critical thinking clinical reasoning and clinical judgement a practical approach

Critical Thinking, Clinical Reasoning, and Clinical Judgment

A practical approach.

• 7th Edition - July 23, 2019
• Author: Rosalinda Alfaro-Lefevre
• Language: English
• Paperback ISBN: 9780323581257 9 7 8 - 0 - 3 2 3 - 5 8 1 2 5 - 7
• Paperback ISBN: 9780323676922 9 7 8 - 0 - 3 2 3 - 6 7 6 9 2 - 2
• eBook ISBN: 9780323594721 9 7 8 - 0 - 3 2 3 - 5 9 4 7 2 - 1

Develop the critical thinking and reasoning skills you need to make sound clinical judgments! Alfaro-LeFevre's Critical Thinking, Clinical Reasoning, and Clinical Judgment: A Pract… Read more

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Develop the critical thinking and reasoning skills you need to make sound clinical judgments! Alfaro-LeFevre's Critical Thinking, Clinical Reasoning, and Clinical Judgment: A Practical Approach, 7th Edition brings these concepts to life through engaging text, diverse learning activities, and real-life examples. Easy-to-understand language and a "how-to" approach equip you to become a sensible, resilient critical thinker with the clinical reasoning skills you need to think think through complex issues and make sound clinical decisions. This edition emphasizes readiness for clinical practice and the Next Generation NCLEX exam, with a focus on systems thinking, interprofessional practice, nursing skills for the 21st century, and Quality and Safety for Nursing Education (QSEN) competencies.

• Clear, straightforward approach and motivational writing style
• Focus on application ("how to") with supporting rationales (theory) makes difficult concepts easy to learn.
• Critical Thinking Indicators feature evidence-based descriptions of behaviors that foster critical thinking in nursing practice.
• Highlighted features and sections that promote deep learning include: This Chapter at a Glance , Learning Outcomes, Key Concepts, Guiding Principle boxes, Critical Moments boxes, Other Perspectives features, Think-Pair-Share activities, H.M.O. (Help Me Out) cartoons, real-life clinical scenarios, Key Points, Critical Thinking Exercises , and more!
• Cultural, spiritual, and lifespan content explores the nurse’s role in hospitals, long-term care settings, and entire communities, presenting a broad approach to critical thinking.
• Inclusion of ethics- and standards-based professional practice reflects the increased demand for accountability in today’s professional climate.
• Timely coverage of the latest in nursing education and critical thinking includes concept-based learning; QSEN and IOM standards; problem-focused versus outcome-focused thinking; prioritization and delegation; developing a culture of safe, healthy work environments; expanding roles related to diagnosis and management; improving grades and passing tests the first time; NCLEX exam preparation; ensuring that documentation reflects critical thinking; communication and interpersonal skills; strategies for common workplace challenges; and more.

1. What are Critical Thinking, Clinical Reasoning, and Clinical Judgment? 2. Becoming a Critical Thinker 3. Critical Thinking and Learning Cultures: Teaching, Learning, and Taking Tests 4. Interprofessional Clinical Reasoning, Decision Making, and Judgment 5. Ethical Reasoning, Professionalism, Evidence-Based Practice, and Quality Improvement 6. Practicing Clinical Reasoning, Clinical Judgment, and Decision-making Skills 7. Interprofessional Practice Skills: Communication, Teamwork, and Self-Management NEW interprofessional collaboration focus!

Appendix A. Concept Mapping Appendix B. Nursing Process Summary Appendix C. Examples of CTIs within 4-Circle Model (New) Appendix D. Patient’s Rights and Nurses’ Rights Appendix E. DEAD ON Game Appendix F. Key Brain Parts Involved in Thinking Appendix G. Example SBAR Tool Appendix H. Results of Two Studies Describing Critical Thinking Skills Appendix I. Example Responses for Critical Thinking and Clinical Reasoning Exercises

• No. of pages : 268
• Language : English
• Edition : 7
• Published : July 23, 2019
• Imprint : Elsevier
• Paperback ISBN : 9780323581257
• Paperback ISBN : 9780323676922
• eBook ISBN : 9780323594721

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• Interactive notebook and read-aloud functionality.
• Look up additional information online by highlighting a word or phrase.
• NEW! Spotlight on systems thinking teaches you to consider how things are related, while coverage of conceptual thinking helps you focus on big ideas first.
• NEW! Information on effective clinical simulations encourages learning through practice and debriefing.
• NEW! Clinical reasoning principles are highlighted throughout to ensure you are practice ready.
• NEW! Current critical judgment models are illustrated and explained in a clear, engaging style.
• NEW! Expanded content on growing nursing trends addresses competency assessment, electronic charting (informatics) and "thinking beyond the EHR," clinical evaluation, and preceptor and learner strategies.
• NEW! Strong emphasis on interprofessional collaboration includes new content on its growing importance in health care.
• Clear, straightforward approach and motivational writing style provides vivid examples, memorable anecdotes, and real-life case scenarios to make content come alive.
• Focus on application ("how to") with supporting rationales (theory) makes difficult concepts easy to learn.
• Critical Thinking Indicators feature evidence-based descriptions of behaviors that foster critical thinking in nursing practice.
• Highlighted features and sections that promote deep learning include: This Chapter at a Glance , Learning Outcomes, Key Concepts, Guiding Principle boxes, Critical Moments boxes, Other Perspectives features, Think-Pair-Share activities, H.M.O. (Help Me Out) cartoons, real-life clinical scenarios, Key Points, Critical Thinking Exercises , and more!
• Cultural, spiritual, and lifespan content explores the nurse’s role in hospitals, long-term care settings, and entire communities, presenting a broad approach to critical thinking.
• Inclusion of ethics- and standards-based professional practice reflects the increased demand for accountability in today’s professional climate.
• Timely coverage of the latest in nursing education and critical thinking includes concept-based learning; QSEN and IOM standards; problem-focused versus outcome-focused thinking; prioritization and delegation; developing a culture of safe, healthy work environments; expanding roles related to diagnosis and management; improving grades and passing tests the first time; NCLEX exam preparation; ensuring that documentation reflects critical thinking; communication and interpersonal skills; strategies for common workplace challenges; and more.

1. What are Critical Thinking, Clinical Reasoning, and Clinical Judgment? 2. Becoming a Critical Thinker 3. Critical Thinking and Learning Cultures: Teaching, Learning, and Taking Tests 4. Interprofessional Clinical Reasoning, Decision Making, and Judgment 5. Ethical Reasoning, Professionalism, Evidence-Based Practice, and Quality Improvement 6. Practicing Clinical Reasoning, Clinical Judgment, and Decision-making Skills 7. Interprofessional Practice Skills: Communication, Teamwork, and Self-Management NEW interprofessional collaboration focus!

Appendix A. Concept Mapping Appendix B. Nursing Process Summary Appendix C. Examples of CTIs within 4-Circle Model (New) Appendix D. Patient’s Rights and Nurses’ Rights Appendix E. DEAD ON Game Appendix F. Key Brain Parts Involved in Thinking Appendix G. Example SBAR Tool Appendix H. Results of Two Studies Describing Critical Thinking Skills Appendix I. Example Responses for Critical Thinking and Clinical Reasoning Exercises

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Critical Thinking, Clinical Reasoning, and Clinical Judgment, 7th Edition

• Share to receive a discount off your next order
• Share on Twitter

• NEW! Spotlight on systems thinking teaches you to consider how things are related, while coverage of conceptual thinking helps you focus on big ideas first.
• NEW! Information on effective clinical simulations encourages learning through practice and debriefing.
• NEW! Clinical reasoning principles are highlighted throughout to ensure you are practice ready.
• NEW! Current critical judgment models are illustrated and explained in a clear, engaging style.
• NEW! Expanded content on growing nursing trends addresses competency assessment, electronic charting (informatics) and "thinking beyond the EHR," clinical evaluation, and preceptor and learner strategies.
• NEW! Strong emphasis on interprofessional collaboration includes new content on its growing importance in health care.
• Clear, straightforward approach and motivational writing style provides vivid examples, memorable anecdotes, and real-life case scenarios to make content come alive.
• Focus on application ("how to") with supporting rationales (theory) makes difficult concepts easy to learn.
• Critical Thinking Indicators feature evidence-based descriptions of behaviors that foster critical thinking in nursing practice.
• Highlighted features and sections that promote deep learning include: This Chapter at a Glance , Learning Outcomes, Key Concepts, Guiding Principle boxes, Critical Moments boxes, Other Perspectives features, Think-Pair-Share activities, H.M.O. (Help Me Out) cartoons, real-life clinical scenarios, Key Points, Critical Thinking Exercises , and more!
• Cultural, spiritual, and lifespan content explores the nurse’s role in hospitals, long-term care settings, and entire communities, presenting a broad approach to critical thinking.
• Inclusion of ethics- and standards-based professional practice reflects the increased demand for accountability in today’s professional climate.
• Timely coverage of the latest in nursing education and critical thinking includes concept-based learning; QSEN and IOM standards; problem-focused versus outcome-focused thinking; prioritization and delegation; developing a culture of safe, healthy work environments; expanding roles related to diagnosis and management; improving grades and passing tests the first time; NCLEX exam preparation; ensuring that documentation reflects critical thinking; communication and interpersonal skills; strategies for common workplace challenges; and more.

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Critical Thinking, Clinical Reasoning, and Clinical Judgment, 7th Edition

• Share to receive a discount off your next order
• Share on Twitter

VitalSource Bookshelf gives you access to content when, where, and how you want. When you read an eBook on VitalSource Bookshelf, enjoy such features as:

• Access online or offline, on mobile or desktop devices.
• Bookmarks, highlights and notes sync across all your devices.
• Smart study tools such as note sharing and subscription, review mode, and Microsoft OneNote integration.
• Search and navigate content across your entire Bookshelf library.
• Interactive notebook and read-aloud functionality.
• Look up additional information online by highlighting a word or phrase.
• NEW! Spotlight on systems thinking teaches you to consider how things are related, while coverage of conceptual thinking helps you focus on big ideas first.
• NEW! Information on effective clinical simulations encourages learning through practice and debriefing.
• NEW! Clinical reasoning principles are highlighted throughout to ensure you are practice ready.
• NEW! Current critical judgment models are illustrated and explained in a clear, engaging style.
• NEW! Expanded content on growing nursing trends addresses competency assessment, electronic charting (informatics) and "thinking beyond the EHR," clinical evaluation, and preceptor and learner strategies.
• NEW! Strong emphasis on interprofessional collaboration includes new content on its growing importance in health care.
• Clear, straightforward approach and motivational writing style provides vivid examples, memorable anecdotes, and real-life case scenarios to make content come alive.
• Focus on application ("how to") with supporting rationales (theory) makes difficult concepts easy to learn.
• Critical Thinking Indicators feature evidence-based descriptions of behaviors that foster critical thinking in nursing practice.
• Highlighted features and sections that promote deep learning include: This Chapter at a Glance , Learning Outcomes, Key Concepts, Guiding Principle boxes, Critical Moments boxes, Other Perspectives features, Think-Pair-Share activities, H.M.O. (Help Me Out) cartoons, real-life clinical scenarios, Key Points, Critical Thinking Exercises , and more!
• Cultural, spiritual, and lifespan content explores the nurse’s role in hospitals, long-term care settings, and entire communities, presenting a broad approach to critical thinking.
• Inclusion of ethics- and standards-based professional practice reflects the increased demand for accountability in today’s professional climate.
• Timely coverage of the latest in nursing education and critical thinking includes concept-based learning; QSEN and IOM standards; problem-focused versus outcome-focused thinking; prioritization and delegation; developing a culture of safe, healthy work environments; expanding roles related to diagnosis and management; improving grades and passing tests the first time; NCLEX exam preparation; ensuring that documentation reflects critical thinking; communication and interpersonal skills; strategies for common workplace challenges; and more.

1. What are Critical Thinking, Clinical Reasoning, and Clinical Judgment? 2. Becoming a Critical Thinker 3. Critical Thinking and Learning Cultures: Teaching, Learning, and Taking Tests 4. Interprofessional Clinical Reasoning, Decision Making, and Judgment 5. Ethical Reasoning, Professionalism, Evidence-Based Practice, and Quality Improvement 6. Practicing Clinical Reasoning, Clinical Judgment, and Decision-making Skills 7. Interprofessional Practice Skills: Communication, Teamwork, and Self-Management NEW interprofessional collaboration focus!

Appendix A. Concept Mapping Appendix B. Nursing Process Summary Appendix C. Examples of CTIs within 4-Circle Model (New) Appendix D. Patient’s Rights and Nurses’ Rights Appendix E. DEAD ON Game Appendix F. Key Brain Parts Involved in Thinking Appendix G. Example SBAR Tool Appendix H. Results of Two Studies Describing Critical Thinking Skills Appendix I. Example Responses for Critical Thinking and Clinical Reasoning Exercises

* Elsevier is a leading publisher of health science books and journals, helping to advance medicine by delivering superior education, reference information and decision support tools to doctors, nurses, health practitioners and students. With titles available across a variety of media, we are able to supply the information you need in the most convenient format.

Copyright © 2024, its licensors, and contributors.

All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Cookies are used by this site. Cookie Settings

For problems or suggestions regarding this site, please visit our Support Hub .

• Update librarian

Key Features

New features.

Very good book, engaging, good use of figures and diagrams. Good application to practice - I will also be adding this to an International Health Assessment reading list.

This is a fantastic update from previous versions giving good scenarios for the students to work through. It includes all the relevant theories of clinical decision making and relates this to up to date practice.

Personally I love the practical approach and as such, it should be of use to my students. It couldn't be a core text though as the module is speciality specific, but I expect students to develop critical thinking and clinical reasoning within the module and they need ideas of ways to do this. Thank you for writing this text.

An excellent book used by other staff members and students. Very helpful when teaching communication and interpersonal skills

An exceptionally well written book, that related to all Healthcare professionals not just Nursing Students - the aspects on critical thinking has been central to the course

This year I was able to use a few chapters of the book to develop the basics of nursing course for English students.

Potter, Perry, Stockert, Hall, A

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Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Chapter 6 clinical reasoning, decisionmaking, and action: thinking critically and clinically.

Patricia Benner ; Ronda G. Hughes ; Molly Sutphen .

Affiliations

This chapter examines multiple thinking strategies that are needed for high-quality clinical practice. Clinical reasoning and judgment are examined in relation to other modes of thinking used by clinical nurses in providing quality health care to patients that avoids adverse events and patient harm. The clinician’s ability to provide safe, high-quality care can be dependent upon their ability to reason, think, and judge, which can be limited by lack of experience. The expert performance of nurses is dependent upon continual learning and evaluation of performance.

• Critical Thinking

Nursing education has emphasized critical thinking as an essential nursing skill for more than 50 years. 1 The definitions of critical thinking have evolved over the years. There are several key definitions for critical thinking to consider. The American Philosophical Association (APA) defined critical thinking as purposeful, self-regulatory judgment that uses cognitive tools such as interpretation, analysis, evaluation, inference, and explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations on which judgment is based. 2 A more expansive general definition of critical thinking is

. . . in short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposes assent to rigorous standards of excellence and mindful command of their use. It entails effective communication and problem solving abilities and a commitment to overcome our native egocentrism and sociocentrism. Every clinician must develop rigorous habits of critical thinking, but they cannot escape completely the situatedness and structures of the clinical traditions and practices in which they must make decisions and act quickly in specific clinical situations. 3

There are three key definitions for nursing, which differ slightly. Bittner and Tobin defined critical thinking as being “influenced by knowledge and experience, using strategies such as reflective thinking as a part of learning to identify the issues and opportunities, and holistically synthesize the information in nursing practice” 4 (p. 268). Scheffer and Rubenfeld 5 expanded on the APA definition for nurses through a consensus process, resulting in the following definition:

Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, openmindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge 6 (Scheffer & Rubenfeld, p. 357).

The National League for Nursing Accreditation Commission (NLNAC) defined critical thinking as:

the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research 7 (p. 8).

These concepts are furthered by the American Association of Colleges of Nurses’ definition of critical thinking in their Essentials of Baccalaureate Nursing :

Critical thinking underlies independent and interdependent decision making. Critical thinking includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity 8 (p. 9).

Course work or ethical experiences should provide the graduate with the knowledge and skills to:

• Use nursing and other appropriate theories and models, and an appropriate ethical framework;
• Apply research-based knowledge from nursing and the sciences as the basis for practice;
• Use clinical judgment and decision-making skills;
• Engage in self-reflective and collegial dialogue about professional practice;
• Evaluate nursing care outcomes through the acquisition of data and the questioning of inconsistencies, allowing for the revision of actions and goals;
• Engage in creative problem solving 8 (p. 10).

Taken together, these definitions of critical thinking set forth the scope and key elements of thought processes involved in providing clinical care. Exactly how critical thinking is defined will influence how it is taught and to what standard of care nurses will be held accountable.

Professional and regulatory bodies in nursing education have required that critical thinking be central to all nursing curricula, but they have not adequately distinguished critical reflection from ethical, clinical, or even creative thinking for decisionmaking or actions required by the clinician. Other essential modes of thought such as clinical reasoning, evaluation of evidence, creative thinking, or the application of well-established standards of practice—all distinct from critical reflection—have been subsumed under the rubric of critical thinking. In the nursing education literature, clinical reasoning and judgment are often conflated with critical thinking. The accrediting bodies and nursing scholars have included decisionmaking and action-oriented, practical, ethical, and clinical reasoning in the rubric of critical reflection and thinking. One might say that this harmless semantic confusion is corrected by actual practices, except that students need to understand the distinctions between critical reflection and clinical reasoning, and they need to learn to discern when each is better suited, just as students need to also engage in applying standards, evidence-based practices, and creative thinking.

The growing body of research, patient acuity, and complexity of care demand higher-order thinking skills. Critical thinking involves the application of knowledge and experience to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. These skills can be cultivated by educators who display the virtues of critical thinking, including independence of thought, intellectual curiosity, courage, humility, empathy, integrity, perseverance, and fair-mindedness. 9

The process of critical thinking is stimulated by integrating the essential knowledge, experiences, and clinical reasoning that support professional practice. The emerging paradigm for clinical thinking and cognition is that it is social and dialogical rather than monological and individual. 10–12 Clinicians pool their wisdom and multiple perspectives, yet some clinical knowledge can be demonstrated only in the situation (e.g., how to suction an extremely fragile patient whose oxygen saturations sink too low). Early warnings of problematic situations are made possible by clinicians comparing their observations to that of other providers. Clinicians form practice communities that create styles of practice, including ways of doing things, communication styles and mechanisms, and shared expectations about performance and expertise of team members.

By holding up critical thinking as a large umbrella for different modes of thinking, students can easily misconstrue the logic and purposes of different modes of thinking. Clinicians and scientists alike need multiple thinking strategies, such as critical thinking, clinical judgment, diagnostic reasoning, deliberative rationality, scientific reasoning, dialogue, argument, creative thinking, and so on. In particular, clinicians need forethought and an ongoing grasp of a patient’s health status and care needs trajectory, which requires an assessment of their own clarity and understanding of the situation at hand, critical reflection, critical reasoning, and clinical judgment.

Critical Reflection, Critical Reasoning, and Judgment

Critical reflection requires that the thinker examine the underlying assumptions and radically question or doubt the validity of arguments, assertions, and even facts of the case. Critical reflective skills are essential for clinicians; however, these skills are not sufficient for the clinician who must decide how to act in particular situations and avoid patient injury. For example, in everyday practice, clinicians cannot afford to critically reflect on the well-established tenets of “normal” or “typical” human circulatory systems when trying to figure out a particular patient’s alterations from that typical, well-grounded understanding that has existed since Harvey’s work in 1628. 13 Yet critical reflection can generate new scientifically based ideas. For example, there is a lack of adequate research on the differences between women’s and men’s circulatory systems and the typical pathophysiology related to heart attacks. Available research is based upon multiple, taken-for-granted starting points about the general nature of the circulatory system. As such, critical reflection may not provide what is needed for a clinician to act in a situation. This idea can be considered reasonable since critical reflective thinking is not sufficient for good clinical reasoning and judgment. The clinician’s development of skillful critical reflection depends upon being taught what to pay attention to, and thus gaining a sense of salience that informs the powers of perceptual grasp. The powers of noticing or perceptual grasp depend upon noticing what is salient and the capacity to respond to the situation.

Critical reflection is a crucial professional skill, but it is not the only reasoning skill or logic clinicians require. The ability to think critically uses reflection, induction, deduction, analysis, challenging assumptions, and evaluation of data and information to guide decisionmaking. 9 , 14 , 15 Critical reasoning is a process whereby knowledge and experience are applied in considering multiple possibilities to achieve the desired goals, 16 while considering the patient’s situation. 14 It is a process where both inductive and deductive cognitive skills are used. 17 Sometimes clinical reasoning is presented as a form of evaluating scientific knowledge, sometimes even as a form of scientific reasoning. Critical thinking is inherent in making sound clinical reasoning. 18

An essential point of tension and confusion exists in practice traditions such as nursing and medicine when clinical reasoning and critical reflection become entangled, because the clinician must have some established bases that are not questioned when engaging in clinical decisions and actions, such as standing orders. The clinician must act in the particular situation and time with the best clinical and scientific knowledge available. The clinician cannot afford to indulge in either ritualistic unexamined knowledge or diagnostic or therapeutic nihilism caused by radical doubt, as in critical reflection, because they must find an intelligent and effective way to think and act in particular clinical situations. Critical reflection skills are essential to assist practitioners to rethink outmoded or even wrong-headed approaches to health care, health promotion, and prevention of illness and complications, especially when new evidence is available. Breakdowns in practice, high failure rates in particular therapies, new diseases, new scientific discoveries, and societal changes call for critical reflection about past assumptions and no-longer-tenable beliefs.

Clinical reasoning stands out as a situated, practice-based form of reasoning that requires a background of scientific and technological research-based knowledge about general cases, more so than any particular instance. It also requires practical ability to discern the relevance of the evidence behind general scientific and technical knowledge and how it applies to a particular patient. In dong so, the clinician considers the patient’s particular clinical trajectory, their concerns and preferences, and their particular vulnerabilities (e.g., having multiple comorbidities) and sensitivities to care interventions (e.g., known drug allergies, other conflicting comorbid conditions, incompatible therapies, and past responses to therapies) when forming clinical decisions or conclusions.

Situated in a practice setting, clinical reasoning occurs within social relationships or situations involving patient, family, community, and a team of health care providers. The expert clinician situates themselves within a nexus of relationships, with concerns that are bounded by the situation. Expert clinical reasoning is socially engaged with the relationships and concerns of those who are affected by the caregiving situation, and when certain circumstances are present, the adverse event. Halpern 19 has called excellent clinical ethical reasoning “emotional reasoning” in that the clinicians have emotional access to the patient/family concerns and their understanding of the particular care needs. Expert clinicians also seek an optimal perceptual grasp, one based on understanding and as undistorted as possible, based on an attuned emotional engagement and expert clinical knowledge. 19 , 20

Clergy educators 21 and nursing and medical educators have begun to recognize the wisdom of broadening their narrow vision of rationality beyond simple rational calculation (exemplified by cost-benefit analysis) to reconsider the need for character development—including emotional engagement, perception, habits of thought, and skill acquisition—as essential to the development of expert clinical reasoning, judgment, and action. 10 , 22–24 Practitioners of engineering, law, medicine, and nursing, like the clergy, have to develop a place to stand in their discipline’s tradition of knowledge and science in order to recognize and evaluate salient evidence in the moment. Diagnostic confusion and disciplinary nihilism are both threats to the clinician’s ability to act in particular situations. However, the practice and practitioners will not be self-improving and vital if they cannot engage in critical reflection on what is not of value, what is outmoded, and what does not work. As evidence evolves and expands, so too must clinical thought.

Clinical judgment requires clinical reasoning across time about the particular, and because of the relevance of this immediate historical unfolding, clinical reasoning can be very different from the scientific reasoning used to formulate, conduct, and assess clinical experiments. While scientific reasoning is also socially embedded in a nexus of social relationships and concerns, the goal of detached, critical objectivity used to conduct scientific experiments minimizes the interactive influence of the research on the experiment once it has begun. Scientific research in the natural and clinical sciences typically uses formal criteria to develop “yes” and “no” judgments at prespecified times. The scientist is always situated in past and immediate scientific history, preferring to evaluate static and predetermined points in time (e.g., snapshot reasoning), in contrast to a clinician who must always reason about transitions over time. 25 , 26

Techne and Phronesis

Distinctions between the mere scientific making of things and practice was first explored by Aristotle as distinctions between techne and phronesis. 27 Learning to be a good practitioner requires developing the requisite moral imagination for good practice. If, for example, patients exercise their rights and refuse treatments, practitioners are required to have the moral imagination to understand the probable basis for the patient’s refusal. For example, was the refusal based upon catastrophic thinking, unrealistic fears, misunderstanding, or even clinical depression?

Techne, as defined by Aristotle, encompasses the notion of formation of character and habitus 28 as embodied beings. In Aristotle’s terms, techne refers to the making of things or producing outcomes. 11 Joseph Dunne defines techne as “the activity of producing outcomes,” and it “is governed by a means-ends rationality where the maker or producer governs the thing or outcomes produced or made through gaining mastery over the means of producing the outcomes, to the point of being able to separate means and ends” 11 (p. 54). While some aspects of medical and nursing practice fall into the category of techne, much of nursing and medical practice falls outside means-ends rationality and must be governed by concern for doing good or what is best for the patient in particular circumstances, where being in a relationship and discerning particular human concerns at stake guide action.

Phronesis, in contrast to techne, includes reasoning about the particular, across time, through changes or transitions in the patient’s and/or the clinician’s understanding. As noted by Dunne, phronesis is “characterized at least as much by a perceptiveness with regard to concrete particulars as by a knowledge of universal principles” 11 (p. 273). This type of practical reasoning often takes the form of puzzle solving or the evaluation of immediate past “hot” history of the patient’s situation. Such a particular clinical situation is necessarily particular, even though many commonalities and similarities with other disease syndromes can be recognized through signs and symptoms and laboratory tests. 11 , 29 , 30 Pointing to knowledge embedded in a practice makes no claim for infallibility or “correctness.” Individual practitioners can be mistaken in their judgments because practices such as medicine and nursing are inherently underdetermined. 31

While phronetic knowledge must remain open to correction and improvement, real events, and consequences, it cannot consistently transcend the institutional setting’s capacities and supports for good practice. Phronesis is also dependent on ongoing experiential learning of the practitioner, where knowledge is refined, corrected, or refuted. The Western tradition, with the notable exception of Aristotle, valued knowledge that could be made universal and devalued practical know-how and experiential learning. Descartes codified this preference for formal logic and rational calculation.

Aristotle recognized that when knowledge is underdetermined, changeable, and particular, it cannot be turned into the universal or standardized. It must be perceived, discerned, and judged, all of which require experiential learning. In nursing and medicine, perceptual acuity in physical assessment and clinical judgment (i.e., reasoning across time about changes in the particular patient or the clinician’s understanding of the patient’s condition) fall into the Greek Aristotelian category of phronesis. Dewey 32 sought to rescue knowledge gained by practical activity in the world. He identified three flaws in the understanding of experience in Greek philosophy: (1) empirical knowing is the opposite of experience with science; (2) practice is reduced to techne or the application of rational thought or technique; and (3) action and skilled know-how are considered temporary and capricious as compared to reason, which the Greeks considered as ultimate reality.

In practice, nursing and medicine require both techne and phronesis. The clinician standardizes and routinizes what can be standardized and routinized, as exemplified by standardized blood pressure measurements, diagnoses, and even charting about the patient’s condition and treatment. 27 Procedural and scientific knowledge can often be formalized and standardized (e.g., practice guidelines), or at least made explicit and certain in practice, except for the necessary timing and adjustments made for particular patients. 11 , 22

Rational calculations available to techne—population trends and statistics, algorithms—are created as decision support structures and can improve accuracy when used as a stance of inquiry in making clinical judgments about particular patients. Aggregated evidence from clinical trials and ongoing working knowledge of pathophysiology, biochemistry, and genomics are essential. In addition, the skills of phronesis (clinical judgment that reasons across time, taking into account the transitions of the particular patient/family/community and transitions in the clinician’s understanding of the clinical situation) will be required for nursing, medicine, or any helping profession.

Thinking Critically

Being able to think critically enables nurses to meet the needs of patients within their context and considering their preferences; meet the needs of patients within the context of uncertainty; consider alternatives, resulting in higher-quality care; 33 and think reflectively, rather than simply accepting statements and performing tasks without significant understanding and evaluation. 34 Skillful practitioners can think critically because they have the following cognitive skills: information seeking, discriminating, analyzing, transforming knowledge, predicating, applying standards, and logical reasoning. 5 One’s ability to think critically can be affected by age, length of education (e.g., an associate vs. a baccalaureate decree in nursing), and completion of philosophy or logic subjects. 35–37 The skillful practitioner can think critically because of having the following characteristics: motivation, perseverance, fair-mindedness, and deliberate and careful attention to thinking. 5 , 9

Thinking critically implies that one has a knowledge base from which to reason and the ability to analyze and evaluate evidence. 38 Knowledge can be manifest by the logic and rational implications of decisionmaking. Clinical decisionmaking is particularly influenced by interpersonal relationships with colleagues, 39 patient conditions, availability of resources, 40 knowledge, and experience. 41 Of these, experience has been shown to enhance nurses’ abilities to make quick decisions 42 and fewer decision errors, 43 support the identification of salient cues, and foster the recognition and action on patterns of information. 44 , 45

Clinicians must develop the character and relational skills that enable them to perceive and understand their patient’s needs and concerns. This requires accurate interpretation of patient data that is relevant to the specific patient and situation. In nursing, this formation of moral agency focuses on learning to be responsible in particular ways demanded by the practice, and to pay attention and intelligently discern changes in patients’ concerns and/or clinical condition that require action on the part of the nurse or other health care workers to avert potential compromises to quality care.

Formation of the clinician’s character, skills, and habits are developed in schools and particular practice communities within a larger practice tradition. As Dunne notes,

A practice is not just a surface on which one can display instant virtuosity. It grounds one in a tradition that has been formed through an elaborate development and that exists at any juncture only in the dispositions (slowly and perhaps painfully acquired) of its recognized practitioners. The question may of course be asked whether there are any such practices in the contemporary world, whether the wholesale encroachment of Technique has not obliterated them—and whether this is not the whole point of MacIntyre’s recipe of withdrawal, as well as of the post-modern story of dispossession 11 (p. 378).

Clearly Dunne is engaging in critical reflection about the conditions for developing character, skills, and habits for skillful and ethical comportment of practitioners, as well as to act as moral agents for patients so that they and their families receive safe, effective, and compassionate care.

Professional socialization or professional values, while necessary, do not adequately address character and skill formation that transform the way the practitioner exists in his or her world, what the practitioner is capable of noticing and responding to, based upon well-established patterns of emotional responses, skills, dispositions to act, and the skills to respond, decide, and act. 46 The need for character and skill formation of the clinician is what makes a practice stand out from a mere technical, repetitious manufacturing process. 11 , 30 , 47

In nursing and medicine, many have questioned whether current health care institutions are designed to promote or hinder enlightened, compassionate practice, or whether they have deteriorated into commercial institutional models that focus primarily on efficiency and profit. MacIntyre points out the links between the ongoing development and improvement of practice traditions and the institutions that house them:

Lack of justice, lack of truthfulness, lack of courage, lack of the relevant intellectual virtues—these corrupt traditions, just as they do those institutions and practices which derive their life from the traditions of which they are the contemporary embodiments. To recognize this is of course also to recognize the existence of an additional virtue, one whose importance is perhaps most obvious when it is least present, the virtue of having an adequate sense of the traditions to which one belongs or which confront one. This virtue is not to be confused with any form of conservative antiquarianism; I am not praising those who choose the conventional conservative role of laudator temporis acti. It is rather the case that an adequate sense of tradition manifests itself in a grasp of those future possibilities which the past has made available to the present. Living traditions, just because they continue a not-yet-completed narrative, confront a future whose determinate and determinable character, so far as it possesses any, derives from the past 30 (p. 207).

It would be impossible to capture all the situated and distributed knowledge outside of actual practice situations and particular patients. Simulations are powerful as teaching tools to enable nurses’ ability to think critically because they give students the opportunity to practice in a simplified environment. However, students can be limited in their inability to convey underdetermined situations where much of the information is based on perceptions of many aspects of the patient and changes that have occurred over time. Simulations cannot have the sub-cultures formed in practice settings that set the social mood of trust, distrust, competency, limited resources, or other forms of situated possibilities.

One of the hallmark studies in nursing providing keen insight into understanding the influence of experience was a qualitative study of adult, pediatric, and neonatal intensive care unit (ICU) nurses, where the nurses were clustered into advanced beginner, intermediate, and expert level of practice categories. The advanced beginner (having up to 6 months of work experience) used procedures and protocols to determine which clinical actions were needed. When confronted with a complex patient situation, the advanced beginner felt their practice was unsafe because of a knowledge deficit or because of a knowledge application confusion. The transition from advanced beginners to competent practitioners began when they first had experience with actual clinical situations and could benefit from the knowledge gained from the mistakes of their colleagues. Competent nurses continuously questioned what they saw and heard, feeling an obligation to know more about clinical situations. In doing do, they moved from only using care plans and following the physicians’ orders to analyzing and interpreting patient situations. Beyond that, the proficient nurse acknowledged the changing relevance of clinical situations requiring action beyond what was planned or anticipated. The proficient nurse learned to acknowledge the changing needs of patient care and situation, and could organize interventions “by the situation as it unfolds rather than by preset goals 48 (p. 24). Both competent and proficient nurses (that is, intermediate level of practice) had at least two years of ICU experience. 48 Finally, the expert nurse had a more fully developed grasp of a clinical situation, a sense of confidence in what is known about the situation, and could differentiate the precise clinical problem in little time. 48

Expertise is acquired through professional experience and is indicative of a nurse who has moved beyond mere proficiency. As Gadamer 29 points out, experience involves a turning around of preconceived notions, preunderstandings, and extends or adds nuances to understanding. Dewey 49 notes that experience requires a prepared “creature” and an enriched environment. The opportunity to reflect and narrate one’s experiential learning can clarify, extend, or even refute experiential learning.

Experiential learning requires time and nurturing, but time alone does not ensure experiential learning. Aristotle linked experiential learning to the development of character and moral sensitivities of a person learning a practice. 50 New nurses/new graduates have limited work experience and must experience continuing learning until they have reached an acceptable level of performance. 51 After that, further improvements are not predictable, and years of experience are an inadequate predictor of expertise. 52

The most effective knower and developer of practical knowledge creates an ongoing dialogue and connection between lessons of the day and experiential learning over time. Gadamer, in a late life interview, highlighted the open-endedness and ongoing nature of experiential learning in the following interview response:

Being experienced does not mean that one now knows something once and for all and becomes rigid in this knowledge; rather, one becomes more open to new experiences. A person who is experienced is undogmatic. Experience has the effect of freeing one to be open to new experience … In our experience we bring nothing to a close; we are constantly learning new things from our experience … this I call the interminability of all experience 32 (p. 403).

Practical endeavor, supported by scientific knowledge, requires experiential learning, the development of skilled know-how, and perceptual acuity in order to make the scientific knowledge relevant to the situation. Clinical perceptual and skilled know-how helps the practitioner discern when particular scientific findings might be relevant. 53

Often experience and knowledge, confirmed by experimentation, are treated as oppositions, an either-or choice. However, in practice it is readily acknowledged that experiential knowledge fuels scientific investigation, and scientific investigation fuels further experiential learning. Experiential learning from particular clinical cases can help the clinician recognize future similar cases and fuel new scientific questions and study. For example, less experienced nurses—and it could be argued experienced as well—can use nursing diagnoses practice guidelines as part of their professional advancement. Guidelines are used to reflect their interpretation of patients’ needs, responses, and situation, 54 a process that requires critical thinking and decisionmaking. 55 , 56 Using guidelines also reflects one’s problem identification and problem-solving abilities. 56 Conversely, the ability to proficiently conduct a series of tasks without nursing diagnoses is the hallmark of expertise. 39 , 57

Experience precedes expertise. As expertise develops from experience and gaining knowledge and transitions to the proficiency stage, the nurses’ thinking moves from steps and procedures (i.e., task-oriented care) toward “chunks” or patterns 39 (i.e., patient-specific care). In doing so, the nurse thinks reflectively, rather than merely accepting statements and performing procedures without significant understanding and evaluation. 34 Expert nurses do not rely on rules and logical thought processes in problem-solving and decisionmaking. 39 Instead, they use abstract principles, can see the situation as a complex whole, perceive situations comprehensively, and can be fully involved in the situation. 48 Expert nurses can perform high-level care without conscious awareness of the knowledge they are using, 39 , 58 and they are able to provide that care with flexibility and speed. Through a combination of knowledge and skills gained from a range of theoretical and experiential sources, expert nurses also provide holistic care. 39 Thus, the best care comes from the combination of theoretical, tacit, and experiential knowledge. 59 , 60

Experts are thought to eventually develop the ability to intuitively know what to do and to quickly recognize critical aspects of the situation. 22 Some have proposed that expert nurses provide high-quality patient care, 61 , 62 but that is not consistently documented—particularly in consideration of patient outcomes—and a full understanding between the differential impact of care rendered by an “expert” nurse is not fully understood. In fact, several studies have found that length of professional experience is often unrelated and even negatively related to performance measures and outcomes. 63 , 64

In a review of the literature on expertise in nursing, Ericsson and colleagues 65 found that focusing on challenging, less-frequent situations would reveal individual performance differences on tasks that require speed and flexibility, such as that experienced during a code or an adverse event. Superior performance was associated with extensive training and immediate feedback about outcomes, which can be obtained through continual training, simulation, and processes such as root-cause analysis following an adverse event. Therefore, efforts to improve performance benefited from continual monitoring, planning, and retrospective evaluation. Even then, the nurse’s ability to perform as an expert is dependent upon their ability to use intuition or insights gained through interactions with patients. 39

Intuition and Perception

Intuition is the instant understanding of knowledge without evidence of sensible thought. 66 According to Young, 67 intuition in clinical practice is a process whereby the nurse recognizes something about a patient that is difficult to verbalize. Intuition is characterized by factual knowledge, “immediate possession of knowledge, and knowledge independent of the linear reasoning process” 68 (p. 23). When intuition is used, one filters information initially triggered by the imagination, leading to the integration of all knowledge and information to problem solve. 69 Clinicians use their interactions with patients and intuition, drawing on tacit or experiential knowledge, 70 , 71 to apply the correct knowledge to make the correct decisions to address patient needs. Yet there is a “conflated belief in the nurses’ ability to know what is best for the patient” 72 (p. 251) because the nurses’ and patients’ identification of the patients’ needs can vary. 73

A review of research and rhetoric involving intuition by King and Appleton 62 found that all nurses, including students, used intuition (i.e., gut feelings). They found evidence, predominately in critical care units, that intuition was triggered in response to knowledge and as a trigger for action and/or reflection with a direct bearing on the analytical process involved in patient care. The challenge for nurses was that rigid adherence to checklists, guidelines, and standardized documentation, 62 ignored the benefits of intuition. This view was furthered by Rew and Barrow 68 , 74 in their reviews of the literature, where they found that intuition was imperative to complex decisionmaking, 68 difficult to measure and assess in a quantitative manner, and was not linked to physiologic measures. 74

Intuition is a way of explaining professional expertise. 75 Expert nurses rely on their intuitive judgment that has been developed over time. 39 , 76 Intuition is an informal, nonanalytically based, unstructured, deliberate calculation that facilitates problem solving, 77 a process of arriving at salient conclusions based on relatively small amounts of knowledge and/or information. 78 Experts can have rapid insight into a situation by using intuition to recognize patterns and similarities, achieve commonsense understanding, and sense the salient information combined with deliberative rationality. 10 Intuitive recognition of similarities and commonalities between patients are often the first diagnostic clue or early warning, which must then be followed up with critical evaluation of evidence among the competing conditions. This situation calls for intuitive judgment that can distinguish “expert human judgment from the decisions” made by a novice 79 (p. 23).

Shaw 80 equates intuition with direct perception. Direct perception is dependent upon being able to detect complex patterns and relationships that one has learned through experience are important. Recognizing these patterns and relationships generally occurs rapidly and is complex, making it difficult to articulate or describe. Perceptual skills, like those of the expert nurse, are essential to recognizing current and changing clinical conditions. Perception requires attentiveness and the development of a sense of what is salient. Often in nursing and medicine, means and ends are fused, as is the case for a “good enough” birth experience and a peaceful death.

• Applying Practice Evidence

Research continues to find that using evidence-based guidelines in practice, informed through research evidence, improves patients’ outcomes. 81–83 Research-based guidelines are intended to provide guidance for specific areas of health care delivery. 84 The clinician—both the novice and expert—is expected to use the best available evidence for the most efficacious therapies and interventions in particular instances, to ensure the highest-quality care, especially when deviations from the evidence-based norm may heighten risks to patient safety. Otherwise, if nursing and medicine were exact sciences, or consisted only of techne, then a 1:1 relationship could be established between results of aggregated evidence-based research and the best path for all patients.

Evaluating Evidence

Before research should be used in practice, it must be evaluated. There are many complexities and nuances in evaluating the research evidence for clinical practice. Evaluation of research behind evidence-based medicine requires critical thinking and good clinical judgment. Sometimes the research findings are mixed or even conflicting. As such, the validity, reliability, and generalizability of available research are fundamental to evaluating whether evidence can be applied in practice. To do so, clinicians must select the best scientific evidence relevant to particular patients—a complex process that involves intuition to apply the evidence. Critical thinking is required for evaluating the best available scientific evidence for the treatment and care of a particular patient.

Good clinical judgment is required to select the most relevant research evidence. The best clinical judgment, that is, reasoning across time about the particular patient through changes in the patient’s concerns and condition and/or the clinician’s understanding, are also required. This type of judgment requires clinicians to make careful observations and evaluations of the patient over time, as well as know the patient’s concerns and social circumstances. To evolve to this level of judgment, additional education beyond clinical preparation if often required.

Sources of Evidence

Evidence that can be used in clinical practice has different sources and can be derived from research, patient’s preferences, and work-related experience. 85 , 86 Nurses have been found to obtain evidence from experienced colleagues believed to have clinical expertise and research-based knowledge 87 as well as other sources.

For many years now, randomized controlled trials (RCTs) have often been considered the best standard for evaluating clinical practice. Yet, unless the common threats to the validity (e.g., representativeness of the study population) and reliability (e.g., consistency in interventions and responses of study participants) of RCTs are addressed, the meaningfulness and generalizability of the study outcomes are very limited. Relevant patient populations may be excluded, such as women, children, minorities, the elderly, and patients with multiple chronic illnesses. The dropout rate of the trial may confound the results. And it is easier to get positive results published than it is to get negative results published. Thus, RCTs are generalizable (i.e., applicable) only to the population studied—which may not reflect the needs of the patient under the clinicians care. In instances such as these, clinicians need to also consider applied research using prospective or retrospective populations with case control to guide decisionmaking, yet this too requires critical thinking and good clinical judgment.

Another source of available evidence may come from the gold standard of aggregated systematic evaluation of clinical trial outcomes for the therapy and clinical condition in question, be generated by basic and clinical science relevant to the patient’s particular pathophysiology or care need situation, or stem from personal clinical experience. The clinician then takes all of the available evidence and considers the particular patient’s known clinical responses to past therapies, their clinical condition and history, the progression or stages of the patient’s illness and recovery, and available resources.

In clinical practice, the particular is examined in relation to the established generalizations of science. With readily available summaries of scientific evidence (e.g., systematic reviews and practice guidelines) available to nurses and physicians, one might wonder whether deep background understanding is still advantageous. Might it not be expendable, since it is likely to be out of date given the current scientific evidence? But this assumption is a false opposition and false choice because without a deep background understanding, the clinician does not know how to best find and evaluate scientific evidence for the particular case in hand. The clinician’s sense of salience in any given situation depends on past clinical experience and current scientific evidence.

Evidence-Based Practice

The concept of evidence-based practice is dependent upon synthesizing evidence from the variety of sources and applying it appropriately to the care needs of populations and individuals. This implies that evidence-based practice, indicative of expertise in practice, appropriately applies evidence to the specific situations and unique needs of patients. 88 , 89 Unfortunately, even though providing evidence-based care is an essential component of health care quality, it is well known that evidence-based practices are not used consistently.

Conceptually, evidence used in practice advances clinical knowledge, and that knowledge supports independent clinical decisions in the best interest of the patient. 90 , 91 Decisions must prudently consider the factors not necessarily addressed in the guideline, such as the patient’s lifestyle, drug sensitivities and allergies, and comorbidities. Nurses who want to improve the quality and safety of care can do so though improving the consistency of data and information interpretation inherent in evidence-based practice.

Initially, before evidence-based practice can begin, there needs to be an accurate clinical judgment of patient responses and needs. In the course of providing care, with careful consideration of patient safety and quality care, clinicians must give attention to the patient’s condition, their responses to health care interventions, and potential adverse reactions or events that could harm the patient. Nonetheless, there is wide variation in the ability of nurses to accurately interpret patient responses 92 and their risks. 93 Even though variance in interpretation is expected, nurses are obligated to continually improve their skills to ensure that patients receive quality care safely. 94 Patients are vulnerable to the actions and experience of their clinicians, which are inextricably linked to the quality of care patients have access to and subsequently receive.

The judgment of the patient’s condition determines subsequent interventions and patient outcomes. Attaining accurate and consistent interpretations of patient data and information is difficult because each piece can have different meanings, and interpretations are influenced by previous experiences. 95 Nurses use knowledge from clinical experience 96 , 97 and—although infrequently—research. 98–100

Once a problem has been identified, using a process that utilizes critical thinking to recognize the problem, the clinician then searches for and evaluates the research evidence 101 and evaluates potential discrepancies. The process of using evidence in practice involves “a problem-solving approach that incorporates the best available scientific evidence, clinicians’ expertise, and patient’s preferences and values” 102 (p. 28). Yet many nurses do not perceive that they have the education, tools, or resources to use evidence appropriately in practice. 103

Reported barriers to using research in practice have included difficulty in understanding the applicability and the complexity of research findings, failure of researchers to put findings into the clinical context, lack of skills in how to use research in practice, 104 , 105 amount of time required to access information and determine practice implications, 105–107 lack of organizational support to make changes and/or use in practice, 104 , 97 , 105 , 107 and lack of confidence in one’s ability to critically evaluate clinical evidence. 108

When Evidence Is Missing

In many clinical situations, there may be no clear guidelines and few or even no relevant clinical trials to guide decisionmaking. In these cases, the latest basic science about cellular and genomic functioning may be the most relevant science, or by default, guestimation. Consequently, good patient care requires more than a straightforward, unequivocal application of scientific evidence. The clinician must be able to draw on a good understanding of basic sciences, as well as guidelines derived from aggregated data and information from research investigations.

Practical knowledge is shaped by one’s practice discipline and the science and technology relevant to the situation at hand. But scientific, formal, discipline-specific knowledge are not sufficient for good clinical practice, whether the discipline be law, medicine, nursing, teaching, or social work. Practitioners still have to learn how to discern generalizable scientific knowledge, know how to use scientific knowledge in practical situations, discern what scientific evidence/knowledge is relevant, assess how the particular patient’s situation differs from the general scientific understanding, and recognize the complexity of care delivery—a process that is complex, ongoing, and changing, as new evidence can overturn old.

Practice communities like individual practitioners may also be mistaken, as is illustrated by variability in practice styles and practice outcomes across hospitals and regions in the United States. This variability in practice is why practitioners must learn to critically evaluate their practice and continually improve their practice over time. The goal is to create a living self-improving tradition.

Within health care, students, scientists, and practitioners are challenged to learn and use different modes of thinking when they are conflated under one term or rubric, using the best-suited thinking strategies for taking into consideration the purposes and the ends of the reasoning. Learning to be an effective, safe nurse or physician requires not only technical expertise, but also the ability to form helping relationships and engage in practical ethical and clinical reasoning. 50 Good ethical comportment requires that both the clinician and the scientist take into account the notions of good inherent in clinical and scientific practices. The notions of good clinical practice must include the relevant significance and the human concerns involved in decisionmaking in particular situations, centered on clinical grasp and clinical forethought.

The Three Apprenticeships of Professional Education

We have much to learn in comparing the pedagogies of formation across the professions, such as is being done currently by the Carnegie Foundation for the Advancement of Teaching. The Carnegie Foundation’s broad research program on the educational preparation of the profession focuses on three essential apprenticeships:

To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: (1) intellectual training to learn the academic knowledge base and the capacity to think in ways important to the profession; (2) a skill-based apprenticeship of practice; and (3) an apprenticeship to the ethical standards, social roles, and responsibilities of the profession, through which the novice is introduced to the meaning of an integrated practice of all dimensions of the profession, grounded in the profession’s fundamental purposes. 109

This framework has allowed the investigators to describe tensions and shortfalls as well as strengths of widespread teaching practices, especially at articulation points among these dimensions of professional training.

Research has demonstrated that these three apprenticeships are taught best when they are integrated so that the intellectual training includes skilled know-how, clinical judgment, and ethical comportment. In the study of nursing, exemplary classroom and clinical teachers were found who do integrate the three apprenticeships in all of their teaching, as exemplified by the following anonymous student’s comments:

With that as well, I enjoyed the class just because I do have clinical experience in my background and I enjoyed it because it took those practical applications and the knowledge from pathophysiology and pharmacology, and all the other classes, and it tied it into the actual aspects of like what is going to happen at work. For example, I work in the emergency room and question: Why am I doing this procedure for this particular patient? Beforehand, when I was just a tech and I wasn’t going to school, I’d be doing it because I was told to be doing it—or I’d be doing CPR because, you know, the doc said, start CPR. I really enjoy the Care and Illness because now I know the process, the pathophysiological process of why I’m doing it and the clinical reasons of why they’re making the decisions, and the prioritization that goes on behind it. I think that’s the biggest point. Clinical experience is good, but not everybody has it. Yet when these students transition from school and clinicals to their job as a nurse, they will understand what’s going on and why.

The three apprenticeships are equally relevant and intertwined. In the Carnegie National Study of Nursing Education and the companion study on medical education as well as in cross-professional comparisons, teaching that gives an integrated access to professional practice is being examined. Once the three apprenticeships are separated, it is difficult to reintegrate them. The investigators are encouraged by teaching strategies that integrate the latest scientific knowledge and relevant clinical evidence with clinical reasoning about particular patients in unfolding rather than static cases, while keeping the patient and family experience and concerns relevant to clinical concerns and reasoning.

Clinical judgment or phronesis is required to evaluate and integrate techne and scientific evidence.

Within nursing, professional practice is wise and effective usually to the extent that the professional creates relational and communication contexts where clients/patients can be open and trusting. Effectiveness depends upon mutual influence between patient and practitioner, student and learner. This is another way in which clinical knowledge is dialogical and socially distributed. The following articulation of practical reasoning in nursing illustrates the social, dialogical nature of clinical reasoning and addresses the centrality of perception and understanding to good clinical reasoning, judgment and intervention.

Clinical Grasp *

Clinical grasp describes clinical inquiry in action. Clinical grasp begins with perception and includes problem identification and clinical judgment across time about the particular transitions of particular patients. Garrett Chan 20 described the clinician’s attempt at finding an “optimal grasp” or vantage point of understanding. Four aspects of clinical grasp, which are described in the following paragraphs, include (1) making qualitative distinctions, (2) engaging in detective work, (3) recognizing changing relevance, and (4) developing clinical knowledge in specific patient populations.

Making Qualitative Distinctions

Qualitative distinctions refer to those distinctions that can be made only in a particular contextual or historical situation. The context and sequence of events are essential for making qualitative distinctions; therefore, the clinician must pay attention to transitions in the situation and judgment. Many qualitative distinctions can be made only by observing differences through touch, sound, or sight, such as the qualities of a wound, skin turgor, color, capillary refill, or the engagement and energy level of the patient. Another example is assessing whether the patient was more fatigued after ambulating to the bathroom or from lack of sleep. Likewise the quality of the clinician’s touch is distinct as in offering reassurance, putting pressure on a bleeding wound, and so on. 110

Engaging in Detective Work, Modus Operandi Thinking, and Clinical Puzzle Solving

Clinical situations are open ended and underdetermined. Modus operandi thinking keeps track of the particular patient, the way the illness unfolds, the meanings of the patient’s responses as they have occurred in the particular time sequence. Modus operandi thinking requires keeping track of what has been tried and what has or has not worked with the patient. In this kind of reasoning-in-transition, gains and losses of understanding are noticed and adjustments in the problem approach are made.

We found that teachers in a medical surgical unit at the University of Washington deliberately teach their students to engage in “detective work.” Students are given the daily clinical assignment of “sleuthing” for undetected drug incompatibilities, questionable drug dosages, and unnoticed signs and symptoms. For example, one student noted that an unusual dosage of a heart medication was being given to a patient who did not have heart disease. The student first asked her teacher about the unusually high dosage. The teacher, in turn, asked the student whether she had asked the nurse or the patient about the dosage. Upon the student’s questioning, the nurse did not know why the patient was receiving the high dosage and assumed the drug was for heart disease. The patient’s staff nurse had not questioned the order. When the student asked the patient, the student found that the medication was being given for tremors and that the patient and the doctor had titrated the dosage for control of the tremors. This deliberate approach to teaching detective work, or modus operandi thinking, has characteristics of “critical reflection,” but stays situated and engaged, ferreting out the immediate history and unfolding of events.

Recognizing Changing Clinical Relevance

The meanings of signs and symptoms are changed by sequencing and history. The patient’s mental status, color, or pain level may continue to deteriorate or get better. The direction, implication, and consequences for the changes alter the relevance of the particular facts in the situation. The changing relevance entailed in a patient transitioning from primarily curative care to primarily palliative care is a dramatic example, where symptoms literally take on new meanings and require new treatments.

Developing Clinical Knowledge in Specific Patient Populations

Extensive experience with a specific patient population or patients with particular injuries or diseases allows the clinician to develop comparisons, distinctions, and nuanced differences within the population. The comparisons between many specific patients create a matrix of comparisons for clinicians, as well as a tacit, background set of expectations that create population- and patient-specific detective work if a patient does not meet the usual, predictable transitions in recovery. What is in the background and foreground of the clinician’s attention shifts as predictable changes in the patient’s condition occurs, such as is seen in recovering from heart surgery or progressing through the predictable stages of labor and delivery. Over time, the clinician develops a deep background understanding that allows for expert diagnostic and interventions skills.

Clinical Forethought

Clinical forethought is intertwined with clinical grasp, but it is much more deliberate and even routinized than clinical grasp. Clinical forethought is a pervasive habit of thought and action in nursing practice, and also in medicine, as clinicians think about disease and recovery trajectories and the implications of these changes for treatment. Clinical forethought plays a role in clinical grasp because it structures the practical logic of clinicians. At least four habits of thought and action are evident in what we are calling clinical forethought: (1) future think, (2) clinical forethought about specific patient populations, (3) anticipation of risks for particular patients, and (4) seeing the unexpected.

Future think

Future think is the broadest category of this logic of practice. Anticipating likely immediate futures helps the clinician make good plans and decisions about preparing the environment so that responding rapidly to changes in the patient is possible. Without a sense of salience about anticipated signs and symptoms and preparing the environment, essential clinical judgments and timely interventions would be impossible in the typically fast pace of acute and intensive patient care. Future think governs the style and content of the nurse’s attentiveness to the patient. Whether in a fast-paced care environment or a slower-paced rehabilitation setting, thinking and acting with anticipated futures guide clinical thinking and judgment. Future think captures the way judgment is suspended in a predictive net of anticipation and preparing oneself and the environment for a range of potential events.

Clinical forethought about specific diagnoses and injuries

This habit of thought and action is so second nature to the experienced nurse that the new or inexperienced nurse may have difficulty finding out about what seems to other colleagues as “obvious” preparation for particular patients and situations. Clinical forethought involves much local specific knowledge about who is a good resource and how to marshal support services and equipment for particular patients.

Examples of preparing for specific patient populations are pervasive, such as anticipating the need for a pacemaker during surgery and having the equipment assembled ready for use to save essential time. Another example includes forecasting an accident victim’s potential injuries, and recognizing that intubation might be needed.

Anticipation of crises, risks, and vulnerabilities for particular patients

This aspect of clinical forethought is central to knowing the particular patient, family, or community. Nurses situate the patient’s problems almost like a topography of possibilities. This vital clinical knowledge needs to be communicated to other caregivers and across care borders. Clinical teaching could be improved by enriching curricula with narrative examples from actual practice, and by helping students recognize commonly occurring clinical situations in the simulation and clinical setting. For example, if a patient is hemodynamically unstable, then managing life-sustaining physiologic functions will be a main orienting goal. If the patient is agitated and uncomfortable, then attending to comfort needs in relation to hemodynamics will be a priority. Providing comfort measures turns out to be a central background practice for making clinical judgments and contains within it much judgment and experiential learning.

When clinical teaching is too removed from typical contingencies and strong clinical situations in practice, students will lack practice in active thinking-in-action in ambiguous clinical situations. In the following example, an anonymous student recounted her experiences of meeting a patient:

I was used to different equipment and didn’t know how things went, didn’t know their routine, really. You can explain all you want in class, this is how it’s going to be, but when you get there … . Kim was my first instructor and my patient that she assigned me to—I walked into the room and he had every tube imaginable. And so I was a little overwhelmed. It’s not necessarily even that he was that critical … . She asked what tubes here have you seen? Well, I know peripheral lines. You taught me PICC [peripherally inserted central catheter] lines, and we just had that, but I don’t really feel comfortable doing it by myself, without you watching to make sure that I’m flushing it right and how to assess it. He had a chest tube and I had seen chest tubes, but never really knew the depth of what you had to assess and how you make sure that it’s all kosher and whatever. So she went through the chest tube and explained, it’s just bubbling a little bit and that’s okay. The site, check the site. The site looked okay and that she’d say if it wasn’t okay, this is what it might look like … . He had a feeding tube. I had done feeding tubes but that was like a long time ago in my LPN experiences schooling. So I hadn’t really done too much with the feeding stuff either … . He had a [nasogastric] tube, and knew pretty much about that and I think at the time it was clamped. So there were no issues with the suction or whatever. He had a Foley catheter. He had a feeding tube, a chest tube. I can’t even remember but there were a lot.

As noted earlier, a central characteristic of a practice discipline is that a self-improving practice requires ongoing experiential learning. One way nurse educators can enhance clinical inquiry is by increasing pedagogies of experiential learning. Current pedagogies for experiential learning in nursing include extensive preclinical study, care planning, and shared postclinical debriefings where students share their experiential learning with their classmates. Experiential learning requires open learning climates where students can discuss and examine transitions in understanding, including their false starts, or their misconceptions in actual clinical situations. Nursing educators typically develop open and interactive clinical learning communities, so that students seem committed to helping their classmates learn from their experiences that may have been difficult or even unsafe. One anonymous nurse educator described how students extend their experiential learning to their classmates during a postclinical conference:

So for example, the patient had difficulty breathing and the student wanted to give the meds instead of addressing the difficulty of breathing. Well, while we were sharing information about their patients, what they did that day, I didn’t tell the student to say this, but she said, ‘I just want to tell you what I did today in clinical so you don’t do the same thing, and here’s what happened.’ Everybody’s listening very attentively and they were asking her some questions. But she shared that. She didn’t have to. I didn’t tell her, you must share that in postconference or anything like that, but she just went ahead and shared that, I guess, to reinforce what she had learned that day but also to benefit her fellow students in case that thing comes up with them.

The teacher’s response to this student’s honesty and generosity exemplifies her own approach to developing an open community of learning. Focusing only on performance and on “being correct” prevents learning from breakdown or error and can dampen students’ curiosity and courage to learn experientially.

Seeing the unexpected

One of the keys to becoming an expert practitioner lies in how the person holds past experiential learning and background habitual skills and practices. This is a skill of foregrounding attention accurately and effectively in response to the nature of situational demands. Bourdieu 29 calls the recognition of the situation central to practical reasoning. If nothing is routinized as a habitual response pattern, then practitioners will not function effectively in emergencies. Unexpected occurrences may be overlooked. However, if expectations are held rigidly, then subtle changes from the usual will be missed, and habitual, rote responses will inappropriately rule. The clinician must be flexible in shifting between what is in background and foreground. This is accomplished by staying curious and open. The clinical “certainty” associated with perceptual grasp is distinct from the kind of “certainty” achievable in scientific experiments and through measurements. Recognition of similar or paradigmatic clinical situations is similar to “face recognition” or recognition of “family resemblances.” This concept is subject to faulty memory, false associative memories, and mistaken identities; therefore, such perceptual grasp is the beginning of curiosity and inquiry and not the end. Assessment and validation are required. In rapidly moving clinical situations, perceptual grasp is the starting point for clarification, confirmation, and action. Having the clinician say out loud how he or she is understanding the situation gives an opportunity for confirmation and disconfirmation from other clinicians present. 111 The relationship between foreground and background of attention needs to be fluid, so that missed expectations allow the nurse to see the unexpected. For example, when the background rhythm of a cardiac monitor changes, the nurse notices, and what had been background tacit awareness becomes the foreground of attention. A hallmark of expertise is the ability to notice the unexpected. 20 Background expectations of usual patient trajectories form with experience. Tacit expectations for patient trajectories form that enable the nurse to notice subtle failed expectations and pay attention to early signs of unexpected changes in the patient's condition. Clinical expectations gained from caring for similar patient populations form a tacit clinical forethought that enable the experienced clinician to notice missed expectations. Alterations from implicit or explicit expectations set the stage for experiential learning, depending on the openness of the learner.

Learning to provide safe and quality health care requires technical expertise, the ability to think critically, experience, and clinical judgment. The high-performance expectation of nurses is dependent upon the nurses’ continual learning, professional accountability, independent and interdependent decisionmaking, and creative problem-solving abilities.

This section of the paper was condensed and paraphrased from Benner, Hooper-Kyriakidis, and Stannard. 23 Patricia Hooper-Kyriakidis wrote the section on clinical grasp, and Patricia Benner wrote the section on clinical forethought.

• Cite this Page Benner P, Hughes RG, Sutphen M. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 6.
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• Nurses' reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study. [Int J Nurs Stud. 2007] Nurses' reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study. Funkesson KH, Anbäcken EM, Ek AC. Int J Nurs Stud. 2007 Sep; 44(7):1109-19. Epub 2006 Jun 27.
• Registered nurses' clinical reasoning skills and reasoning process: A think-aloud study. [Nurse Educ Today. 2016] Registered nurses' clinical reasoning skills and reasoning process: A think-aloud study. Lee J, Lee YJ, Bae J, Seo M. Nurse Educ Today. 2016 Nov; 46:75-80. Epub 2016 Aug 15.
• Combining the arts: an applied critical thinking approach in the skills laboratory. [Nursingconnections. 2000] Combining the arts: an applied critical thinking approach in the skills laboratory. Peterson MJ, Bechtel GA. Nursingconnections. 2000 Summer; 13(2):43-9.
• Review About critical thinking. [Dynamics. 2004] Review About critical thinking. Hynes P, Bennett J. Dynamics. 2004 Fall; 15(3):26-9.
• Review The 'five rights' of clinical reasoning: an educational model to enhance nursing students' ability to identify and manage clinically 'at risk' patients. [Nurse Educ Today. 2010] Review The 'five rights' of clinical reasoning: an educational model to enhance nursing students' ability to identify and manage clinically 'at risk' patients. Levett-Jones T, Hoffman K, Dempsey J, Jeong SY, Noble D, Norton CA, Roche J, Hickey N. Nurse Educ Today. 2010 Aug; 30(6):515-20. Epub 2009 Nov 30.

Critical Thinking, Clinical Reasoning, and Clinical Judgment

A practical approach, by rosalinda alfaro-lefevre.

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What's behind every healed patient? Critical thinking! Critical Thinking, Clinical Reasoning, and Clinical Judgment: A Practical Approach, 5th Edition, provides the tools you need to become a safe, competent nurse. Using an inspiring, insightful, "how-to" approach, this book helps you develop critical thinking, clinical reasoning, and test-taking skills in preparation for the NCLEX® Examination and, even more importantly, apply critical thinking and clinical reasoning to nursing practice. Critical thinking and clinical reasoning strategies come to life through the use of real-life scenarios and decision-making tools, all supported with evidence for why the strategies work. Expert author Rosalinda Alfaro-LeFevre makes the concepts of critical thinking and clinical reasoning come alive, so you can start thinking like a nurse and learn essential critical thinking and clinical judgment reasoning skills for nursing practice. - Publisher.

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Develop the critical thinking and reasoning skills you need to make sound clinical judgments! Alfaro-LeFevre's Critical Thinking, Clinical Reasoning, and Clinical Judgment: A Practical Approach, 7th Edition brings these concepts to life through engaging text, diverse learning activities, and real-life examples. Easy-to-understand language and a "how-to" approach equip you to become a sensible, resilient critical thinker with the clinical reasoning skills you need to think think through complex issues and make sound clinical decisions. This edition emphasizes readiness for clinical practice and the Next Generation NCLEX exam, with a focus on systems thinking, interprofessional practice, nursing skills for the 21st century, and Quality and Safety for Nursing Education (QSEN) competencies. Clear, straightforward approach and motivational writing style provides vivid examples, memorable anecdotes, and real-life case scenarios to make content come alive. Focus on application ("how to") with supporting rationales (theory) makes difficult concepts easy to learn. Critical Thinking Indicators feature evidence-based descriptions of behaviors that foster critical thinking in nursing practice. Highlighted features and sections that promote deep learning include: This Chapter at a Glance, Learning Outcomes, Key Concepts, Guiding Principle boxes, Critical Moments boxes, Other Perspectives features, Think-Pair-Share activities, H.M.O. (Help Me Out) cartoons, real-life clinical scenarios, Key Points, Critical Thinking Exercises, and more! Cultural, spiritual, and lifespan content explores the nurse’s role in hospitals, long-term care settings, and entire communities, presenting a broad approach to critical thinking. Inclusion of ethics- and standards-based professional practice reflects the increased demand for accountability in today’s professional climate. Timely coverage of the latest in nursing education and critical thinking includes concept-based learning; QSEN and IOM standards; problem-focused versus outcome-focused thinking; prioritization and delegation; developing a culture of safe, healthy work environments; expanding roles related to diagnosis and management; improving grades and passing tests the first time; NCLEX exam preparation; ensuring that documentation reflects critical thinking; communication and interpersonal skills; strategies for common workplace challenges; and more. NEW! Spotlight on systems thinking teaches you to consider how things are related, while coverage of conceptual thinking helps you focus on big ideas first. NEW! Information on effective clinical simulations encourages learning through practice and debriefing. NEW! Clinical reasoning principles are highlighted throughout to ensure you are practice ready. NEW! Current critical judgment models are illustrated and explained in a clear, engaging style. NEW! Expanded content on growing nursing trends addresses competency assessment, electronic charting (informatics) and "thinking beyond the EHR," clinical evaluation, and preceptor and learner strategies. NEW! Strong emphasis on interprofessional collaboration includes new content on its growing importance in health care.

Table of Contents

1. What are Critical Thinking, Clinical Reasoning, and Clinical Judgment? 2. Becoming a Critical Thinker 3. Critical Thinking and Learning Cultures: Teaching, Learning, and Taking Tests 4. Interprofessional Clinical Reasoning, Decision Making, and Judgment 5. Ethical Reasoning, Professionalism, Evidence-Based Practice, and Quality Improvement 6. Practicing Clinical Reasoning, Clinical Judgment, and Decision-making Skills 7. Interprofessional Practice Skills: Communication, Teamwork, and Self-Management NEW interprofessional collaboration focus!

Appendix A. Concept Mapping Appendix B. Nursing Process Summary Appendix C. Examples of CTIs within 4-Circle Model (New) Appendix D. Patient’s Rights and Nurses’ Rights Appendix E. DEAD ON Game Appendix F. Key Brain Parts Involved in Thinking Appendix G. Example SBAR Tool Appendix H. Results of Two Studies Describing Critical Thinking Skills Appendix I. Example Responses for Critical Thinking and Clinical Reasoning Exercises

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Critical Thinking, Clinical Reasoning and Clinical Judgment - Elsevier eBook on Intel Education Study (Retail Access Card): A Practical Approach 6th Edition

What's behind every healed patient? Critical thinking! And what book best equips you to master the critical thinking skills needed for success on the NCLEX examination and in professional nursing practice? Alfaro's Critical Thinking, Clinical Reasoning, and Clinical Judgment, 6 th Edition ! With a motivational style and insightful "how-to" approach, this unique textbook draws upon real-life scenarios and evidence-based strategies as it guides you in learning to think critically in clinically meaningful ways. The new edition features a more streamlined, full-color design, and expanded coverage on some of key trends, including: interdisciplinary care teams, competency-based education, the IOM’s Leading Health Indicators, legal considerations, the effects of the Affordable Care Act, and much more. If you want to truly succeed in nursing practice today and be thinking-oriented rather than task-oriented, then look no further than this one-of-a-kind textbook.

• Simple approach and motivational writing style include vivid examples, memorable anecdotes, and real case scenarios to make content come alive.
• Practical strategies to promote critical thinking, clinical reasoning, and clinical judgment are incorporated along with supporting evidence as to why the strategies work.
• Focus on application (or "how to") and inclusion of supporting rationales (theory) make difficult concepts easy to learn.
• Critical thinking indicators feature evidence-based descriptions from the author of behaviors that promote critical thinking in nursing practice.
• Highlighted features and sections ― such as Chapter at a Glance , Pre-Chapter Self-Tests , Guiding Principles , Critical Moments, Other Perspectives, Think-Pair-Share, Help Me Out cartoons, real-life clinical scenarios, key points, critical thinking exercises, and more ― promote independent learning.
• UNIQUE! Brain-based learning principles utilize strategies that challenge the mind and are incorporated throughout the text.
• Timely coverage includes topical issues, such as: problem-focused versus outcome-focused thinking, prioritizing, developing a culture of safety, healthy work environments, expanding roles related to diagnosis and management, applying delegation principles, evidence-based practice, improving grades and passing tests the first time, NCLEX preparation, ensuring documentation reflects critical thinking, communication and interpersonal skills, strategies for common workplace challenges, and more.
• Inclusion of ethics- and standards-based professional practice reflects today’s professional climate which demands increasing accountability.
• Incorporation of cultural, spiritual, and lifespan content along with the nurse’s role in hospitals, communities, and long-term care settings presents a broad approach to critical thinking. 
• Discussion of Tanner and Benner’s most recent work on what the research says about critical thinking and clinical judgment in nursing keeps readers up to date on the evidence-based side of practice.
• Coverage of IOM, QSEN, and other patient safety standards also keeps readers up to date on safe and effective nursing care.
• NEW! Full-color, eye-catching design facilitates learning.
• NEW! Additional coverage of key trends in nursing education and practice, discuss important topics such as interdisciplinary care teams, competency-based education, clinical residencies, leadership at the bedside, and implications of the Affordable Care Act.
• NEW! Carefully improved pedagogy throughout the text features streamlined headings, learning features, and content to help readers focus on what’s most important to know. 
• NEW! Inclusion of key concepts from Jean Giddens' work are now listed in the chapter openers. 
• NEW! Expanded coverage of legal considerations brings this increasingly important subject area to the forefront of consideration.
• NEW! Interactive NCLEX practice questions are now available on the Evolve companion website to better simulate the NCLEX test-taking experience. 
• NEW! Shorter chapter organization gives readers more manageable reading assignments.
• ISBN-10 0323358934
• ISBN-13 978-0323358934
• Edition 6th
• Publisher Saunders
• Publication date December 17, 2015
• Language English
• Print length 288 pages
• See all details

Product details

• Publisher ‏ : ‎ Saunders; 6th edition (December 17, 2015)
• Language ‏ : ‎ English
• Printed Access Code ‏ : ‎ 288 pages
• ISBN-10 ‏ : ‎ 0323358934
• ISBN-13 ‏ : ‎ 978-0323358934
• Item Weight ‏ : ‎ 0.705 ounces

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OTHY612 - Enhancing Clinical Reasoning in Rehabilitation for Occupational Therapists

Unit rationale, description and aim.

This post graduate unit is for occupational therapists looking to enhance their clinical reasoning within rehabilitation practice. Occupational therapists wishing to advance their rehabilitation practice will need to critically reflect on and apply enhanced knowledge of rehabilitation practice, to optimise holistic outcomes for clients across the continuum of care.

Building on current trends in occupational therapy rehabilitation practice, this unit will use collaborative and reflective activities, to critically evaluate and justify clinical decision making for a range of clinical cases in diverse rehabilitation contexts. Students will explore models of clinical reasoning across the health discipline and will be encouraged to critically evaluate personal and professional knowledge, skills and attitudes on holistic patient centred care, with a focus on integrating and applying concepts such as goal setting, self-management and evidence based practice. Students will be encouraged to embrace reflective practice for long-life learning, as well as develop reflective practice in collaboration with colleagues.

This unit aims to guide students in their critical analysis and enhancement of current practice, to optimise the professional management of clients across the continuum of care, within a multicultural society and varied rehabilitation contexts.

Campus offering

Prerequisites, incompatible.

OTHY600 Advanced Clinical Reasoning for Occupational Therapists in Aged and Neurological Rehabilitation

Learning outcomes

To successfully complete this unit you will be able to demonstrate you have achieved the learning outcomes (LO) detailed in the below table. Each outcome is informed by a number of graduate capabilities (GC) to ensure your work in this, and every unit, is part of a larger goal of graduating from ACU with the attributes of insight, empathy, imagination and impact. Explore the graduate capabilities.

Demonstrate knowledge of concepts and processes of...

Learning outcome 01, critically analyse the concepts and processes of c..., learning outcome 02, critically evaluate and discuss the impact of inte..., learning outcome 03, apply continuous improvement of clinical reasoning..., learning outcome 04.

Topics will include:

Models of clinical reasoning

• Clinical reasoning models used by novices vs. experts related to different presenting patients/conditions/setting (Hypothetico-deductive; pattern recognition; narrative reasoning; collaborative
• Decision making frameworks in rehabilitation practice
• Reflective practice and its importance in the development of clinical reasoning, quality improvement and clinical expertise for occupational therapists and other health professions 

o   Communication of clinical reasoning 

o   Strategies to enhance reflective practice and clinical practice 

• Risk reduction and rehabilitation – person-centred approach to clinical reasoning and risk

Internal and external contexts influencing clinical reasoning including the triad of the patient, the Healthcare professional and the societal / environment that underpins rehabilitation practice 

o   Disease specific 

o   Contextual factors

• Support 
• Environment
• Healthcare professionals

o   Personal and professional knowledge, skills, values and attitudes

o   Health sector – structure, changes

o   Legislation and regulation

o   Work / practice settings

o   Internal and external stakeholders

o   Funding models

Person centred care

• Clinical assessment and diagnostic reasoning

Evidence based practice

o   Clinical application of evidence based practice 

Integration and application of self-management

• Behaviour change – facilitators and barriers including risk management
• Self-management principles and strategies
• Motivational interviewing techniques and collaborative goal setting 
• Assisting people to make informed decisions, patient involvement in decision making 

Assessment strategy and rationale

OTHY612 assessments have been purposefully designed to replicate authentic reflection on reasoning, thinking and problem solving within personal clinical practice.  The assessments incorporate a broad range of tasks aligned to andragogic principles of adult learning, facilitating choice and self-direction for the post graduate student.  Unit assessments tools have been designed from an “Assessment for Learning” approach in order to not only provide evidence for judgement of learning, but also to reinforce, facilitate and support learning and application of learning. 

In the first assessment task students will be asked using a case study example from their clinical practice to identify and reflect on the factors influencing collaborative clinical reasoning and clinical decision making within their teams and workplace. In assessment task 2 students will video record their treatment of a client and provide a written critique of their application of clinical reasoning, critical thinking, clinical judgement, and evidence to practice when making the clinical decisions relevant for the client and treatment. Assessment tasks 3 seeks students to reflect on their personal and collaborative clinical reasoning practice and communicate these reflections relevant to their work setting using evidence based reasoning and decision making, to management and peers. 

The broad range of assessment activities encourages application of clinical reasoning, critical thinking, clinical judgement, and evidence to practice when solving simple to complex problems and making clinical decisions.  These assessments have been specifically timed to provide optimal enhancement for learning.  Assessment has been aligned to the emerging complexities as students learn, assimilate and apply progressively advanced levels of professional and theoretical knowledge and enhanced critical analysis skills with the aim of optimising each student’s ability to personally and professionally reflect, analyse and appraise clinical practice. Scheduling of assessments will be equitable for both modes of delivery. Assessment tasks may be delivered and assessed locally with moderation according to University Policies and Procedures. All assessments will be submitted electronically.

Overview of assessments

Assignment 1 (case study): enables students to re....

Enables students to reflect on learning and factors that influence clinical reasoning and decision making

Assignment 2  Practice Video with Critique: Enabl...

Practice Video with Critique:

Enables students to develop knowledge and skills through self-reflection and analysis of clinical reasoning in relation to clinical practice

Assignment 3 Self-reflective Critique – Verbal se...

Self-reflective Critique –  Verbal seminar

Enables students to use clinical reasoning of self and peers to foster improvement in their future practice  

Learning and teaching strategy and rationale

This unit is offered through multi-modal and online delivery for specific on and off shore cohorts. Both modes aim to facilitate learner centred activities and workplace application of learning in relation to selected themes.  Learning and teaching strategies for this post graduate level unit are based on a blend of constructivism, social constructivism, and experiential learning. These strategies focus on active participation and developing a community of inquiry.  Content and types of activities that are the same or similar for all participants regardless of the mode of delivery have been identified. This has led to the development of purposefully designed learning activities that are transferable and work well across both delivery mediums whilst maintaining the flexibility to create and deliver mode specific activities focusing on inquiry based learning principles aimed at encouraging critical thinking, application of knowledge and skills, evidence for practice, collaborative peer learning, and critical self-reflection. 

Multi-mode delivery requires participation in a workshop providing underpinning knowledge and skills that are enhanced throughout the unit. Where possible, workshop activities are designed as reusable learning content able to be provided online or modified slightly as required, to take into account current information and communication technologies for online delivery. As required, for example in different time zones, learning and teaching strategies will be adapted for online delivery to specific cohorts. In addition, students in both delivery modes, will participate in individual and small group activities, based on analysis of current practice, assimilation and application of enhanced knowledge aimed at facilitating the translation of learning into personal clinical practice.

Representative texts and references

Atkinson H L, & Nixon-Cave K (2011). A tool for clinical reasoning and reflection using the international classification of functioning, disability and health (ICF) framework and patient management model. Physical Therapy, 91(3), 416-30 

Higgs J, Jones M, Christensen N, Loftus S (2018) Clinical reasoning in the health professions (4th ed.) New York, NY. Elsevier/Butterworth Heinemann. 610 CLI 

Hoffman T, Bennett S, Del Mar C (2017) Evidence based practice across the health professions. 3rd edition. Chatswood, NSWL Elsevier. 616HOF

Kinsella, E A (2010). The art of reflective practice in health and social care: Reflections on the legacy of Donald Schön.  Reflective Practice ,  11 (4), 565-575

McKivett A, Paul D, Hudson N (2018) Healing conversations: developing a practical framework for clinical communication between aboriginal communities and healthcare practitioners. Journal of Immigrant and Minority Health. doi-org.ezproxy2.acu.edu.au/10.1007/s10903-018-0793-7

National Stroke Foundation (2017). Stroke Clinical Guidelines. Melbourne, Australia.  National Stroke Foundation (2010). Stroke Clinical Guidelines. Melbourne, Australia. 

Oakland T and Mpofy E (2009) Rehabilitation and Health Assessment: Applying the ICF Guidelines New York: Springer Publishing Company LLC 

Rose A, Rosewilliam S, Soundy A (2017) Shared decision making within goal setting in rehabilitation settings: A systematic review. Patient Education and Counseling 100:65-75.

Robertson L (Ed) (2012) Clinical Reasoning in occupational therapy: controversies in practice. 

Siegert RJ, Levack WMM (2015) Rehabilitation Goal Setting: Therapy, Practice and Evidence. Chapman and Hall, CRC.

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Most Recent Article

Using Riddles and Interactive Computer Games to Teach Problem-Solving Skills

John H. Doolittle California State University, Sacramento Reprinted from: TEACHING OF PSYCHOLOGY, Vol. 22, No. 1, February, 1995, 33-36.

Cognitive flexibility, which is defined as the ability to generate several categories of possible solutions is identified as the most critical aspect of creativity training. Word tables, interactive computer games, and riddles are used to develop cognitive flexibility. Preliminary results from analyses with quasi-experimental designs provide promising evidence that these methods are effective in enhancing creative and other forms of critical thought in college students.

Ruggiero (1984) took the approach, popular among psychologists, of characterizing the problem-solving process as having two complementary phases: production and judgment. In the production phase, which he associated with creative thinking, potential solutions to the problem are generated. In the judgment phase, which he associated with critical thinking, the ideas generated are evaluated. This approach seems to elevate the importance of teaching students how to generate ideas to a level approaching the importance of being able to evaluate ideas. However, a closer examination of the evaluation process shows that it, too, frequently calls on the problem solver to think creatively (J. H. Doolittle, 1992b). For example, if one is evaluating the assertion, "He must be the killer; he's holding the murder weapon!," part of what one needs to do is to generate ways in which someone could be holding a murder weapon and not be the killer. This process includes generating various scenarios or models (Johnson-Laird, 1983), which may or may not involve images, and then judging their plausibility (Kaufmann, 1980).

The purpose of this article is to suggest exercises and activities to help students become better idea generators using riddles and computer games as the context in which problem solving occurs.

Flexibility and Metacognition

Flexibility, which is the process of generating a variety of types of potential solutions, may be more important to good problem solving than fluency, which is the process of generating more potential solutions regardless of type. For students to become more flexible as solutions generators, they need to be made aware of the types of solutions that they are generating. This process, one aspect of self-monitoring or metacognition, is at the heart of successful problem solving and can be improved in the important area of verbal associations by having students construct word tables.

In constructing word tables, students brainstorm as many associations as they can think of to a word such as fish. The generation of associations should take approximately 2 min. Next, have them categorize the associations they generated. Each student will produce a word table with categories, such as kinds of fish (guppy, trout, etc.), parts of a fish (fin, gills, etc.), things you take fishing, and so on. An interesting phenomenon then occurs: Students not only begin to add new associations, such as salmon and scales, to the table but also begin to add new categories, such as places where fish live. J. H. Doolittle and Bourg (1991) showed that brief training with generating associations to one word was followed by increased production on an unrelated, follow-up word. More recently, I assigned 10 word tables as a supplemental homework exercise for those of my students who scored in the lowest 20% of the class on a verbal-association measure. On a later and more difficult verbal-association quiz, 80% (12 of 15) of these remedial students passed the test as compared with 53% (32 of 60) of the other students, who were not required to produce word tables. It may be that any activity that causes problem solvers to pause, retrieve relevant information from memory, and examine their production is beneficial.

Flexibility and Mental Models

The notion of thinking as the construction and manipulation of mental models (Johnson-Laird, 1983) suggests another realm for flexibility training. Riddles, puns, jokes, and other word-association games help students shift mental models. The primary skill learned in these exercises is a willingness to let go of an unsuccessful solution or model. It provides a way to circumvent the common problem of functional fixedness in which problem solvers are not able to go beyond the usual functions of an object. Jokes and riddles work because the listener develops a likely model or interpretation, which then proves to be incorrect. For example, in the joke, "Question: How do porcupines make love? Answer: Very carefully!," the question leads to a distant and clinical mental model of the mechanics of mating, which the answer switches to a porcupine's perspective of the dangers of being close. The popularity of jokes, puns, and riddles suggest that people enjoy the surprise of shifting mental models in certain situations. This built-in source of motivation can be tapped by the instructor to make the learning of thinking skills fun.

The enjoyment of riddles, as opposed to jokes and puns, calls on the listener to at least attempt to shift the model. In the riddle, "What's black and white and read all over?" (answer: a newspaper), which works better as a spoken riddle, the solver is fooled by the words black and white to misinterpret read as red. Psycholinguists call these garden path sentences because the reader is misled "down the garden path" by key words in the sentence that suggest another meaning than the one that is intended. To use riddles as a teaching tool, I decided to generate riddles in a sequence from easy to difficult so that solvers would have a reasonable chance of solving each riddle while building their skill level (J. H. Doolittle, 1991). An example of a college-level riddle is as follows:

"What you did to the letter, Before it was sent; You memorized the poem, Not knowing what it meant." (wrote/rote)

Riddles like this from the Dr. DooRiddles series or other riddles can be selected for appropriate difficulty level and read aloud to the class or presented on an overhead transparency. In these exercises, students must be cautioned against blurting out answers so that others will have a period of quiet in which to generate models and possible word tables. Popular parlor games, such as 20 Questions and Charades, foster model flexibility as well. Because these group can inhibit the production of some students, computer riddle exercises have been developed (J. H. Doolittle & T. A. Doolittle, 1992a, 1992b) to allow individuals to solve riddles without social judgment and without getting completely stuck.

Visualization and Imagination

A process similar to the use of jokes and riddles to encourage cognitive flexibility occurfs when we read or listen to a story. Symbols and sounds are converted into visual images, models, and scenarios that we continuously transform and examine in order to comprehend the text. Because readers and listeners have to construct their own mental models, these experiences have been shown to be beneficial to the development of students' imaginations when compared to comprehension based on film presentations (Greenfield & Beagles-Roos, 1988). Presumably, television and other visual media provide images and models so that the production of mental models and creative imagination on the mart of the recipient are less necessary. In interactive-fictions experiences, sukch as those available as computer software, one is a participant in rather than a recipient of the story. Although participants make maps and other notations as they move about an imaginary world, it is their mental representation of that world that allows them to speculate about the possibilities of a given scene. For example, in the all-text computer program, "Cursed Castle" (J. H. Doolittle, 1992a), the student must see the dirt floor of the dungeon as a potential hiding place in addition to its more usual use.

Students solving interactive-fiction problems on a computer generate a variety of solutions, but they become frustrated on finding that not one of their solutions leads to progress toward the goal. This frustration can quickly build into discouragement and a sense of failure and must be countered by either the sequencing of task difficulty or the judicious application of hints. For example, in "Hangtown" (J. H. Doolittle, 1989b), students must frighten off a vicious dog barring the entrance to the miner's shack by threatening the dog with the carcass of a huge rattlesnake. Because most students do not think of this right away, the software monitors each student's progress and introduces a hint after a judicious amount of floundering has occurred. In this case, the next time the student is in the vicinity of the dead reattlesnake, the student is informed that a coyote has strolled by, seen the dead snake, and run off in terror. If this hint does not work, the student is later given a more direct hint. To determine when and where hints are necessary, the software can record which obstacles are the hardest to overcome and where students seem to get stuck. The instructor can then retrieve this information and improve the flow of the program.

Empirical Evidence for the Effectiveness of Using Riddles and Computer Games for Training Students to be Problem Solvers

During the past 8 years, I have gathered preliminary data using a quasi-experimental design. The comparison group was several sections of my introductory psychology classes at California State University, Sacramento. Two experimental groups received practice with the riddles and computer games described earlier -- students in my freshman-level critical-thinking course and students enrolled in the Summer Academic Study Program (SASP) at the University of California School of Medicine, Davis. Several dependent measures were used: Cornell Critical Thinking Test (Level X; Ennis & Millman, 1985), the Ennis-Weir Critical Thinking Essay Test (Ennis & Weir, 1985), the Remote Associates Test of creativity (Mednick & Mednick, 1967), the Creative Reasoning Test (J. H. Doolittle, 1989a), the Unusual Uses Test of creativity (Guilford, Merrifield, & Wilson, 1958), the Purdue Non-language Test of intelligence (Tiftin, Gruber, & Inaba, 1957), and the Coopersmith Inventory of self-esteem (Coopersmith, 1981). Although the introductory psychology students did not show gains on these measures beyond chance expectation, students in the critical-thinking courses and the SASP students showed statistically significant gains on all of these measures (most at a p Independent analyses conducted by the Dean's Office at the University of California Medical School, Davis, have indicated an improvement for SASP students in grade point average, undergraduate dropout rates, and medical school admission and retention rates.

Although these results are highly encouraging, they must be viewed as preliminary because of the quasi-experimental design used, the fact that there were some year-to-year changes in the type of test used to assess critical thinking, and the fact that these analyses do not indicate the relative benefits of the various educational experiences of these students.

Conclusions

The pricipal barriers to a society of better problem solvers may simply be that too few teachers are attempting to teach students the skills of creativity. As teachers plunge into these waters, it may be useful if they follow these few precepts: (a) make cognitive flexibility the top priority; (b) if flexibility is not forthcoming, focus on metacognition; (c) provide tasks that are rich in imagery; and (d) closely monitor the frustration level of students so that the tasks will be fun.

Coopersmith, S. (1981). Coopersmith Inventory . Palo Alto, CA: Consulting Psycholgists Press. Doolittle, J.H. (1989a). The Creative Reasoning Test . Pacific Grove, CA: Critical Thinking Press & Software. Doolittle, J.H. (1989b). The hangtown trilogy . Pacific Grove, CA: Critical Thinking Press & Software. Doolittle, J.H. (1991). Dr. DooRiddles . Pacific Grove, CA: Critical Thinking Press & Software.   Doolittle, J.H. (1992a). Adventures in Danger . Pacific Grove, CA: Critical Thinking Press & Software. Doolittle, J.H. (1992b). Imagining possibilities: A neglected aspect of critical thinking training .   Paper  presented at the International Conference on Critical Thinking and Educational Reform, Rohnert Park, CA.                                                                                                                                        Doolittle, J.H. & Bourg, T.M. (1991, April). The effects of metacognitive training on a word-association task .  Paper presented at the meeting of the Western Psychological Association, San Francisco.   Doolittle, J.H. & Doolittle, T.A. (1992a). Escape from the pyramid of riddles. Pacific Grove, CA: Critical Thinking Press & Software.                                                                                                     Doolittle, J.H. & Doolittle, T.A. (1992b). The riddle mysteries. Pacific Grove, CA: Critical Thinking Press & Software.                                                                                                                         Ennis, R.H. & Millman, J. (1985). Cornell Critical Thinking Test (Level X) . Pacific Grove, CA: Critical Thinking Press & Software.                                                                                                           Ennis, R.H. & Weir, E. (1985). Ennis-Weir Critical Thinking Essay Test .   Pacific Grove, CA: Critical Thinking Press & Software.                                                                                                   Greenfield, P. & Beagles-Roos, J. (1988) Radio versus television: Their cognitive impact on children of different socioeconomic and ethnic groups. Journal of Communication . 38, 71-91.                          Guilford, J.P., Merrifield, P.R. & Wilson, R.C. (1958) Unusual Uses Test . Orange, CA:Sheridan Psychological Services.                                                                                                     Johnson-Laird, P.N. (1983). Mental models: Toward a cognitive science of language, influence, and consciousness .  Cambridge, MA:Harvard University Press.                                                         Kaufmann, G. (1980) Imagery, Language, and Cognition .  New York:Columbia University Press.     Mednick, S.A. & Mednick, M.T. (1967). Remote Associates Test. Boston:Houghton Mifflin.            Riggiero, V.R. (1984). The Art of Thinking . New York:Harper & Row.

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