Yes, critical thinking is indeed essential for developing clinical judgment in

nursing. Nursing involves making complex decisions in often

unpredictable situations, where patient outcomes depend on accurate
assessment and timely intervention. Critical thinking enables nurses to
analyze information, consider multiple perspectives, evaluate evidence,
and make reasoned judgments about patient care. It helps them
recognize patterns, anticipate potential complications, and adapt their
interventions accordingly. Without critical thinking, nurses may rely solely
on rote procedures or protocols, which can be insufficient or inappropriate
in diverse clinical scenarios. Ultimately, critical thinking empowers nurses
to provide safe, effective, and patient-centered care, enhancing overall
healthcare outcomes.

High quality, safe patient care is dependent upon the healthcare

provider’s ability to reason, think, and make judgments about care.
Critical thinking, clinical reasoning and judgment are integral to quality
clinical decisions and actions. Today’s healthcare landscape has
transitioned towards an environment where patients are more medically
complex, an aging population with chronic illness, and increased
socioeconomic diversity. In order to provide quality patient-centered care,
nurses need to develop CT skills in order to provide patients with expert
care (Brunt, 2005).

Developing CT is an ethical responsibility of professional nursing practice,

and a component for sound clinical judgments and safe decision-making.
Thinking in a logical, systematic way, being open to questioning current
practice, and reflecting on one’s practice regularly are some key features
that strengthen nurses’ CT skills.

The quality of clinical decision-making is influenced by a number of

factors, including experience, level of education, time pressures, and also
the culture of the nursing unit (Johansson, Pilhammar, & Willman 2009).
Developing critical thinking skills has the potential to improve personal
practice and patient outcomes.

Critical thinking (CT) is a process used for problem-solving and decision-

making. CT is a broad term that encompasses clinical reasoning and
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clinical judgment. Clinical reasoning (CR) is a process of analyzing
information that is relevant to patient care. When data is analyzed, clinical
judgments about care is made. The process of analyzing the data,
making decisions is the result of CT—thinking critically throughout the
entire patient situation, weighing all relevant options and using CT skills to
make the best decision for the patient.

While many definitions have been cited for CT (see below), there is a
general agreement that CT is a purposeful action that includes analysis,
logical reasoning, intuition, and reflection. Making a concerted effort to
critically think during patient care leads to safe, effective decisions.
Developing CT skills is key for all nurses, they spend the most time with
patients, and are able to recognize subtle changes in their patients and
are positioned to make quick, precise decisions, often lifesaving. Using
effective CT skills allows nurses to shape the outcome of a patient’s
experience with the healthcare system.

Critical Thinking

The concept of critical thinking has been an integral part of professional

frameworks for generations, yet scholars still debate a universal accepted
definition. Dozens of CT definitions have been published, with each of
them sharing some common features, such as reflection, contemplation,
holism, and intuition. The list below shares a variety of CT definitions:

“The rational examination of ideas, inferences, assumptions, principles,

arguments, conclusions, ideas, statement beliefs and action” (Bandman &
Bandman, 1995, p. 7)

A reflective skepticism; “reflecting on the assumptions underlying our and

others’ ideas and actions and contemplative alternative ways of thinking
and living” (Brookfield, 1987, p. 18)

“The process of purposeful self-regulatory judgment . . . gives reasoned

consideration to evidence, context, conceptualization, methods and
criteria: (Facione, 2006, p. 21)

“Reasonable and reflective thinking that is focused upon deciding what to

believe or do” (Kennedy, Fisher, & Ennis, 1991, p.46)

“An investigation whose purpose is to explore a situation, phenomenon,

question, or problem to arrive at a hypothesis or conclusion about it that
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integrates all available information and that, therefore, can be
convincingly justified” (Kurfiss, 1988, p. 37)

“The propensity and skill to engage in an activity with reflective

skepticism” (McPeck, 1961, p. 8)

“The deliberative nonlinear process of collecting, interpreting, analyzing,

drawing conclusions about, presenting and evaluating information that is
both factual and belief based” (National League for Nursing Accrediting
Commission, 2000, p. 8)

“A unique kind of purposeful thinking in which the thinker systematically

and habitually imposes criteria and intellectual standards upon the
thinking, taking charge of the construction of thinking, guiding the
construction of the thinking according to the standard, and assessing the
effectiveness of the thinking according to the purpose, the criteria and the
standards” (Paul, 1993, p. 21)

“In nursing . . . an essential component of professional accountability and

quality nursing care [that exhibits] confidence, contextual perspective,
creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-
mindedness, perseverance and reflection.” (Scheffer & Ruberfeld, 2000,
p. 357)

Concepts Related to Critical Thinking

Clinical Reasoning

 A process where nurses integrate and analyze patient data to make

decisions about patient care (Simmons, Lanuza, Fonteyn, & Hicks,
2003)

Clinical Decision-Making

 A process of choosing between different options or alternatives

(Thompson & Stapley, 2011)

Clinical Judgment

 A cognitive process used to make judgments based on patient data

and cues. Nurses interpret a patient’s concerns, needs, and health
problems for proper decision-making (Tanner, 2006, p. 204)

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  Outcome of critical thinking in nursing practice; judgments begin with
the end goal in mind; outcomes are met, involves evidence (Pesut,
2001)

Logical Reasoning

 Arriving at a conclusion based on relatively small amounts of

knowledge and/or information (Westcott, 1968)

Intuition

 “Drawing inferences or conclusions that are supported in or justified

by evidence (Alfaro-LeFevre, 2015, p. 232)

Reflection

 A purposeful analysis of one’s current and past actions (Schon, 1987)

Experience and Clinical Reasoning

According to Benner’s (1984) novice to expert model, expert nurses have

an intuitive grasp of their patients’ problems, their approach is fluid,
flexible, and proficient. Compared to novice nurses, they are more task
oriented and require frequent verbal and physical cues to provide care.

Novice nurses are challenged with overcoming a knowledge gap, leading

to less effective decisions and actions. Compared to experienced nurses,
who are challenged with traditional thinking, leading to less effective
clinical judgments and decisions (Cappelletti et al., 2014). Successful CR
and decision-making require a balance of intuition and evidence-based
thinking to make effective clinical decisions (Simmons et al., 2003).

Andersson et al. (2012) found nurses who were specialized in their

setting (more experience) used a more holistic approach to making
decisions (p. 876), compared to less experienced nurses who used a
“task-and action-oriented approach” (p. 873). Gaining experience and
knowledge is one way to improve thinking and decision-making, though
improving CT skills can close the gap. Being open-minded, self-aware,
and reflective offers nurses important information that can improve CR
and decision-making. Clinical judgment (akin to CR) improves over time
with nurses who uses reflection as a guide for decisions and actions
(Cappelletti et al., 2014).

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Critical Thinking and Clinical Decision-Making

Lee et al. (2017) conducted an integrated review on nine studies to

determine whether effective CT impacted clinical decision-making. Four
studies found CT impacted decision-making, though five studies did not
find a correlation. Due to poor study designs, Lee et al. (2017) could not
come to a clear decision on whether there was as significant correlation.

CT continues to be an important factor for problem-solving, regardless if

studies can confirm a correlation to decision-making. Developing CT
skills, such as reflection, intuition, and logical reasoning, are essential
behaviors that lead to a patient-centered approach. Nurses who stop and
think about what worked for a patient in the past, may consider the same
option again, or may choose an alternative. Considering all possibilities
with the patient’s best interest in mind is part of CT and making clinical
decisions.

Researchers will continue to study the impact of CT on nursing care.

Nurse educators will continue emphasize CT in the curriculum and assist
students in developing CT skills throughout all levels of education as they
offer students tools and methods for problem-solving.

Rubenfeld and Scheffer (2001) explain the essence of CT in nursing

practice:

Critical thinking in nursing is an essential component of professional

accountability and quality nursing care. Critical thinkers exhibit these
habits of the mind: confidence, contextual perspective, creativity,
flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness,
perseverance, and reflection. Critical thinkers in nursing practice the
cognitive skills of analyzing, applying standards, discriminating,
information seeking, logical reasoning, predicting and transforming
knowledge (2001, p. 125).

Standards of Practice

Critical thinking and clinical reasoning are weaved throughout

the Nursing Scope and Standards of Practice and Code of
Ethics (American Nurses Association [ANA], 2021). The nursing process
itself, Standards 1-6, are essentially a tool used for clinical reasoning. The
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standards require core cognitive competencies and guide nurses to use
patient data to make effective clinical decisions.

The Essentials

Clinical Judgement is one of the eight featured concepts within The

Essentials (American Association of Colleges of Nursing [AACN], 2021,
p.12). The process of clinical judgement, as earlier in this section, is the
outcome of critical thinking.

The Essentials explains how a liberal arts education is critical to exposing

nurses to a broad worldview, giving them a holistic perspective that
engages them in promoting health equity and social justice, , and “forms
the basis for clinical reasoning and subsequent clinical judgments”
(AACN, 2021, p. ).

Problem-Solving Approaches
Reflective Thinking

Reflection is a powerful tool for recognizing errors in judgment,

questioning one’s response, and ultimately improving outcomes. Below
are two practice examples that illustrate the power of reflective thinking
with interprofessional communication and patient care:

Novice and senior nurse communication

 Problem: A novice nurse is struggling with inserting IVs just about
every shift. One day, the nurse asks the same more experienced
nurse for help again. The nurse listens though does not turn around
to face the nurse when questioned, and responds in a swift,
aggressive way, “I’m swamped, we have no aides today and I’m
falling behind with everything. I’ll help you when I get time, but it’s
going to be a while.”
 Impact: The nurse’s patient is at risk for injury without an IV line. The
patient may be upset and unsatisfied with care knowing the IV was
out for an extended period of time. The nurse feels dejected, does
not feel like she is a valued team member, and loses further
confidence in her abilities. She considers quitting her job or
transferring to another unit.
 Reflection: The experienced nurse realizes she was not empathetic
to the nurse’s needs and impatient and aggressive in her response.
She realizes the nurse is new and doesn’t have much confidence in
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 her skills yet. She also knows the nurse is probably disappointed in
the lack of teamwork and camaraderie. Most of all, she feels bad
about disrespecting her coworker.
 Impact of reflection: After reflection of the situation, the nurse
apologizes for her poor behavior. She states she will work with her
each shift they work together, she will share personal tips and review
educational materials. Additionally, she will offer to have her observe
her IV insertions until she has mastered the skill. She will also make
sure the new nurse feels like she is part of the team, not just the new
nurse.
Shift report
 Problem: The oncoming nurse enters his patient room for the first
time and finds the foley bag is full and the patient is complaining of
abdominal discomfort.
 Impact: The patient is at risk for infection and may be disappointed
with the quality of nursing care.
 Reflection: The oncoming nurse realizes there is always one or two
problems or inconsistencies when he assesses his patients for the
first time. He knows the outgoing nurses are skilled and provide
quality care and considers another reason for the errors. After
thinking about this for a while, he believes the process for shift report
can help reduce change of shift errors. The nurse realizes there
needs to be a better way for sharing patient information during
change of shift.
 Impact of reflection: The nurse researches evidence-based
practices to improve safety and quality during shift change. The nurse
shares a copy of the review article on bedside report with his
manager. The nurse offers to be a change champion on the unit to
implement a new process for shift report.
Long-term impact of reflection:
 Improved team cohesiveness, nurse retention and job satisfaction

 Improved patient satisfaction experience and quality of care, leading

to higher insurance reimbursement

Glynn (2012) states reflective thinking enhances clinical judgment and

gives nurses the opportunity to learn from actual or perceived errors. In
regard to the communication scenario, it’s through reflection that nurses
can think about their behaviors and responses. Reflect on the message
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for clarity, and whether it was shared in an empathetic and respective
way.

As discussed in the communication chapter, poor communication is the

number one reason for medication errors and sentinel events. Through
reflection, miscommunication can be identified, solutions found, and
implemented. In order for this process to come to fruition, nurses must
take the initiative to reflect on their practice.

Creative Thinking

Creative thinking helps nurses generate alternative approaches to clinical

decision-making. This type of thinking works especially well with
medically complex patients, where care needs to be individualized to
reach desired outcomes.

Akin to the concept of “thinking outside the box”, finding a novel approach
to patient care prevents traditional, stagnant thinking. Choosing
alternatives based solely on creative thinking can negatively impact
outcomes unless it is paired with the skill of critical thinking. Critical
thinking requires the nurse to view the patient holistically,

Intuition

Nurses access knowledge unconsciously and trust this information as

fact. Often referred to as a “gut feeling”, intuition comes naturally. Intuition
is not a tool that is sought out at will, instead the knowledge emerges
naturally during a care experience, resulting in firm actions and decisions.
Intuition is a measure of professional expertise (Smith, Thurkettle, & Cruz,
2004), a type of clinical judgement that develops over time (Benner,
1984). Since this knowledge is considered intangible or irrelevant, some
disregard it, though many studies have shown its positive influence in
making accurate decisions and improving the quality of care (Robert,
Tilley & Petersen, 2014).

 Nurses will recognize something about their patient that they can’t
explain, and will make decisions on care without concrete evidence to
back up their actions. Such actions can be lifesaving (Billay, Myrick,
Luhanga & Yonge 2007). Each clinical experience acts as a learning

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 experience for which lessons are learned and applied to the next
experience (McCutcheon & Pincombe, 2001).
 Holtslander (2008) states Carper’s (1978) seminal work on the
fundamental ways of knowing was published as a reaction to the
overemphasis of empirical (scientific) knowledge in nursing practice.
One of the four ways of knowing, called aesthetic knowing, explains
the component of art within nursing practice, an, awareness of the
patient, viewing the patient as unique. This viewpoint allows nurses to
consider more than just empirical knowledge to guide practice.

Critical Thinking Skills

As discussed earlier, CT encompasses a broad range of reasoning skills

that lead to effective decision-making. Through the process of clinical
reasoning and judgment, nurses make best choice after assembling and
analyzing patient data.

White (2003) studied senior baccalaureate nurses and found the following
five themes were essential to developing clinical decision-making skills:

1. Gaining confidence in clinical skills

2. Building relationships with staff
3. Connecting with patients
4. Gaining comfort in self as a nurse
5. Understanding the clinical picture

Scheffer and Rubenfeld (2000) found CT is comprised of affective and

cognitive components. Affective components refer to an individual’s
feelings and attitudes, and cognitive components refer to thought
processes. The CT components include 10 habits of the mind (affective
components) and seven skills (cognitive components), as follows:

Habits of the mind

 Confidence: assurance of one’s reasoning abilities

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  Contextual perspective: considerate of the whole situation,
including relationships, background and environment relevant to
some happening
 Creativity: intellectual inventiveness used to generate, discover, or
restructure ideas; imagining alternatives
 Flexibility: capacity to adapt, accommodate, modify or change
thoughts, ideas, and behaviors
 Inquisitiveness: an eagerness to know by seeking knowledge and
understanding through observation and thoughtful questioning in
order to explore possibilities and alternatives
 Intellectual integrity: seeking the truth through sincere, honest
processes, even if the results are contrary to one’s assumptions and
beliefs
 Intuition: insightful sense of knowing without conscious use of
reason
 Open-mindedness: a viewpoint characterized by being receptive to
divergent views and sensitive to one’s biases
 Perseverance: pursuit of a course with determination to overcome
obstacles
 Reflection: contemplation upon a subject, especially one’s
assumptions and thinking for the purposes of deeper understanding
and self-evaluation (Scheffer & Rubenfeld, 2000, p. 358)
Skills
 Analyzing: separating or breaking a whole into parts to discover their
nature, function and relationships
 Applying standards: judging according to established personal,
professional or social rules or criteria
 Discriminating: recognizing differences and similarities among
things or situations and distinguishing carefully as to category or rank
 Information seeking: searching for evidence, facts or knowledge by
identifying relevant sources and gathering objective, subjective,
historical, and current data from those sources
 Logical reasoning: drawing inferences or conclusions that are
supported in or justified by evidence
 Predicting: envisioning a plan and its consequences
 Transforming knowledge: changing or converting the condition,
nature, form, or function of concepts among contexts (Scheffer &
Rubenfeld, 2000, p. 358)

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Development of CT is a lifelong process that requires nurses to be self-
aware, and to use knowledge and experience as a tool to become a
critical thinker. As nurses move along the continuum from novice to
expert, one’s competence and ability to critically think will expand (Brunt,
2005).

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