaluation. In other words, the nursing leadership in that academic medical center truly valued critical thinking and was willing to assign it priority.

Nursing has reached the point in its evolution in which a consistent and continuous pattern of critical thinking by its practitioners is a mandate—a sine qua non. The assurance that critical thinking will be truly woven into the fabric of our profession will depend on our ability to recruit and retain intelligent, interested, and committed nurses; to provide challenging educational opportunities that develop the requisite competencies; and to provide and sustain the kinds of environments in which critical thinking is valued and demanded.


The ability to process information from multiple sources and make decisions is a fundamental ability of professional nursing practice. Dramatic changes in the health care system and the practice of nursing have occurred during the past decade as a result of an aging population, cost containment efforts, technological advances, increased complexity of clients’ health care needs, decreased average hospital length of stay, and a shift from acute care to community-based care. All of these changes have emphasized the need for professional nurses to think critically in order to provide safe and effective client care to diverse populations. To function effectively in complex, rapidly changing health care environments, nurses must use higher-order thinking skills and apply content knowledge to clinical practice. The critical thinking process provides nurses with the ability to use purposeful thinking and reflective reasoning to examine ideas, assumptions, principles, conclusions, beliefs, and actions in the context of professional nursing practice (Brunt, 2005). Professional nurses must think critically to process complex data from multiple sources and make intelligent decisions in planning, managing, delivering, and evaluating the health care of their clients. Nurses also use their critical thinking skills to reduce health care errors and improve client safety (Fero, Witsberger, Wesmiller, Zullo, & Hoffman, 2008). To become a critical thinker, a nurse must understand the concept of critical thinking; possess or acquire the essential knowledge, skills, and attributes required to think critically; and deliberately apply critical thinking principles in making clinical judgments. This chapter covers both classical and current sources to examine critical thinking, clinical judgment, and the nursing process.

imageDefining Critical Thinking

Critical thinking, as a concept, has been examined and presented from a variety of perspectives. An early definition, proposed by Watson and Glaser (1964), described critical thinking as the combination of abilities needed to define a problem, recognize stated and unstated assumptions, formulate and select hypotheses, draw conclusions, and judge the validity of inferences. A less prescriptive definition was offered by Ennis (1989), who characterized critical thinking as “reasonable reflective thinking focused on deciding what to believe or do” (p. 4). Paul (1992) stated that critical thinking is a process of disciplined, self-directed rational thinking that “certifies what we know and makes clear wherein we are ignorant” (p. 47). Alfaro-LeFevre (2006) presented critical thinking for nursing as informed, purposeful, and outcome-focused thinking that requires the ability to identify problems, issues, and risks and make judgments based on evidence. Bandman and Bandman (1995) describe critical thinking for nursing as “the rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs, and actions” (p. 7) and include the following functions:

Conclusions are drawn as a result of this reasoning process. In nursing practice, the desired outcome of this reasoning is effective action.

Conflicting viewpoints exist regarding whether critical thinking is subject specific or generalizable (U.S. Department of Education, 1995). Most authors agree that the critical thinking processes are not discipline specific but, rather, are generalizable (Ennis, 1987; Facione, 1990; Paul, 1992; Watson & Glaser, 1964). The same critical thinking skills of interpretation, analysis, inference, and evaluation are applied in different subjects. However, the difference lies in how the critical thinking processes are applied to specific disciplines. For example, professional nurses apply critical thinking skills to client care situations in order to make sound clinical judgments, whereas engineers apply critical thinking skills to business or industrial situations in order to make sound decisions. Meyers (1991) and McPeck (1990) believe that mastery of basic terms, concepts, and methodologies must occur before critical thinking skills can be developed. Ennis (1987) agrees that some familiarity with subject matter is necessary for the development of critical thinking; however, some principles of critical thinking bridge many disciplines and can transfer to new situations.

An attempt to define critical thinking by consensus was begun in the late 1980s, and the results became known as the Delphi Report. The Delphi research project used an expert panel of theoreticians representing several disciplines from the United States and Canada to develop a conceptualization of critical thinking from a broad perspective (Facione, 1990). The resulting work described critical thinking in terms of cognitive skills and affective dispositions. The outcome was a definition of critical thinking as the process of purposeful, self-regulatory judgments: an interactive, reflective reasoning process (Facione & Facione, 1996). A critical thinker gives reasoned consideration to evidence, context, theories, methods, and criteria to form a purposeful judgment. At the same time, the critical thinker monitors, corrects, and improves the judgment. The Delphi project produced the following consensus definition from its panel of experts:

The Delphi participants identified core critical thinking skills as interpretation, analysis, inference, evaluation, and explanation. These critical thinking cognitive skills and subskills are listed in Box 9-1.

imageCritical Thinking in Nursing

Scheffer and Rubenfeld (2000) replicated the Delphi study with a panel of 55 nurse educators to obtain a consensus definition of critical thinking for nursing. That study resulted in the identification of 17 dimensions of critical thinking and agreement on the definition of critical thinking for nursing as:

Although many areas overlap with the American Philosophical Association’s (1990) Delphi Report definition of critical thinking, some important differences also exist. According to Allen, Rubenfeld, and Scheffer (2004), the dimensions of creativity, intuition, and transforming knowledge that are so crucial to effective clinical practice were not included in the Delphi Report definition. These dimensions emerged in the consensus definition of critical thinking for nursing.


Although a universally accepted definition of critical thinking has not emerged, agreement exists that it is a complex process. The variety of definitions helps provide insight into the myriad dimensions of critical thinking. Commonalities in definitions include an emphasis on knowledge, cognitive skills, beliefs, actions, problem identification, and consideration of alternative views and possibilities (Daly, 1998). The definitions presented earlier are summarized for comparison in Table 9-1, and characteristics of critical thinking are listed in Box 9-2.

The activities involved in the process of critical thinking include appraisal, problem solving, creativity, and decision making. The interrelationships among these concepts are illustrated in Figure 9-1. These activities are embedded in the critical thinking process in both nursing education and nursing practice.


In nursing, critical thinking has often been portrayed as a rational, linear process that is synonymous with clinical judgment, problem solving, and the nursing process (Ford & Profetto-McGrath, 1994; Huckabay, 2009; Jones & Brown, 1993; Kintgen-Andrews, 1991; Wilkinson, 1996). However, some critics believe that the problem-solving emphasis of the nursing process constrains critical thinking because it does not incorporate the creativity and open-mindedness components of critical thinking (Conger & Mezza, 1996; Duchscher, 1999; Jones & Brown, 1993; Miller & Malcolm, 1990).

Although critical thinking skills are important components of the nursing process and problem solving, these are not synonymous terms. The nursing process serves as a tool for applying critical thinking to nursing practice. The nurse uses critical thinking throughout the nursing process, by sorting and categorizing data; identifying patterns in the data; drawing inferences; developing hypotheses that are stated in the form of outcomes; testing these hypotheses as care is delivered; and making criterion-based judgments of effectiveness. Therefore critical thinking can distinguish between fact and fiction, providing a rational basis for clinical judgments and the delivery of nursing care. Although an argument can be made that the nursing process constrains critical thinking because of its structured format, general agreement exists that critical thinking skills and subskills are evident throughout the nursing process (Alfaro-LeFevre, 2006). Although the components of the nursing process are described as separate and distinct steps, they become an integrated way of thinking as nurses gain more clinical experience. An overview of critical thinking throughout the nursing process is presented in Table 9-2. A thorough understanding of the nursing process reveals that critical thinking is indeed an integral part of its most effective use.

imageThe Nursing Process

The nursing process is a systematic, problem-solving approach used extensively in the United States and Canada for the delivery of nursing care. The nursing process was first described in the literature in 1955 by Lydia Hall. Her approach was built around three interrelated spheres of nursing activity: care, core, and cure. The focus in the care sphere is the body, including assessment and evaluation of the client’s ability to perform basic functions and activities of daily living. The focal point in the core sphere was on the therapeutic use of self in providing nursing care, whereas nursing activities related to the cure sphere centered on the administration of treatments and therapies, as well as supporting the patient and family during the treatment process.

Subsequently, many others have described a “nursing process,” but the model that has withstood the test of time is that developed by Yura and Walsh (1988). They proposed a four-step nursing process model that consisted of assessing, planning, implementing, and evaluating. The current model closely resembles the Yura and Walsh model, but with the addition of a diagnostic component. The five-step nursing process consists of the following elements:

The American Nurses Association (ANA), in its publication Nursing: Scope and Standards of Practice (2004), parallels the steps of the nursing process and supports its use. Outcome identification, which follows the nursing diagnosis phase and precedes the planning phase, is identified as a separate step in the ANA model.

The nursing process is sometimes depicted as a systematic, linear model proceeding from assessment through diagnosis, planning, implementation, and evaluation. It is more appropriately conceptualized as a continuous and interactive model (Figure 9-2), thereby providing a flexible and dynamic approach to client care. This model can accommodate changes in the client’s health status or failure to achieve expected outcomes through a feedback mechanism. The interactive nature of the model with its feedback mechanism permits the nurse to reenter the nursing process at the appropriate stage to collect additional data, restructure nursing diagnoses, design a new plan, or change implementation strategies. This model is consistent with the concept of critical thinking as a continuous reflective process. Further examination of the elements of the nursing process reveals the multiple activities embedded in each step.


In the assessment phase, the nurse deliberately and systematically collects data to determine the client’s health, functional status, strengths, and risk factors (Carpenito, 2008). Data collection centers on the use of multiple sources and types of data, a variety of data collection techniques, and the use of reliable and valid measurement instruments. All these elements are critical to building a comprehensive database.

Data Collection Techniques

Assessment techniques include measurement, observation, and interview. Measurement is used to determine the dimensions of a given indicator (e.g., blood pressure) or to ascertain characteristics such as quantity, size, or frequency. Measurement may require the use of specialized equipment (e.g., stethoscope, thermometer) or specialized assessment tools (e.g., pain scale, depression scale) to assess functional, behavioral, social, or cognitive domains. Data collection by observation requires the use of the senses, including visual observation and tactile (palpation) and auditory techniques (auscultation). Observation provides a variety and depth of data that may be difficult to obtain by other methods. A structured or unstructured interview may be used to obtain information such as a health history and demographic data. A structured interview is commonly used in emergency situations when the nurse needs to gather specific information. An unstructured interview is commonly used in situations in which the nurse wishes to elicit information from the client’s perspective or gain insight to the client’s understanding of a problem. The unstructured interview allows the nurse to use active listening skills while building rapport with the client through the use of an open-ended interview format. These communication techniques are discussed in chapter 8

Data Collection Instruments

The use of selected data collection measures and instruments can assist the nurse in compiling a comprehensive database and organizing data into meaningful patterns. Assessment usually begins by taking a nursing history and conducting a physical examination. Many clinical areas have developed nursing history and physical forms specific to the type of agency and the clients served. Regardless of the format, the nursing database should include the following categories of information (Edelman & Mandle, 1994):

Oct 26, 2016 | Posted by in NURSING | Comments Off on Critical Thinking, Clinical Judgment, and the Nursing Process
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