5. Critical Thinking and Clinical Reasoning
Open Resources for Nursing (Open RN) and Amy Ertwine
Prioritization of patient care should be grounded in critical thinking rather than just a checklist of items to be done. Critical thinking is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[1] Certainly, there are many actions that nurses must complete during their shift, but nursing requires adaptation and flexibility to meet emerging patient needs. It can be challenging for a novice nurse to change their mindset regarding their established “plan” for the day, but the sooner a nurse recognizes prioritization is dictated by their patients’ needs, the less frustration the nurse might experience. Prioritization strategies include collection of information and utilization of clinical reasoning to determine the best course of action. Clinical reasoning is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.”[2] Clinical reasoning is fostered within nurses when they are challenged to integrate data in various contexts. The clinical reasoning cycle begins when nurses first consider a client situation and progress to collecting cues and information. As nurses process the information, they begin to identify problems and establish realistic goals. They then take appropriate actions and evaluate outcomes. Finally, they reflect upon the process and the learning that has occurred. The reflection piece is critical for solidifying or changing future actions and developing knowledge.
When nurses use critical thinking and clinical reasoning skills, they set forth on a purposeful course of intervention to best meet patient-care needs. Rather than focusing on one’s own priorities, nurses utilizing critical thinking and reasoning skills recognize their actions must be responsive to their patients. For example, a nurse using critical thinking skills understands that scheduled morning medications for their patients may be late if one of the patients on their care team suddenly develops chest pain. Many actions may be added or removed from planned activities throughout the shift based on what is occurring holistically on the patient-care team.
Additionally, in today’s complex health care environment, it is important for the novice nurse to recognize the realities of the current health care environment. Patients have become increasingly complex in their health care needs, and organizations are often challenged to meet these care needs with limited staffing resources. It can become easy to slip into the mindset of disenchantment with the nursing profession when first assuming the reality of patient-care assignments as a novice nurse. The workload of a nurse in practice often looks and feels quite different than that experienced as a nursing student. As a nursing student, there may have been time for lengthy conversations with patients and their family members, ample time to chart, and opportunities to offer personal cares, such as a massage or hair wash. Unfortunately, in the time-constrained realities of today’s health care environment, novice nurses should recognize that even though these “extra” tasks are not always possible, they can still provide quality, safe patient care using the “CURE” prioritization framework. Rather than feeling frustrated about “extras” that cannot be accomplished in time-constrained environments, it is vital to use prioritization strategies to ensure appropriate actions are taken to complete what must be done. With increased clinical experience, a novice nurse typically becomes more comfortable with prioritizing and reprioritizing care.
- Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41(4), 215-221. https://doi.org/10.1097/01.nep.0000000000000669 ↵
- Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41(4), 215-221. https://doi.org/10.1097/01.nep.0000000000000669 ↵
Time management is not an unfamiliar concept to nursing students because many students are balancing time demands related to work, family, and school obligations. To determine where time should be allocated, prioritization processes emerge. Although the prioritization frameworks of nursing may be different than those used as a student, the concept of prioritization remains the same. Despite the context, prioritization is essentially using a structure to organize tasks to ensure the most critical tasks are completed first and then identify what to move onto next. To truly maximize time management, in addition to prioritization, individuals should be organized, strive for accuracy, minimize waste, mobilize resources, and delegate when appropriate.
Time management is one of the greatest challenges that nurses face in their busy workday. As novice nurses develop their practice, it is important to identify organizational strategies to ensure priority tasks are completed and time is optimized. Each nurse develops a personal process for organizing information and structuring the timing of their assessments, documentation, medication administration, interventions, and patient education. However, one must always remember that this process and structure must be flexible because in a moment’s time, a patient’s condition can change, requiring a reprioritization of care. An organizational tool is important to guide a nurse’s daily task progression. Organizational tools may be developed individually by the nurse or may be recommended by the organization. Tools can be rudimentary in nature, such as a simple time column format outlining care activities planned throughout the shift, or more complex and integrated within an organization’s electronic medical record. No matter the format, an organizational tool is helpful to provide structure and guide progression toward task achievement.
In addition to using an organizational tool, novice nurses should utilize other time management strategies to optimize their time. For example, assessments can start during bedside handoff report, such as what fluids and medications are running and what will need to be replaced soon. Take a moment after handoff reports to prioritize which patients you will see first during your shift. Other strategies such as grouping tasks, gathering appropriate equipment prior to initiating nursing procedures, and gathering assessment information while performing tasks are helpful in minimizing redundancy and increasing efficiency. For example, observe an experienced nurse providing care and note the efficient processes they use. They may conduct an assessment, bring in morning medications, flush an IV line, collect a morning blood glucose level, and provide patient education about medications all during one patient encounter. Efficiency becomes especially important if the patient has transmission-based precautions and the time spent donning and doffing PPE are considered. The realities of the time-constrained health care environments often necessitate clustering tasks to ensure that all patient-care tasks are completed. Furthermore, nurses who do not manage their time effectively may inadvertently place their patients at risk as a result of delayed care.[1] Effective time management benefits both the patient and the nursing staff.
Time estimation is an additional helpful strategy to facilitate time management. Time estimation involves the review of planned tasks for the day and allocating time estimated to complete the task. Time estimation is especially helpful for novice nurses as they begin to structure and prioritize their shift based on the list of tasks that are required.[2] For example, estimating the time it will take to perform an assessment and administer morning medications to one patient allows the nurse to better plan when to complete the dressing change on another patient. Without using time estimation, the nurse may attempt to group all care tasks with the morning assessments and not leave themselves enough time to administer morning medications within the desired administration time window. Additionally, working in a time-constrained environment without using time estimation strategies increases the likelihood of performing tasks “in a rush” and subsequently increasing the potential for error.
Who’s On My Team?
One of the most critical strategies to enhance time management is to mobilize the resources of the nursing team. The nursing care team includes advanced practice registered nurses (APRN), registered nurses (RN), licensed practical/vocational nurses (LPN/VN), and assistive personnel (AP). AP (formerly referred to as unlicensed assistive personnel [UAP]) include, but are not limited to, certified nursing assistants or aides (CNA), patient-care technicians (PCT), certified medical assistants (CMA), certified medication aides, and home health aides.[3] Each care environment may have a blend of staff, and it is important to understand the legalities associated with the scope and role of each member and what can be safely and appropriately delegated to other members of the team. For example, assistive personnel may be able to assist with ambulating a patient in the hallway, but they would not be able to help administer morning medications. Dividing tasks appropriately among nursing team members can help ensure that the required tasks are completed and individual energies are best allocated to meet patient needs. The nursing care team and requirements around the process of delegation are explored in detail in the "Delegation and Supervision" chapter.
Prioritization of patient care should be grounded in critical thinking rather than just a checklist of items to be done. Critical thinking is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow."[4] Certainly, there are many actions that nurses must complete during their shift, but nursing requires adaptation and flexibility to meet emerging patient needs. It can be challenging for a novice nurse to change their mindset regarding their established “plan” for the day, but the sooner a nurse recognizes prioritization is dictated by their patients’ needs, the less frustration the nurse might experience. Prioritization strategies include collection of information and utilization of clinical reasoning to determine the best course of action. Clinical reasoning is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.”[5] Clinical reasoning is fostered within nurses when they are challenged to integrate data in various contexts. The clinical reasoning cycle begins when nurses first consider a client situation and progress to collecting cues and information. As nurses process the information, they begin to identify problems and establish realistic goals. They then take appropriate actions and evaluate outcomes. Finally, they reflect upon the process and the learning that has occurred. The reflection piece is critical for solidifying or changing future actions and developing knowledge.
When nurses use critical thinking and clinical reasoning skills, they set forth on a purposeful course of intervention to best meet patient-care needs. Rather than focusing on one’s own priorities, nurses utilizing critical thinking and reasoning skills recognize their actions must be responsive to their patients. For example, a nurse using critical thinking skills understands that scheduled morning medications for their patients may be late if one of the patients on their care team suddenly develops chest pain. Many actions may be added or removed from planned activities throughout the shift based on what is occurring holistically on the patient-care team.
Additionally, in today’s complex health care environment, it is important for the novice nurse to recognize the realities of the current health care environment. Patients have become increasingly complex in their health care needs, and organizations are often challenged to meet these care needs with limited staffing resources. It can become easy to slip into the mindset of disenchantment with the nursing profession when first assuming the reality of patient-care assignments as a novice nurse. The workload of a nurse in practice often looks and feels quite different than that experienced as a nursing student. As a nursing student, there may have been time for lengthy conversations with patients and their family members, ample time to chart, and opportunities to offer personal cares, such as a massage or hair wash. Unfortunately, in the time-constrained realities of today's health care environment, novice nurses should recognize that even though these “extra” tasks are not always possible, they can still provide quality, safe patient care using the “CURE” prioritization framework. Rather than feeling frustrated about “extras” that cannot be accomplished in time-constrained environments, it is vital to use prioritization strategies to ensure appropriate actions are taken to complete what must be done. With increased clinical experience, a novice nurse typically becomes more comfortable with prioritizing and reprioritizing care.
