Chapter 6. Clinical Reasoning, Decisionmaking, and 

Action: Thinking Critically and Clinically 

Patricia Benner, Ronda G. Hughes, Molly Sutphen 

Background 

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 Rubenfeld5

 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 knowledge6 (Scheffer & Rubenfeld, 

p. 357).

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

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 research7 (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 

creativity8 (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 solving8 (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

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Critical Reasoning, Decisonmaking, and Action 

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 wellestablished 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

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

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. Halpern19 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 educators21 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 

4 
Critical Reasoning, Decisonmaking, and Action 

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 

habitus28 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 

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

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. Dewey32 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 decisions42 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 

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Critical Reasoning, Decisonmaking, and Action 

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 dispossession11 (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 past30 (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 

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

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. 

Experience 

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 goals48 (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 Gadamer29 points out, experience involves a turning around 

of preconceived notions, preunderstandings, and extends or adds nuances to understanding. 

Dewey49 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 

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Critical Reasoning, Decisonmaking, and Action 

nothing to a close; we are constantly learning new things from our experience ... 

this I call the interminability of all experience32 (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 problemsolving 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 patterns39 (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 highlevel 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 colleagues65 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

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

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 Appleton62 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 

Barrow68, 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 

novice79 (p. 23). 

Shaw80 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 

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Critical Reasoning, Decisonmaking, and Action 

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 researchbased knowledge87 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 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

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 responses92 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 experience96, 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 evidence101 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 

12 
Critical Reasoning, Decisonmaking, and Action 

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 selfimproving 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 bestsuited 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:

13 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

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 crossprofessional 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, 

14 
Critical Reasoning, Decisonmaking, and Action 

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 Chan20 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 

 

*

 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. 

15 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

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 

16 
Critical Reasoning, Decisonmaking, and Action 

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 lifesustaining 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 

17 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

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. Bourdieu29 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 

18 
Critical Reasoning, Decisonmaking, and Action 

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. 

Conclusion 

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. 

Author Affiliation 

Patricia Benner, R.N., Ph.D., F.A.A.N., Carnegie Foundation for the Advancement of 

Teaching. E-mail: Benner@carnegiefoundation.org. 

Ronda G. Hughes, Ph.D., M.H.S., R.N., senior health scientist administrator, Agency for 

Healthcare Research and Quality. E-mail: Ronda.Hughes@ahrq.hhs.gov. 

Molly Sutphen, Ph.D., Carnegie Foundation for the Advancement of Teaching. E-mail: 

Sutphen@carnegiefoundation.org. 

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