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Critical Thinking and Clinical Reasoning

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Clinical reasoning and critical thinking are both key items to nursing practice and occurs every day on the job. Both of these terms are necessary for nurses to utilize in their everyday practice. Without clinical reasoning and critical thinking nurses would no longer face any challenges and patients would have worsening outcomes. Thinking is a skill, just like music or tennis. It flows and changes depending on current conditions, and it requires gaining specific knowledge, skills, experience, and hands-on practice. Critical Thinking

Critical thinking is your ability to focus your thinking to get the results you need in various situations makes the difference between whether you succeed or fail. Whether you need to set patient priorities, figure out how to collaborate with a difficult doctor, or develop a plan of care, critical thinking deliberate, informed thought is the key. The journey to developing critical thinking starts with having a good understanding of what it is. Critical thinking involves a certain skepticism, or suspension of assent, towards a given statement, established norm or mode of doing things. This skepticism might ultimately give way to acceptance, but it does not take truth for granted. Instead, it considers alternative hypotheses and possibilities. (Daly, 1998) Clinical Reasoning

Clinical reasoning is the practitioner’s ability to assess patient problems or needs and analyze data to accurately identify and frame problems within the context of the individual patient’s environment. In nursing education, effective clinical reasoning skills enable students to collect data, solve problems, make decisions, provide quality care and survive in the workplace in every day settings. Effective and efficient clinical reasoning requires knowledge, skills and abilities grounded in theory and supported by evidence. Student clinical reasoning involves elements of focused reflection, written or verbal articulation of thoughts, assignments that connect new experiences to existing knowledge, critical thinking, creative thinking, and nursing judgment.

Compare and Contrast
A good synonym for critical thinking is reasoning. Critical reasoning is a good synonym because it implies careful, deliberate thought. Critical thinking in nursing which includes clinical reasoning and clinical judgment is purposeful, informed, outcome-focused thinking that is guided by standards, policies, ethics codes, and laws. It is also based on principles of nursing process, problem-solving and the scientific method. Critical reasoning and critical thinking focus on safety and quality, constantly re-evaluating, self-correcting and striving to improve. They both carefully identify the key problems, issues and risk involved, including patients and families in decision-making early in the process. Contrast

Often, it seemed the terms clinical reasoning and critical thinking were being used interchangeably. Critical thinking is the process of constant evaluation and application of available information, including analyzing your results. The difference between clinical reasoning and critical thinking occurs with confirmation bias, or searching for evidence to confirm a preconceived hypothesis. Critical thinking is constantly required to recognize these biases we all possess, and continue to analyze and challenge them by considering other potential courses of action. Personal Evolution

Throughout my career thus far as an RN, I have many different moments where I have practiced clinical reasoning. One particular night that I was working on the medical-surgical floor came to mind. I was in charge on this shift and was making rounds on all of the patients. I noticed our long-term tracheostomy patient was more lethargic, color was gray and he had new onset confusion. I immediately took the patients vital signs and notified our physician on-call. I began to check through the patients chart and it was noted that the patient had a critically high CO2 level and he refused transfer to ICU to be hooked up to the ventilator on the previous shift. This was not passed on in report from the oncoming shift so if walking rounds had not been completed the patient could of coded and not made it.

The patient had multiple co-morbidities and was dependent on his trach-collar. I notified the patients’ wife and talked to both of them on the phone at the same time. I educated each of them about the importance of “blowing” off the CO2 with the ventilator. The wife immediately agreed that a transfer to ICU was the right thing to do but the patient was still skeptical. We ended up transferring him within 30 minutes due to worsening condition. The patient was hooked up to the ventilator and was transferred back to the medical-surgical floor in 24 hours and was back to him normal self. Conclusion

Critical thinking and clinical reasoning are very difficult in the nursing world. It isn’t for everyone and can be forced to allow us to face honest assessments of how little we actually know. Whether you are faced with using critical thinking or clinical reasoning in the nursing field, recognize the opportunity to expand your understanding of other models and methods that you may be less familiar with and gain valuable experience from this. Lives depend on competent clinical reasoning. Thus it is a moral imperative for health care providers to strive to monitor and improve their clinical reasoning and care related judgments.

Benner, P., Hughes, R. and Sutphen, M. (2008). Clinical reasoning, decision making, and action: Thinking critically and clinically. In R.G. Hughes (Ed.). Patient safety and quality: An evidence-based handbook for nurses (pp. (Prepared with support from the Robert Wood Johnson Foundation). AHRQ Publication No. 08-0043. Retrieved from http://archive.ahrq.gov/professionals/clinicians-

providers/resources/nursing/resources/nurseshdbk/BennerP_CRDA.pdf Cody, W. K (2002). Critical thinking and nursing science: Judgment or vision? Nursing Science Quarterly, 15 (3), 187-189. doi:10.1177/08918402015003002

Daly, W. (1998). Critical thinking as an outcome of nursing education. What is it? Why is it important to nursing practice? Journal of Advanced Nursing. 28 (2): 323-331. DOI: 10.1177/08918402015003002

Robert, R. R., & Petersen, S. (2013). Critical thinking at the bedside: Providing safe passage to patients. MEDSURG Nursing, 22(2), 85-118.
Simmons, B. (2010). Clinical reasoning: Concept analysis. Journal of Advanced Nursing, 66 (5), 1151- 1158. doi: 10.111/j.1365-2648.2010.05262.x
Tucker, C & Bradshaw, M. (2013). Clinical reasoning: Action-focused thinking. In M. Bradshaw and A. Lowenstein (Eds.). Innovative teaching strategies, 6th edition. (pp. 65- 77). Burlington, MA: Jones & Bartlett.

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