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10 Critical Thinking and Clinical Reasoning

The term “thinking like a nurse” was introduced by Dr. Christine
Tanner in 2006. To think like a nurse, critical thinking and clinical
reasoning must be defined and understood. This chapter examines
the influence of critical thinking and clinical reasoning on the care of
clients. Both these terms describe the mental processes nurses use to
ensure that they are doing their best thinking and decision making.

The practice of nursing requires critical thinking and clinical
reasoning. Critical thinking is the process of intentional higher level
thinking to define a client’s problem, examine the evidence-based
practice in caring for the client, and make choices in the delivery of
care. Clinical reasoning is the cognitive process that uses thinking
strategies to gather and analyze client information, evaluate the rel-
evance of the information, and decide on possible nursing actions to
improve the client’s physiological and psychosocial outcomes. Clini-
cal reasoning requires the integration of critical thinking in the iden-
tification of the most appropriate interventions that will improve the
client’s condition. The concept of clinical reasoning “evolved from
the application of decision-making to the health care professions”
(Simmons, 2010, p. 1153). “Clinical reasoning also guides nurses in
assessing, assimilating, retrieving, and/or discarding components of
information that affect patient care” (p. 1151). Clinical reasoning is
often defined in practice-based disciplines, such as nursing and med-
icine, as the “application of critical thinking to the clinical situation”
(Victor-Chmil, 2013, p. 35).

Critical thinking involves the differentiation of statements of fact,
judgment, and opinion. The process of critical thinking requires
the nurse to think creatively, use reflection, and engage in analytical
thinking (Alfaro-LeFevre, 2013). Alfaro-LeFevre’s 4-Circle Critical

Thinking Model provides a visual representation of critical think-
ing abilities and promotes making meaningful connections between
nursing research and critical thinking and practice (Figure 10–1 •).
Critical thinking is an essential skill needed for the identification of
client problems and the implementation of interventions to promote
effective care outcomes (Bittencourt & Crossetti, 2012). The process
of providing feedback and reflection is vital to the improvement of
nursing practice. A study by Asselin (2011) revealed that students
who reflected on new knowledge developed new insights regarding
practice. The insights nurses acquired led to changes in their ap-
proach to practice.

According to Scheffer and Rubenfeld (2010), critical thinking
is a metaphorical bridge between information and action. Criti-
cal thinking in nursing involves habits of the mind and requires the
implementation of cognitive skills. In 2000, Scheffer and Ruben-
feld conducted a landmark study in which internationally diverse
expert nurses from nine countries defined ten habits of the mind
(affective components) and seven skills (cognitive components) of
critical thinking in nursing. The ten affective components are con-
fidence, contextual perspective, creativity, flexibility, inquisitiveness,
intellectual integrity, intuition, open-mindedness, perseverance, and
reflection. The seven skills are analyzing, applying standards, dis-
criminating, information seeking, logical reasoning, predicting, and
transforming knowledge. Lunney (2010) used the affective and cog-
nitive components to demonstrate the use of critical thinking in the
diagnostic process and the identification of an accurate nursing di-
agnosis. The study indicated that nurses need to utilize all 17 critical
thinking concepts in the identification of nursing diagnoses.

Nurses use critical thinking skills in a variety of ways:

• Nurses use knowledge from other subjects and fields. Nurses use
critical thinking skills when they reflect on knowledge derived


After completing this chapter, you will be able to:
1. Describe the significance of developing critical thinking abili-

ties in order to practice safe, effective, and professional nurs-
ing care.

2. Describe the actions of clinical reasoning in the implementa-
tion of the nursing process.

3. Discuss the attitudes and skills needed to develop critical
thinking and clinical reasoning.


clinical judgment, 147
clinical reasoning, 144
cognitive processes, 149
concept mapping, 151

creativity, 145
critical analysis, 145
critical thinking, 144
deductive reasoning, 146

inductive reasoning, 146
intuition, 147
metacognitive processes, 149
nursing process, 147

problem solving, 147
Socratic questioning, 146
trial and error, 147

4. Describe the components of clinical reasoning.
5. Integrate strategies to enhance critical thinking and clinical

reasoning as the provider of nursing care.
6. Describe the process of concept mapping to enhance

critical thinking and clinical reasoning for the provision of
nursing care.

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Figure 10–1 • Alfaro-LeFevre’s 4-Circle Critical Thinking Model.
Adapted with permission from Critical Thinking Indicators (CTIs): 2014 Evidence-Based Version,
by R. Alfaro-LeFevre, 2014. Retrieved from

Theoretical & Experiential Knowledge
Intellectual Skills / Competencies

CT Characteristics
(Attitudes / Behaviors)

Technical Skills /

Starting at the top and going clockwise around the circles above, here’s what you
need to do to develop your ability to think critically.

1. Develop a critical thinking character. Hold yourself to high standards. Make
a commitment to developing critical thinking characteristics such as; honesty,
fair-mindedness, creativity, patience, and confidence.
2. Take responsibility and seek out learning experiences to help you get the
theoretical and experiential knowledge to think critically. Practice intellectual skills
such as assessing systematically and comprehensively. Just as practicing
physical skills improves your ability to perform physically, practicing thinking skills
improves your ability to perform intellectually.
3. Gain interpersonal skills such as teamwork, resolving conflict, and being an
advocate. Keep in mind that “being too nice” problems (e.g., not giving
constructive criticism because of concerns of not offending someone) can be as
bad as “not being very nice” problems (e.g., demonstrating arrogance, sarcasm,
and or intolerance of other ways of doing things). Learn how to give and take
feedback. To improve you must get through the negative aspects of criticism.
4. Practice related technical skills (e.g., using computers, managing IV’s). Until
these skills become like second natures, they create a “brain drain” making it
difficult to focus on other important things such as monitoring patient responses
to care.

Interpersonal Skills /


from other interdisciplinary subject areas such as the biophysi-
cal and behavioral sciences and the humanities in order to pro-
vide holistic nursing care. For example, when providing care to
a client at the end of life, it is important to have knowledge of
culture and religion to enhance the delivery of culturally sensi-
tive care and enhance the client’s spiritual well-being to promote
a good death.

• Nurses deal with change in stressful environments. A client’s
condition may rapidly change and routine protocol may not
be adequate to cover ever y unexpected situation. Critical
thinking enables the nurse to recognize important cues, re-
spond quickly, and adapt inter ventions to meet specific client
needs at the right time. Box 10–1 lists some personal critical
thinking indicators.

• Nurses make important decisions. Every day, and every moment
during the day, nurses use critical thinking skills and clinical rea-
soning to make judgments about a client’s care. For example, de-
termining which observations must be reported to the primary

care provider immediately and which can be noted
in the electronic medical record for later consulta-
tion with the primary care provider requires critical
thinking. Also clients have different health needs
simultaneously. For example, a client who is experi-
encing an acute asthma attack with air hunger will
also experience anxiety. The nurse must administer
a medication to improve breathing before addressing
the client’s anxiety.

Critical thinking cognitively fuels the intellectual
artistic activity of creativity. When nurses incorporate
creativity, they are able to find unique solutions to unique
problems. Creativity is thinking that results in the de-
velopment of new ideas and products. Creativity in prob-
lem solving and decision making is the ability to develop
and implement new and better solutions for health care

Creativity is required when the nurse encounters a
new situation or a client situation in which traditional
interventions are not effective. Creative thinkers must
assess a problem and be knowledgeable about the un-
derlying facts and principles that apply. An example
would be a 4-year-old child who has sustained a severe
burn and has been discharged from the hospital. The
home care nurse has orders to soak and cleanse the
wound in the bathtub. After arriving at the child’s home,
the nurse determines the family does not have hot water
service due to an inability to pay the gas bill. The nurse
warms water on the electric stove so the wound can be
cleansed in the bathtub as ordered by the primary care
provider. Next the nurse contacts the social worker to
help the family obtain financial assistance so the gas bill
can be paid and the hot water restored.

In this clinical scenario the nurse has utilized cre-
ativity by warming the water on the stove. The nurse
has also utilized knowledge of the role the social worker
plays in providing care to the child and family. The use of
creativity provides the nurse with the ability to:

• Generate many ideas rapidly.
• Be generally flexible and natural; that is, able to change viewpoints

or directions in thinking rapidly and easily.
• Create original solutions to problems.
• Be independent and self confident, even when under pressure.
• Demonstrate individuality.

In addition to the ten affective and seven cognitive components of
critical thinking, the nurse uses other techniques to ensure effective
problem solving and decision making. These techniques include
critical analysis, inductive and deductive reasoning, making valid
inferences, differentiating facts from opinions, evaluating the cred-
ibility of information sources, clarifying concepts, and recognizing

Critical analysis is the application of a set of questions to a
particular situation or idea to determine essential information and

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BOX 10–1 Personal Critical Thinking Indicators: Behaviors, Attitudes, and Characteristics

• Self-aware: Clarifies biases, inclinations, strengths, and
limitations; acknowledges when thinking may be influenced by
emotions or self-interest.

• Genuine/authentic: Shows true self; demonstrates behaviors
that indicate stated values.

• Effective communicator: Listens well (shows deep understand-
ing of others’ thoughts, feelings, and circumstances); speaks
and writes with clarity.

• Health: Promotes a healthy lifestyle; uses healthy behaviors to
manage stress.

• Careful and prudent: Knows own limits—seeks help as
needed; suspends or revises judgment as indicated by new
or incomplete data.

• Confident and resilient: Expresses faith in ability to reason and
learn; overcomes disappointments.

• Honest and upright: Seeks the truth, even if it sheds unwanted
light; upholds standards; admits flaws in thinking.

• Curious and inquisitive: Looks for reasons, explanations, and
meaning; seeks new information to broaden understanding.

• Alert to context: Looks for changes in circumstances that
warrant a need to modify thinking or approaches.

• Analytical and insightful: Identifies relationships; expresses deep

• Logical and intuitive: Draws reasonable conclusions (if this is so,
then it follows that . . . because . . .); uses intuition as a guide
to search for evidence; acts on intuition only with knowledge of
risks involved.

• Open and fair-minded; Shows tolerance for different viewpoints;
questions how own viewpoints are influencing thinking.

• Sensitive to diversity: Expresses appreciation of human
differences related to values, culture, personality, or learning
style preferences; adapts to preferences when feasible.

• Creative: Offers alternative solutions and approaches; comes
up with useful ideas.

• Realistic and practical: Admits when things are not feasible;
looks for user-friendly solutions.

• Reflective and self-corrective: Carefully considers meaning of
data and interpersonal interactions, asks for feedback; corrects
own thinking, is alert to potential errors by self and others, finds
ways to avoid future mistakes.

• Proactive: Anticipates consequences, plans ahead, acts on

• Courageous: Stands up for beliefs, advocates for others, does
not hide from challenges.

• Patient and persistent: Waits for the right moment; perseveres
to achieve best results.

• Flexible: Changes approaches as needed to get the best

• Empathetic: Listens well; shows ability to imagine others’
feelings and difficulties.

• Improvement-oriented (self, patients, systems): Self— identifies
learning needs; finds ways to overcome limitations, seeks out
new knowledge. Patients—promotes health care systems;
promotes safety, quality, satisfaction, and cost-containment.

From Critical Thinking Indicators (CTIs): 2014 Evidence-Based Version (p. 7), by
R. Alfaro-LeFevre, 2014, Stuart, FL, p. 7. Reprinted with permission. Retrieved from

ideas and discard unimportant information and ideas. The questions
are not sequential steps; rather they are a set of criteria for judging an
idea. Not all questions will need to be applied to every situation, but
one should be aware of all of the questions in order to choose those
questions appropriate to a given situation.

Socrates was a Greek philosopher who developed the method
of posing questions and seeking an answer. Socratic questioning
is a technique one can use to look beneath the surface, recognize and
examine assumptions, search for inconsistencies, examine multiple
points of view, and differentiate what one knows from what one
merely believes. Box 10–2 lists Socratic questions to use in critical
analysis. Nurses should employ Socratic questioning when reporting
about a client’s condition and current status, reviewing a client’s his-
tory and progress notes, and planning care.

Two other critical thinking skills are inductive and deductive
reasoning. In inductive reasoning, generalizations are formed
from a set of facts or observations. When viewed together, certain
bits of information suggest a particular interpretation. Inductive
reasoning moves from specific examples (premises) to a generalized
conclusion—for example, after touching several hot flames (prem-
ise), we conclude that all flames are hot. A nurse who observes a
client who has dry skin, poor turgor, sunken eyes, and dark amber
urine and who is determined to be dehydrated (premise) concludes
that the presence of those signs in other clients indicates that they are

Deductive reasoning, by contrast, is reasoning from general
premise to the specific conclusion. If you begin with the premise

BOX 10–2 Socratic Questions

• Is this question clear, understandable, and correctly

• Is this question important?
• Could this question be broken down into smaller parts?
• How might _____________ state this question?

• You seem to be assuming _____________; is that so?
• What could you assume instead? Why?
• Does this assumption always hold true?

• You seem to be using the perspective of _____________.

• What would someone who disagrees with your

perspective say?
• Can you see this any other way?

• What evidence do you have for that?
• Is there any reason to doubt the evidence?
• How do you know?
• What would change your mind?

• What effect would that have?
• What is the probability that will actually happen?
• What are the alternatives?

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that the sum of the angles in any triangle is always 180 degrees, you
can conclude that the sum of the angles in the triangle you happen
to have is also 180 degrees. A nurse might start with a premise that
all children love peanut butter sandwiches. Thus, if the nurse is try-
ing to encourage a child to eat, then the nurse should offer the child
a peanut butter sandwich. This is an example in which the premise
is not always valid and, thus, the conclusion also may not be valid.
Nurses use critical thinking to help analyze situations and establish
which premises are valid.

In critical thinking, the nurse also differentiates statements of
fact, inference, judgment, and opinion. Table 10–1 shows how these
statements may be applied to nursing care. Evaluating the credibil-
ity of information sources is an important step in critical thinking.
Unfortunately, we cannot always believe what we read or are told.
The nurse must ascertain the accuracy of information by checking
other documents or with other informants. Hence, the expanding
need for evidence-based nursing practice. To comprehend a client
situation clearly, the nurse and the client must agree on the mean-
ing of terms. For example, if the clients says to the nurse “I think
I  have a tumor,” the nurse needs to clarify what the word means to
the client—the medical definition of a tumor (a solid mass) or the
common lay meaning of cancer—before responding. People also live
their lives under certain assumptions. Some people view humans as
having a basically generous nature, whereas others believe that the
human tendency is to act in their own best interest. The nurse may
believe that life should be considered worth living no matter what
the condition, whereas the client may believe that quality of life is
more important than quantity of life. If the nurse and client recog-
nize that they make choices based on these assumptions, they can
still work together toward an acceptable plan of care. Difficulty arises
when people do not take the time to consider what assumptions un-
derlie their beliefs and actions.

When a nurse uses intentional thinking, a relationship develops
among the knowledge, skills, and attitudes that are ascribed to criti-
cal thinking and clinical reasoning, the nursing process, and the
problem-solving process.

Implementation of the nursing process provides nurses with a
creative approach to thinking and doing to obtain, categorize, and
analyze client data and plan actions that will meet the client’s needs.
The nursing process is a systematic, rational method of planning
and providing individualized nursing care. It begins with assessment

Statement Description Example
Facts Can be verified through investigation Blood pressure is affected by blood volume.

Inferences Conclusions drawn from the facts; going beyond facts to
make a statement about something not currently known

If blood volume is decreased (e.g., in hemorrhagic shock), the
blood pressure will drop.

Judgments Evaluation of facts or information that reflects values or
other criteria; a type of opinion

It is harmful to the client’s health if the blood pressure drops
too low.

Opinions Beliefs formed over time; include judgments that may fit
facts or be erroneous

Nursing interventions can assist in maintaining the client’s
blood pressure within normal limits.

TABLE 10–1 Differentiating Types of Statements

of the client and use of clinical reasoning to identify client problems.
The phases of the nursing process are assessing, diagnosing, plan-
ning, implementing, and evaluating. These phases are described in
detail in Chapters 11 through 14 .

Problem Solving
Problem solving is a mental activity in which a problem is identified
that represents an unsteady state. It requires the nurse to obtain infor-
mation that clarifies the nature of the problem and suggests possible
solutions. Throughout the problem-solving process the implementa-
tion of critical thought may or may not be required in working toward
a solution (Wilkinson, 2012). The nurse carefully evaluates the pos-
sible solutions and chooses the best one to implement. The situation is
carefully monitored over time to ensure that its initial and continued
effectiveness returns the client to a steady state. The nurse does not
discard the other solutions, but holds them in reserve in the event that
the first solution is not effective. Therefore, problem solving for one
situation contributes to the nurse’s body of knowledge for problem
solving in similar situations. Commonly used approaches to problem
solving include trial and error, intuition, and the research process.

One way to solve problems is through trial and error, in which a
number of approaches are tried until a solution is found. However,
without considering alternatives systematically, one cannot know
why the solution works. The use of trial-and-error methods in nurs-
ing care can be dangerous because the client might suffer harm if an
approach is inappropriate. However, nurses often use trial and error
in the home setting due to logistics, equipment, and client lifestyle.
For example, when teaching a client to perform a colostomy irriga-
tion, a bent coat hanger hung on the shower curtain rod provides an
appropriate height to perform the irrigation. In the hospital setting a
lowered intravenous (IV) pole is more likely utilized.

Intuition is a problem-solving approach that relies on a nurse’s in-
ner sense. It is a legitimate aspect of a nursing judgment in the imple-
mentation of care (Wilkinson, 2012). Intuition is the understanding
or learning of things without the conscious use of reasoning. It is
also known as sixth sense, hunch, instinct, feeling, or suspicion. As
a problem-solving approach, intuition is viewed by some people as a
form of guessing and, as such, an inappropriate basis for nursing de-
cisions. However, others view intuition as an essential and legitimate
aspect of clinical judgment acquired through knowledge and experi-
ence. Clinical judgment in nursing is a decision-making process to

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2012). Fair-mindedness helps one to consider opposing points of
view and to try to understand new ideas fully before rejecting or ac-
cepting them. Critical thinkers strive to be open to the possibility
that new evidence could change their minds. The nurse listens to
the opinions of all members of a family, young and old. Sometimes
the traditional approach will emerge as the most effective strategy,
whereas at other times a new and possibly unproven approach should
be tried. In every case, the nurse must be able to provide the rationale
for any action taken.

Insight into Egocentricity
Critical thinkers are open to the possibility that their personal biases
or social pressures and customs could unduly affect their think-
ing. They actively try to examine their own biases and bring them
to awareness each time they think or make a decision. By failing to
reflect on personal biases, the nurse may reach inappropriate conclu-
sions for the individual client. For example, a nurse spends extensive
time teaching a client who is obese about nutrition and weight loss to
prevent recurrence of back pain, but is mystified when the client ap-
pears uninterested and does not follow the nurse’s advice. The nurse’s
bias of assuming that all clients will incorporate preventive care (just
because the nurse would do this) resulted in an inaccurate assess-
ment of the client’s motivation; both the nurse’s and the client’s time
was wasted. Possibly, the client’s cultural views of weight are differ-
ent from those of the nurse. Had the nurse assessed the client’s back-
ground and beliefs about weight and collected sufficient evidence,
the nurse might have identified a problem more relevant to the client’s
priorities and, thus, developed a better care plan.

Intellectual Humility
Intellectual humility means having an awareness of the limits of one’s
own knowledge. Critical thinkers are willing to admit what they do
not know; they are willing to seek new information and to rethink
their conclusions in light of new knowledge. They never assume that
what everybody believes to be right will always be right, because new
evidence may emerge. A hospital nurse might be unable to imagine
how an older adult’s wife will care for her husband who has recently
had a stroke. However, the nurse also recognizes that it is not really
possible to know what the couple can achieve.

Intellectual Courage to Challenge
the Status Quo and Rituals
With an attitude of courage, a nurse is willing to consider and exam-
ine fairly his or her own ideas or views, especially those to which the
nurse may have a strongly negative reaction. This type of courage
comes from recognizing that beliefs are sometimes false or mislead-
ing. Values and beliefs are not always acquired rationally. Rational
beliefs are those that have been examined and found to be supported
by solid reasons and data. After such examination, it is inevitable
that some beliefs previously held to be true will be found to contain
questionable elements and that some truth will emerge from ideas
considered dangerous or false. Courage is needed to be true to new
thinking in such cases, especially if social penalties for nonconfor-
mity are severe. For example, many nurses previously believed that
allowing family members to observe emergency procedures (such as
cardiopulmonary resuscitation) would be psychologically harmful
to the family and that members would get in the health care team’s

ascertain the right nursing action to be implemented at the appro-
priate time in the client’s care. The nurse must first have the knowl-
edge base necessary to practice in the clinical area and then use that
knowledge in clinical practice. Clinical experience allows the nurse to
recognize cues and patterns and begin to reach correct conclusions.

Experience is important in improving intuition because the ra-
pidity of the judgment depends on the nurse having seen similar cli-
ent situations many times before. Sometimes nurses use the words “I
had a feeling” to describe the critical thinking element of considering
evidence. These nurses are able to judge quickly which evidence is
most important and to act on that limited evidence. Nurses in critical
care often pay closer attention than usual to a client when they sense
that the client’s condition could change suddenly.

Although the intuitive method of problem solving is gaining
recognition as part of nursing practice, it is not recommended for
novices or students, because they usually lack the knowledge base
and clinical experience on which to make a valid judgment.

The research process, discussed in Chapter 2 …

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