why critical thinking is important in healthcare

The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

Images sourced from Getty Images

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What is Critical Thinking in Nursing? (With Examples, Importance, & How to Improve)

Successful nursing requires learning several skills used to communicate with patients, families, and healthcare teams. One of the most essential skills nurses must develop is the ability to demonstrate critical thinking. If you are a nurse, perhaps you have asked if there is a way to know how to improve critical thinking in nursing? As you read this article, you will learn what critical thinking in nursing is and why it is important. You will also find 18 simple tips to improve critical thinking in nursing and sample scenarios about how to apply critical thinking in your nursing career.

What Is Critical Thinking In Nursing?

4 reasons why critical thinking is so important in nursing, 1. critical thinking skills will help you anticipate and understand changes in your patient’s condition., 2. with strong critical thinking skills, you can make decisions about patient care that is most favorable for the patient and intended outcomes., 3. strong critical thinking skills in nursing can contribute to innovative improvements and professional development., 4. critical thinking skills in nursing contribute to rational decision-making, which improves patient outcomes., what are the 8 important attributes of excellent critical thinking in nursing, 1. the ability to interpret information:, 2. independent thought:, 3. impartiality:, 4. intuition:, 5. problem solving:, 6. flexibility:, 7. perseverance:, 8. integrity:, examples of poor critical thinking vs excellent critical thinking in nursing, 1. scenario: patient/caregiver interactions, poor critical thinking:, excellent critical thinking:, 2. scenario: improving patient care quality, 3. scenario: interdisciplinary collaboration, 4. scenario: precepting nursing students and other nurses, how to improve critical thinking in nursing, 1. demonstrate open-mindedness., 2. practice self-awareness., 3. avoid judgment., 4. eliminate personal biases., 5. do not be afraid to ask questions., 6. find an experienced mentor., 7. join professional nursing organizations., 8. establish a routine of self-reflection., 9. utilize the chain of command., 10. determine the significance of data and decide if it is sufficient for decision-making., 11. volunteer for leadership positions or opportunities., 12. use previous facts and experiences to help develop stronger critical thinking skills in nursing., 13. establish priorities., 14. trust your knowledge and be confident in your abilities., 15. be curious about everything., 16. practice fair-mindedness., 17. learn the value of intellectual humility., 18. never stop learning., 4 consequences of poor critical thinking in nursing, 1. the most significant risk associated with poor critical thinking in nursing is inadequate patient care., 2. failure to recognize changes in patient status:, 3. lack of effective critical thinking in nursing can impact the cost of healthcare., 4. lack of critical thinking skills in nursing can cause a breakdown in communication within the interdisciplinary team., useful resources to improve critical thinking in nursing, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. will lack of critical thinking impact my nursing career, 2. usually, how long does it take for a nurse to improve their critical thinking skills, 3. do all types of nurses require excellent critical thinking skills, 4. how can i assess my critical thinking skills in nursing.

• Ask relevant questions • Justify opinions • Address and evaluate multiple points of view • Explain assumptions and reasons related to your choice of patient care options

5. Can I Be a Nurse If I Cannot Think Critically?

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Cultivating Critical Thinking in Healthcare

Published: 06 January 2019

Critical thinking skills have been linked to improved patient outcomes, better quality patient care and improved safety outcomes in healthcare (Jacob et al. 2017).

Given this, it's necessary for educators in healthcare to stimulate and lead further dialogue about how these skills are taught , assessed and integrated into the design and development of staff and nurse education and training programs (Papp et al. 2014).

So, what exactly is critical thinking and how can healthcare educators cultivate it amongst their staff?

What is Critical Thinking?

In general terms, ‘ critical thinking ’ is often used, and perhaps confused, with problem-solving and clinical decision-making skills .

In practice, however, problem-solving tends to focus on the identification and resolution of a problem, whilst critical thinking goes beyond this to incorporate asking skilled questions and critiquing solutions .

Several formal definitions of critical thinking can be found in literature, but in the view of Kahlke and Eva (2018), most of these definitions have limitations. That said, Papp et al. (2014) offer a useful starting point, suggesting that critical thinking is:

‘The ability to apply higher order cognitive skills and the disposition to be deliberate about thinking that leads to action that is logical and appropriate.’

The Foundation for Critical Thinking (2017) expands on this and suggests that:

‘Critical thinking is that mode of thinking, about any subject, content, or problem, in which the thinker improves the quality of his or her thinking by skillfully analysing, assessing, and reconstructing it.’

They go on to suggest that critical thinking is:

• Self-directed
• Self-disciplined
• Self-monitored
• Self-corrective.

Key Qualities and Characteristics of a Critical Thinker

Given that critical thinking is a process that encompasses conceptualisation , application , analysis , synthesis , evaluation and reflection , what qualities should be expected from a critical thinker?

In answering this question, Fortepiani (2018) suggests that critical thinkers should be able to:

• Formulate clear and precise questions
• Gather, assess and interpret relevant information
• Reach relevant well-reasoned conclusions and solutions
• Think open-mindedly, recognising their own assumptions
• Communicate effectively with others on solutions to complex problems.

All of these qualities are important, however, good communication skills are generally considered to be the bedrock of critical thinking. Why? Because they help to create a dialogue that invites questions, reflections and an open-minded approach, as well as generating a positive learning environment needed to support all forms of communication.

Lippincott Solutions (2018) outlines a broad spectrum of characteristics attributed to strong critical thinkers. They include:

• Inquisitiveness with regard to a wide range of issues
• A concern to become and remain well-informed
• Alertness to opportunities to use critical thinking
• Self-confidence in one’s own abilities to reason
• Open mindedness regarding divergent world views
• Flexibility in considering alternatives and opinions
• Understanding the opinions of other people
• Fair-mindedness in appraising reasoning
• Honesty in facing one’s own biases, prejudices, stereotypes or egocentric tendencies
• A willingness to reconsider and revise views where honest reflection suggests that change is warranted.

Papp et al. (2014) also helpfully suggest that the following five milestones can be used as a guide to help develop competency in critical thinking:

Stage 1: Unreflective Thinker

At this stage, the unreflective thinker can’t examine their own actions and cognitive processes and is unaware of different approaches to thinking.

Stage 2: Beginning Critical Thinker

Here, the learner begins to think critically and starts to recognise cognitive differences in other people. However, external motivation  is needed to sustain reflection on the learners’ own thought processes.

Stage 3: Practicing Critical Thinker

By now, the learner is familiar with their own thinking processes and makes a conscious effort to practice critical thinking.

Stage 4: Advanced Critical Thinker

As an advanced critical thinker, the learner is able to identify different cognitive processes and consciously uses critical thinking skills.

Stage 5: Accomplished Critical Thinker

At this stage, the skilled critical thinker can take charge of their thinking and habitually monitors, revises and rethinks approaches for continual improvement of their cognitive strategies.

Facilitating Critical Thinking in Healthcare

A common challenge for many educators and facilitators in healthcare is encouraging students to move away from passive learning towards active learning situations that require critical thinking skills.

Just as there are similarities among the definitions of critical thinking across subject areas and levels, there are also several generally recognised hallmarks of teaching for critical thinking . These include:

• Promoting interaction among students as they learn
• Asking open ended questions that do not assume one right answer
• Allowing sufficient time to reflect on the questions asked or problems posed
• Teaching for transfer - helping learners to see how a newly acquired skill can apply to other situations and experiences.

(Lippincott Solutions 2018)

Snyder and Snyder (2008) also make the point that it’s helpful for educators and facilitators to be aware of any initial resistance that learners may have and try to guide them through the process. They should aim to create a learning environment where learners can feel comfortable thinking through an answer rather than simply having an answer given to them.

Examples include using peer coaching techniques , mentoring or preceptorship to engage students in active learning and critical thinking skills, or integrating project-based learning activities that require students to apply their knowledge in a realistic healthcare environment.

Carvalhoa et al. (2017) also advocate problem-based learning as a widely used and successful way of stimulating critical thinking skills in the learner. This view is echoed by Tsui-Mei (2015), who notes that critical thinking, systematic analysis and curiosity significantly improve after practice-based learning .

Integrating Critical Thinking Skills Into Curriculum Design

Most educators agree that critical thinking can’t easily be developed if the program curriculum is not designed to support it. This means that a deep understanding of the nature and value of critical thinking skills needs to be present from the outset of the curriculum design process , and not just bolted on as an afterthought.

In the view of Fortepiani (2018), critical thinking skills can be summarised by the statement that 'thinking is driven by questions', which means that teaching materials need to be designed in such a way as to encourage students to expand their learning by asking questions that generate further questions and stimulate the thinking process. Ideal questions are those that:

• Embrace complexity
• Challenge assumptions and points of view
• Question the source of information
• Explore variable interpretations and potential implications of information.

To put it another way, asking questions with limiting, thought-stopping answers inhibits the development of critical thinking. This means that educators must ideally be critical thinkers themselves .

Drawing these threads together, The Foundation for Critical Thinking (2017) offers us a simple reminder that even though it’s human nature to be ‘thinking’ most of the time, most thoughts, if not guided and structured, tend to be biased, distorted, partial, uninformed or even prejudiced.

They also note that the quality of work depends precisely on the quality of the practitioners’ thought processes. Given that practitioners are being asked to meet the challenge of ever more complex care, the importance of cultivating critical thinking skills, alongside advanced problem-solving skills , seems to be taking on new importance.

Additional Resources

• The Emotionally Intelligent Nurse | Ausmed Article
• Refining Competency-Based Assessment | Ausmed Article
• Socratic Questioning in Healthcare | Ausmed Article
• Carvalhoa, D P S R P et al. 2017, 'Strategies Used for the Promotion of Critical Thinking in Nursing Undergraduate Education: A Systematic Review', Nurse Education Today , vol. 57, pp. 103-10, viewed 7 December 2018, https://www.sciencedirect.com/science/article/abs/pii/S0260691717301715
• Fortepiani, L A 2017, 'Critical Thinking or Traditional Teaching For Health Professionals', PECOP Blog , 16 January, viewed 7 December 2018, https://blog.lifescitrc.org/pecop/2017/01/16/critical-thinking-or-traditional-teaching-for-health-professions/
• Jacob, E, Duffield, C & Jacob, D 2017, 'A Protocol For the Development of a Critical Thinking Assessment Tool for Nurses Using a Delphi Technique', Journal of Advanced Nursing, vol. 73, no. 8, pp. 1982-1988, viewed 7 December 2018, https://onlinelibrary.wiley.com/doi/10.1111/jan.13306
• Kahlke, R & Eva, K 2018, 'Constructing Critical Thinking in Health Professional Education', Perspectives on Medical Education , vol. 7, no. 3, pp. 156-165, viewed 7 December 2018, https://link.springer.com/article/10.1007/s40037-018-0415-z
• Lippincott Solutions 2018, 'Turning New Nurses Into Critical Thinkers', Lippincott Solutions , viewed 10 December 2018, https://www.wolterskluwer.com/en/expert-insights/turning-new-nurses-into-critical-thinkers
• Papp, K K 2014, 'Milestones of Critical Thinking: A Developmental Model for Medicine and Nursing', Academic Medicine , vol. 89, no. 5, pp. 715-720, https://journals.lww.com/academicmedicine/Fulltext/2014/05000/Milestones_of_Critical_Thinking___A_Developmental.14.aspx
• Snyder, L G & Snyder, M J 2008, 'Teaching Critical Thinking and Problem Solving Skills', The Delta Pi Epsilon Journal , vol. L, no. 2, pp. 90-99, viewed 7 December 2018, https://dme.childrenshospital.org/wp-content/uploads/2019/02/Optional-_Teaching-Critical-Thinking-and-Problem-Solving-Skills.pdf
• The Foundation for Critical Thinking 2017, Defining Critical Thinking , The Foundation for Critical Thinking, viewed 7 December 2018, https://www.criticalthinking.org/pages/our-conception-of-critical-thinking/411
• Tsui-Mei, H, Lee-Chun, H & Chen-Ju MSN, K 2015, 'How Mental Health Nurses Improve Their Critical Thinking Through Problem-Based Learning', Journal for Nurses in Professional Development , vol. 31, no. 3, pp. 170-175, viewed 7 December 2018, https://journals.lww.com/jnsdonline/Abstract/2015/05000/How_Mental_Health_Nurses_Improve_Their_Critical.8.aspx

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What is Critical Thinking in Nursing? (Explained W/ Examples)

Last updated on August 23rd, 2023

Critical thinking is a foundational skill applicable across various domains, including education, problem-solving, decision-making, and professional fields such as science, business, healthcare, and more.

It plays a crucial role in promoting logical and rational thinking, fostering informed decision-making, and enabling individuals to navigate complex and rapidly changing environments.

In this article, we will look at what is critical thinking in nursing practice, its importance, and how it enables nurses to excel in their roles while also positively impacting patient outcomes.

What is Critical Thinking?

Critical thinking is a cognitive process that involves analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

It’s a mental activity that goes beyond simple memorization or acceptance of information at face value.

Critical thinking involves careful, reflective, and logical thinking to understand complex problems, consider various perspectives, and arrive at well-reasoned conclusions or solutions.

Key aspects of critical thinking include:

• Analysis: Critical thinking begins with the thorough examination of information, ideas, or situations. It involves breaking down complex concepts into smaller parts to better understand their components and relationships.
• Evaluation: Critical thinkers assess the quality and reliability of information or arguments. They weigh evidence, identify strengths and weaknesses, and determine the credibility of sources.
• Synthesis: Critical thinking involves combining different pieces of information or ideas to create a new understanding or perspective. This involves connecting the dots between various sources and integrating them into a coherent whole.
• Inference: Critical thinkers draw logical and well-supported conclusions based on the information and evidence available. They use reasoning to make educated guesses about situations where complete information might be lacking.
• Problem-Solving: Critical thinking is essential in solving complex problems. It allows individuals to identify and define problems, generate potential solutions, evaluate the pros and cons of each solution, and choose the most appropriate course of action.
• Creativity: Critical thinking involves thinking outside the box and considering alternative viewpoints or approaches. It encourages the exploration of new ideas and solutions beyond conventional thinking.
• Reflection: Critical thinkers engage in self-assessment and reflection on their thought processes. They consider their own biases, assumptions, and potential errors in reasoning, aiming to improve their thinking skills over time.
• Open-Mindedness: Critical thinkers approach ideas and information with an open mind, willing to consider different viewpoints and perspectives even if they challenge their own beliefs.
• Effective Communication: Critical thinkers can articulate their thoughts and reasoning clearly and persuasively to others. They can express complex ideas in a coherent and understandable manner.
• Continuous Learning: Critical thinking encourages a commitment to ongoing learning and intellectual growth. It involves seeking out new knowledge, refining thinking skills, and staying receptive to new information.

Definition of Critical Thinking

Critical thinking is an intellectual process of analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

What is Critical Thinking in Nursing?

Critical thinking in nursing is a vital cognitive skill that involves analyzing, evaluating, and making reasoned decisions about patient care.

It’s an essential aspect of a nurse’s professional practice as it enables them to provide safe and effective care to patients.

Critical thinking involves a careful and deliberate thought process to gather and assess information, consider alternative solutions, and make informed decisions based on evidence and sound judgment.

This skill helps nurses to:

• Assess Information: Critical thinking allows nurses to thoroughly assess patient information, including medical history, symptoms, and test results. By analyzing this data, nurses can identify patterns, discrepancies, and potential issues that may require further investigation.
• Diagnose: Nurses use critical thinking to analyze patient data and collaboratively work with other healthcare professionals to formulate accurate nursing diagnoses. This is crucial for developing appropriate care plans that address the unique needs of each patient.
• Plan and Implement Care: Once a nursing diagnosis is established, critical thinking helps nurses develop effective care plans. They consider various interventions and treatment options, considering the patient’s preferences, medical history, and evidence-based practices.
• Evaluate Outcomes: After implementing interventions, critical thinking enables nurses to evaluate the outcomes of their actions. If the desired outcomes are not achieved, nurses can adapt their approach and make necessary changes to the care plan.
• Prioritize Care: In busy healthcare environments, nurses often face situations where they must prioritize patient care. Critical thinking helps them determine which patients require immediate attention and which interventions are most essential.
• Communicate Effectively: Critical thinking skills allow nurses to communicate clearly and confidently with patients, their families, and other members of the healthcare team. They can explain complex medical information and treatment plans in a way that is easily understood by all parties involved.
• Identify Problems: Nurses use critical thinking to identify potential complications or problems in a patient’s condition. This early recognition can lead to timely interventions and prevent further deterioration.
• Collaborate: Healthcare is a collaborative effort involving various professionals. Critical thinking enables nurses to actively participate in interdisciplinary discussions, share their insights, and contribute to holistic patient care.
• Ethical Decision-Making: Critical thinking helps nurses navigate ethical dilemmas that can arise in patient care. They can analyze different perspectives, consider ethical principles, and make morally sound decisions.
• Continual Learning: Critical thinking encourages nurses to seek out new knowledge, stay up-to-date with the latest research and medical advancements, and incorporate evidence-based practices into their care.

In summary, critical thinking is an integral skill for nurses, allowing them to provide high-quality, patient-centered care by analyzing information, making informed decisions, and adapting their approaches as needed.

It’s a dynamic process that enhances clinical reasoning , problem-solving, and overall patient outcomes.

What are the Levels of Critical Thinking in Nursing?

The development of critical thinking in nursing practice involves progressing through three levels: basic, complex, and commitment.

The Kataoka-Yahiro and Saylor model outlines this progression.

1. Basic Critical Thinking:

At this level, learners trust experts for solutions. Thinking is based on rules and principles. For instance, nursing students may strictly follow a procedure manual without personalization, as they lack experience. Answers are seen as right or wrong, and the opinions of experts are accepted.

2. Complex Critical Thinking:

Learners start to analyze choices independently and think creatively. They recognize conflicting solutions and weigh benefits and risks. Thinking becomes innovative, with a willingness to consider various approaches in complex situations.

3. Commitment:

At this level, individuals anticipate decision points without external help and take responsibility for their choices. They choose actions or beliefs based on available alternatives, considering consequences and accountability.

As nurses gain knowledge and experience, their critical thinking evolves from relying on experts to independent analysis and decision-making, ultimately leading to committed and accountable choices in patient care.

Why Critical Thinking is Important in Nursing?

Critical thinking is important in nursing for several crucial reasons:

Patient Safety:

Nursing decisions directly impact patient well-being. Critical thinking helps nurses identify potential risks, make informed choices, and prevent errors.

Clinical Judgment:

Nursing decisions often involve evaluating information from various sources, such as patient history, lab results, and medical literature.

Critical thinking assists nurses in critically appraising this information, distinguishing credible sources, and making rational judgments that align with evidence-based practices.

Enhances Decision-Making:

In nursing, critical thinking allows nurses to gather relevant patient information, assess it objectively, and weigh different options based on evidence and analysis.

This process empowers them to make informed decisions about patient care, treatment plans, and interventions, ultimately leading to better outcomes.

Promotes Problem-Solving:

Nurses encounter complex patient issues that require effective problem-solving.

Critical thinking equips them to break down problems into manageable parts, analyze root causes, and explore creative solutions that consider the unique needs of each patient.

Drives Creativity:

Nursing care is not always straightforward. Critical thinking encourages nurses to think creatively and explore innovative approaches to challenges, especially when standard protocols might not suffice for unique patient situations.

Fosters Effective Communication:

Communication is central to nursing. Critical thinking enables nurses to clearly express their thoughts, provide logical explanations for their decisions, and engage in meaningful dialogues with patients, families, and other healthcare professionals.

Aids Learning:

Nursing is a field of continuous learning. Critical thinking encourages nurses to engage in ongoing self-directed education, seeking out new knowledge, embracing new techniques, and staying current with the latest research and developments.

Improves Relationships:

Open-mindedness and empathy are essential in nursing relationships.

Critical thinking encourages nurses to consider diverse viewpoints, understand patients’ perspectives, and communicate compassionately, leading to stronger therapeutic relationships.

Empowers Independence:

Nursing often requires autonomous decision-making. Critical thinking empowers nurses to analyze situations independently, make judgments without undue influence, and take responsibility for their actions.

Facilitates Adaptability:

Healthcare environments are ever-changing. Critical thinking equips nurses with the ability to quickly assess new information, adjust care plans, and navigate unexpected situations while maintaining patient safety and well-being.

Strengthens Critical Analysis:

In the era of vast information, nurses must discern reliable data from misinformation.

Critical thinking helps them scrutinize sources, question assumptions, and make well-founded choices based on credible information.

How to Apply Critical Thinking in Nursing? (With Examples)

Here are some examples of how nurses can apply critical thinking.

Assess Patient Data:

Critical Thinking Action: Carefully review patient history, symptoms, and test results.

Example: A nurse notices a change in a diabetic patient’s blood sugar levels. Instead of just administering insulin, the nurse considers recent dietary changes, activity levels, and possible medication interactions before adjusting the treatment plan.

Diagnose Patient Needs:

Critical Thinking Action: Analyze patient data to identify potential nursing diagnoses.

Example: After reviewing a patient’s lab results, vital signs, and observations, a nurse identifies “ Risk for Impaired Skin Integrity ” due to the patient’s limited mobility.

Plan and Implement Care:

Critical Thinking Action: Develop a care plan based on patient needs and evidence-based practices.

Example: For a patient at risk of falls, the nurse plans interventions such as hourly rounding, non-slip footwear, and bed alarms to ensure patient safety.

Evaluate Interventions:

Critical Thinking Action: Assess the effectiveness of interventions and modify the care plan as needed.

Example: After administering pain medication, the nurse evaluates its impact on the patient’s comfort level and considers adjusting the dosage or trying an alternative pain management approach.

Prioritize Care:

Critical Thinking Action: Determine the order of interventions based on patient acuity and needs.

Example: In a busy emergency department, the nurse triages patients by considering the severity of their conditions, ensuring that critical cases receive immediate attention.

Collaborate with the Healthcare Team:

Critical Thinking Action: Participate in interdisciplinary discussions and share insights.

Example: During rounds, a nurse provides input on a patient’s response to treatment, which prompts the team to adjust the care plan for better outcomes.

Ethical Decision-Making:

Critical Thinking Action: Analyze ethical dilemmas and make morally sound choices.

Example: When a terminally ill patient expresses a desire to stop treatment, the nurse engages in ethical discussions, respecting the patient’s autonomy and ensuring proper end-of-life care.

Patient Education:

Critical Thinking Action: Tailor patient education to individual needs and comprehension levels.

Example: A nurse uses visual aids and simplified language to explain medication administration to a patient with limited literacy skills.

Adapt to Changes:

Critical Thinking Action: Quickly adjust care plans when patient conditions change.

Example: During post-operative recovery, a nurse notices signs of infection and promptly informs the healthcare team to initiate appropriate treatment adjustments.

Critical Analysis of Information:

Critical Thinking Action: Evaluate information sources for reliability and relevance.

Example: When presented with conflicting research studies, a nurse critically examines the methodologies and sample sizes to determine which study is more credible.

Making Sense of Critical Thinking Skills

What is the purpose of critical thinking in nursing.

The purpose of critical thinking in nursing is to enable nurses to effectively analyze, interpret, and evaluate patient information, make informed clinical judgments, develop appropriate care plans, prioritize interventions, and adapt their approaches as needed, thereby ensuring safe, evidence-based, and patient-centered care.

Why critical thinking is important in nursing?

Critical thinking is important in nursing because it promotes safe decision-making, accurate clinical judgment, problem-solving, evidence-based practice, holistic patient care, ethical reasoning, collaboration, and adapting to dynamic healthcare environments.

Critical thinking skill also enhances patient safety, improves outcomes, and supports nurses’ professional growth.

How is critical thinking used in the nursing process?

Critical thinking is integral to the nursing process as it guides nurses through the systematic approach of assessing, diagnosing, planning, implementing, and evaluating patient care. It involves:

• Assessment: Critical thinking enables nurses to gather and interpret patient data accurately, recognizing relevant patterns and cues.
• Diagnosis: Nurses use critical thinking to analyze patient data, identify nursing diagnoses, and differentiate actual issues from potential complications.
• Planning: Critical thinking helps nurses develop tailored care plans, selecting appropriate interventions based on patient needs and evidence.
• Implementation: Nurses make informed decisions during interventions, considering patient responses and adjusting plans as needed.
• Evaluation: Critical thinking supports the assessment of patient outcomes, determining the effectiveness of intervention, and adapting care accordingly.

Throughout the nursing process , critical thinking ensures comprehensive, patient-centered care and fosters continuous improvement in clinical judgment and decision-making.

What is an example of the critical thinking attitude of independent thinking in nursing practice?

An example of the critical thinking attitude of independent thinking in nursing practice could be:

A nurse is caring for a patient with a complex medical history who is experiencing a new set of symptoms. The nurse carefully reviews the patient’s history, recent test results, and medication list.

While discussing the case with the healthcare team, the nurse realizes that the current treatment plan might not be addressing all aspects of the patient’s condition.

Instead of simply following the established protocol, the nurse independently considers alternative approaches based on their assessment.

The nurse proposes a modification to the treatment plan, citing the rationale and evidence supporting the change.

This demonstrates independent thinking by critically evaluating the situation, challenging assumptions, and advocating for a more personalized and effective patient care approach.

How to use Costa’s level of questioning for critical thinking in nursing?

Costa’s levels of questioning can be applied in nursing to facilitate critical thinking and stimulate a deeper understanding of patient situations. The levels of questioning are as follows:

• 15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)
• Nursing Concept Map (FREE Template)
• Clinical Reasoning In Nursing (Explained W/ Example)
• 8 Stages Of The Clinical Reasoning Cycle
• How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples
• What is the “5 Whys” Technique?
• What Are Socratic Questions?

Critical thinking in nursing is the foundation that underpins safe, effective, and patient-centered care.

Critical thinking skills empower nurses to navigate the complexities of their profession while consistently providing high-quality care to diverse patient populations.

Reading Recommendation

Potter, P.A., Perry, A.G., Stockert, P. and Hall, A. (2013) Fundamentals of Nursing

Comments are closed.

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Developing critical thinking skills for delivering optimal care

Scott IA, Hubbard RE, Crock C, et al. Developing critical thinking skills for delivering optimal care. Intern Med J. 2021;51(4):488-493. doi: 10.1111/imj.15272

Sound critical thinking skills can help clinicians avoid cognitive biases and diagnostic errors. This article describes three critical thinking skills essential to effective clinical care – clinical reasoning, evidence-informed decision-making, and systems thinking – and approaches to develop these skills during clinician training.

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Critical thinking in nursing clinical practice, education and research: From attitudes to virtue

Affiliations.

• 1 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, Consolidated Research Group Quantitative Psychology (2017-SGR-269), University of Barcelona, Barcelona, Spain.
• 2 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, Consolidated Research Group on Gender, Identity and Diversity (2017-SGR-1091), University of Barcelona, Barcelona, Spain.
• 3 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, University of Barcelona, Barcelona, Spain.
• 4 Multidisciplinary Nursing Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Hospital, Barcelona, Spain.
• PMID: 33029860
• DOI: 10.1111/nup.12332

Critical thinking is a complex, dynamic process formed by attitudes and strategic skills, with the aim of achieving a specific goal or objective. The attitudes, including the critical thinking attitudes, constitute an important part of the idea of good care, of the good professional. It could be said that they become a virtue of the nursing profession. In this context, the ethics of virtue is a theoretical framework that becomes essential for analyse the critical thinking concept in nursing care and nursing science. Because the ethics of virtue consider how cultivating virtues are necessary to understand and justify the decisions and guide the actions. Based on selective analysis of the descriptive and empirical literature that addresses conceptual review of critical thinking, we conducted an analysis of this topic in the settings of clinical practice, training and research from the virtue ethical framework. Following JBI critical appraisal checklist for text and opinion papers, we argue the need for critical thinking as an essential element for true excellence in care and that it should be encouraged among professionals. The importance of developing critical thinking skills in education is well substantiated; however, greater efforts are required to implement educational strategies directed at developing critical thinking in students and professionals undergoing training, along with measures that demonstrate their success. Lastly, we show that critical thinking constitutes a fundamental component in the research process, and can improve research competencies in nursing. We conclude that future research and actions must go further in the search for new evidence and open new horizons, to ensure a positive effect on clinical practice, patient health, student education and the growth of nursing science.

Keywords: critical thinking; critical thinking attitudes; nurse education; nursing care; nursing research.

© 2020 John Wiley & Sons Ltd.

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• Armstrong, A. (2007). Nursing ethics. A virtue-based approach. Palgrave Macmillian.
• Banks-Wallace, J., Despins, L., Adams-Leander, S., McBroom, L., & Tandy, L. (2008). Re/Affirming and re/conceptualizing disciplinary knowledge as the foundations for doctoral education. Advances in Nursing Sciencies, 31(1), 67-78. https://doi.org/10.1097/01.ANS.0000311530.81188.88
• Banning, M. (2008). Clinical reasoning and its application to nursing: Concepts and research studies. Nurse Education in Practice, 8(3), 177-183.
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Why Critical Thinking Is Important in Nursing

Most nursing professionals have natural nurturing abilities, a desire to give others support, and an appreciation for science and anatomy. Successful nurses also possess a skill that is often overlooked: they can think critically.

A critical thinker will identify the problem, determine the best solution, and choose the most effective method. Critical thinkers evaluate the execution of a plan to see if it was effective and if it could have been done better. 

The ability to think critically has multiple applications in your life, as you can see. But Why is critical thinking important in nursing? Learn why and how you can improve this skill by reading on.

Why Are Critical Thinking Skills in Nursing Important?

Critical thinking is an essential skill for nursing students to have. It’s not something that it can teach in a classroom, and it must be developed over time through experience and practice. 

Critical thinking is the process of applying logic and reason to make decisions or solve problems. The ability to think critically will help you make better decisions on your own and collaborate with others when solving problems – both are essential skills for nurses.

Nursing has always been a profession that relies on critical thinking. Nurses are constantly faced with new situations and problems, which they need to think critically about to solve. 

Critical thinking is essential for nurses because it helps them make decisions based on the available information and their past experiences and knowledge of the field. It also allows nurses to plan before making any changes to be most effective as possible.

It is an essential skill for nurses to have to provide the best care possible. Critical thinkers can comprehend a problem and think about how they can solve it, rather than reactively or automatically.

Critical thinking is a crucial skill for doctors, nurses, and other health care providers.

How can you develop your critical thinking skills?

As you know, learning doesn’t end when you graduate from nursing school. You must continue to grow as a professional and develop your critical thinking skills.

Critical thinkers are better problem solvers than others in the same situation because they examine all the facts before coming up with solutions. They can also take many different perspectives into account when solving problems.

It’s easy for people to come to conclusions too quickly, but those who think critically will avoid this trap by first looking at every possible angle.

When faced with difficult decisions, these nurses won’t just rely on their gut feelings or what seems right according to society’s norms; instead, they’ll analyze all available information carefully until they develop the best solution.

Critical thinking is also crucial because it helps nurses avoid making mistakes in their work by providing them with a way to examine each situation and identify any potential risks or problems that may arise from subsequent actions before they take place.

It’s not enough for you to have empathy if your compassion isn’t backed up by critical thought and understanding of how certain decisions might affect others in various circumstances, so keep learning ways to become more thoughtful about the world around you.

The skills involved in being a good nurse are many and varied, but one thing all nurses need, regardless of what specialty they choose, is critical solid thinking abilities.

Reasons Critical Thinking In Nursing Is Important

Nurses’ experiences often include making life-altering decisions, establishing authority in stressful situations, and helping patients and their loved ones cope with some of the most stressful and emotional times of their lives.  Critical thinking is an essential aspect of nursing.

Following are the reasons:

• Nurses’ critical thinking has a significant impact on patient care 
• Recognizing changes in patient status is essential 
• It’s essential to an honest and open exchange of ideas 
• It enables you to ensure patient safety 
• Nurses can find quick fixes with it 
• Improvements can be made through critical thinking 
• It Contributes to Rational Decision Making

Further critical thinking is essential to nursing because nurses can establish authority in a stressful situation, such as issuing orders or administering care when needed.

This can be difficult because it may require balancing medical expertise with empathy and compassion towards patients’ feelings, leading them to question your judgment at some point in time.

Another reason this skill set is crucial involves making decisions that will have life-changing effects on a patient’s health and well-being.

These are often irreversible choices that only you know how much weight they carry within the context of each situation, so you need to make sure all factors are carefully considered before deciding what action must be taken next without hesitation.

Skills that Critical Thinkers Need

When it comes to critical thinking, some skills are more important than others. Using a framework known as the Nursing Process, some of these skills are applied to patient care. The most important skills are:

Interpretation: Understanding and explaining a specific event or piece of information.

Analysis: Studying data based on subjective and objective information to determine the best course of action.

Evaluation: Here, you assess the information you received. Is the information accurate, reliable, and credible? The ability to determine if outcomes have been fully achieved requires this skill as well.

The nurse can then use clinical reasoning to determine what the problem is based on those three skills. 

The decisions need to be based on sound reasoning:

Provide a clear, concise explanation of your conclusions. Nurses should provide a rationale for their answers.

Self-regulation – You need to be aware of your thought processes. As a result, you must reflect on the process that led to your conclusion. In this process, you should self-correct as necessary. Keep an eye out for bias and incorrect assumptions.

Critical Thinking Pitfalls

It can fall by the wayside when it’s not seen as necessary or when there are more pressing issues.

• Critical thinking is important in nursing because it can fall by the wayside when it’s not seen as an essential or more pressing issue.
• It can be difficult to think critically about complex, ambiguous situations with a shortage of information and time in healthcare settings.
• If we don’t use critical thinking skills, problems might go undetected or unresolved, leading to further complications down the road.

Sometimes nurses can’t differentiate between a less acute clinical problem and one that needs immediate attention. When a large amount of complex data must be processed in a time-critical manner, errors can also occur.

Conclusion:

Nurses cannot overstate the importance of critical thinking. The clinical presentations of patients are diverse. To provide safe, high-quality care, nurses must make rational clinical decisions and solve problems. Nurses need critical thinking skills to handle increasingly complex cases.

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Why Critical Thinking Skills in Nursing Matter (And What You Can Do to Develop Them)

By Hannah Meinke on 07/05/2021

The nursing profession tends to attract those who have natural nurturing abilities, a desire to help others, and a knack for science or anatomy. But there is another important skill that successful nurses share, and it's often overlooked: the ability to think critically.

Identifying a problem, determining the best solution and choosing the most effective method to solve the program are all parts of the critical thinking process. After executing the plan, critical thinkers reflect on the situation to figure out if it was effective and if it could have been done better. As you can see, critical thinking is a transferable skill that can be leveraged in several facets of your life.

But why is it so important for nurses to use? We spoke with several experts to learn why critical thinking skills in nursing are so crucial to the field, the patients and the success of a nurse. Keep reading to learn why and to see how you can improve this skill.

Why are critical thinking skills in nursing important?

You learn all sorts of practical skills in nursing school, like flawlessly dressing a wound, taking vitals like a pro or starting an IV without flinching. But without the ability to think clearly and make rational decisions, those skills alone won’t get you very far—you need to think critically as well.

“Nurses are faced with decision-making situations in patient care, and each decision they make impacts patient outcomes. Nursing critical thinking skills drive the decision-making process and impact the quality of care provided,” says Georgia Vest, DNP, RN and senior dean of nursing at the Rasmussen University School of Nursing.

For example, nurses often have to make triage decisions in the emergency room. With an overflow of patients and limited staff, they must evaluate which patients should be treated first. While they rely on their training to measure vital signs and level of consciousness, they must use critical thinking to analyze the consequences of delaying treatment in each case.

No matter which department they work in, nurses use critical thinking in their everyday routines. When you’re faced with decisions that could ultimately mean life or death, the ability to analyze a situation and come to a solution separates the good nurses from the great ones.

How are critical thinking skills acquired in nursing school?

Nursing school offers a multitude of material to master and upholds high expectations for your performance. But in order to learn in a way that will actually equip you to become an excellent nurse, you have to go beyond just memorizing terms. You need to apply an analytical mindset to understanding course material.

One way for students to begin implementing critical thinking is by applying the nursing process to their line of thought, according to Vest. The process includes five steps: assessment, diagnosis, outcomes/planning, implementation and evaluation.

“One of the fundamental principles for developing critical thinking is the nursing process,” Vest says. “It needs to be a lived experience in the learning environment.”

Nursing students often find that there are multiple correct solutions to a problem. The key to nursing is to select the “the most correct” solution—one that will be the most efficient and best fit for that particular situation. Using the nursing process, students can narrow down their options to select the best one.

When answering questions in class or on exams, challenge yourself to go beyond simply selecting an answer. Start to think about why that answer is correct and what the possible consequences might be. Simply memorizing the material won’t translate well into a real-life nursing setting.

How can you develop your critical thinking skills as a nurse?

As you know, learning doesn’t stop with graduation from nursing school. Good nurses continue to soak up knowledge and continually improve throughout their careers. Likewise, they can continue to build their critical thinking skills in the workplace with each shift.

“To improve your critical thinking, pick the brains of the experienced nurses around you to help you get the mindset,” suggests Eileen Sollars, RN ADN, AAS. Understanding how a seasoned nurse came to a conclusion will provide you with insights you may not have considered and help you develop your own approach.

The chain of command can also help nurses develop critical thinking skills in the workplace.

“Another aid in the development of critical thinking I cannot stress enough is the utilization of the chain of command,” Vest says. “In the chain of command, the nurse always reports up to the nurse manager and down to the patient care aide. Peers and fellow healthcare professionals are not in the chain of command. Clear understanding and proper utilization of the chain of command is essential in the workplace.”

How are critical thinking skills applied in nursing?

“Nurses use critical thinking in every single shift,” Sollars says. “Critical thinking in nursing is a paramount skill necessary in the care of your patients. Nowadays there is more emphasis on machines and technical aspects of nursing, but critical thinking plays an important role. You need it to understand and anticipate changes in your patient's condition.”

As a nurse, you will inevitably encounter a situation in which there are multiple solutions or treatments, and you'll be tasked with determining the solution that will provide the best possible outcome for your patient. You must be able to quickly and confidently assess situations and make the best care decision in each unique scenario. It is in situations like these that your critical thinking skills will direct your decision-making.

Do critical thinking skills matter more for nursing leadership and management positions?

While critical thinking skills are essential at every level of nursing, leadership and management positions require a new level of this ability.

When it comes to managing other nurses, working with hospital administration, and dealing with budgets, schedules or policies, critical thinking can make the difference between a smooth-running or struggling department. At the leadership level, nurses need to see the big picture and understand how each part works together.

A nurse manager , for example, might have to deal with being short-staffed. This could require coaching nurses on how to prioritize their workload, organize their tasks and rely on strategies to keep from burning out. A lead nurse with strong critical thinking skills knows how to fully understand the problem and all its implications.

• How will patient care be affected by having fewer staff?
• What kind of strain will be on the nurses?

Their solutions will take into account all their resources and possible roadblocks.

• What work can be delegated to nursing aids?
• Are there any nurses willing to come in on their day off?
• Are nurses from other departments available to provide coverage?

They’ll weigh the pros and cons of each solution and choose those with the greatest potential.

• Will calling in an off-duty nurse contribute to burnout?
• Was this situation a one-off occurrence or something that could require an additional hire in the long term?

Finally, they will look back on the issue and evaluate what worked and what didn’t. With critical thinking skills like this, a lead nurse can affect their entire staff, patient population and department for the better.

Beyond thinking

You’re now well aware of the importance of critical thinking skills in nursing. Even if you already use critical thinking skills every day, you can still work toward strengthening that skill. The more you practice it, the better you will become and the more naturally it will come to you.

If you’re interested in critical thinking because you’d like to move up in your current nursing job, consider how a Bachelor of Science in Nursing (BSN) could help you develop the necessary leadership skills.

EDITOR’S NOTE: This article was originally published in July 2012. It has since been updated to include information relevant to 2021.

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Critical Thinking in Medicine and Health

• First Online: 01 March 2020

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This chapter addresses why there is a need for experts and lay people to think critically about medicine and health. It will be argued that illogical, misleading, and contradictory information in medicine and health can have pernicious consequences, including patient harm and poor compliance with health recommendations. Our cognitive resources are our only bulwark to the misinformation and faulty logic that exists in medicine and health. One resource in particular—reasoning—can counter the flawed thinking that pervades many medical and health issues. This chapter examines how concepts such as reasoning, logic and argument must be conceptualised somewhat differently (namely, in non-deductive terms) to accommodate the rationality of the informal fallacies. It also addresses the relevance of the informal fallacies to medicine and health and considers how these apparently defective arguments are a source of new analytical possibilities in both domains.

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Albano, J. D., Ward, E., Jemal, A., Anderson, R., Cokkinides, V. E., Murray, T., et al. (2007). Cancer mortality in the United States by education level and race. Journal of the National Cancer Institute, 99 (18), 1384–1394.

Article   Google Scholar  

Coxon, J., & Rees, J. (2015). Avoiding medical errors in general practice. Trends in Urology & Men’s Health, 6 (4), 13–17.

Google Scholar  

Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78 (8), 775–780.

Cummings, L. (2002). Reasoning under uncertainty: The role of two informal fallacies in an emerging scientific inquiry. Informal Logic, 22 (2), 113–136.

Cummings, L. (2004). Analogical reasoning as a tool of epidemiological investigation. Argumentation, 18 (4), 427–444.

Cummings, L. (2009). Emerging infectious diseases: Coping with uncertainty. Argumentation, 23 (2), 171–188.

Cummings, L. (2010). Rethinking the BSE crisis: A study of scientific reasoning under uncertainty . Dordrecht: Springer.

Book   Google Scholar  

Cummings, L. (2011). Considering risk assessment up close: The case of bovine spongiform encephalopathy. Health, Risk & Society, 13 (3), 255–275.

Cummings, L. (2012a). Scaring the public: Fear appeal arguments in public health reasoning. Informal Logic, 32 (1), 25–50.

Cummings, L. (2012b). The public health scientist as informal logician. International Journal of Public Health, 57 (3), 649–650.

Cummings, L. (2013a). Public health reasoning: Much more than deduction. Archives of Public Health, 71 (1), 25.

Cummings, L. (2013b). Circular reasoning in public health. Cogency, 5 (2), 35–76.

Cummings, L. (2014a). Informal fallacies as cognitive heuristics in public health reasoning. Informal Logic, 34 (1), 1–37.

Cummings, L. (2014b). The ‘trust’ heuristic: Arguments from authority in public health. Health Communication, 29 (10), 1043–1056.

Cummings, L. (2014c). Coping with uncertainty in public health: The use of heuristics. Public Health, 128 (4), 391–394.

Cummings, L. (2014d). Circles and analogies in public health reasoning. Inquiry, 29 (2), 35–59.

Cummings, L. (2014e). Analogical reasoning in public health. Journal of Argumentation in Context, 3 (2), 169–197.

Cummings, L. (2015). Reasoning and public health: New ways of coping with uncertainty . Cham, Switzerland: Springer.

Fowler, F. J., Jr., Levin, C. A., & Sepucha, K. R. (2011). Informing and involving patients to improve the quality of medical decisions. Health Affairs, 30 (4), 699–706.

Graber, M. L., Franklin, N., & Gordon, R. (2005). Diagnostic error in internal medicine. Archives of Internal Medicine, 165 (13), 1493–1499.

Hamblin, C. L. (1970). Fallacies . London: Methuen.

Johnson, R. H. (2011). Informal logic and deductivism. Studies in Logic, 4 (1), 17–37.

Kahane, H. (1971). Logic and contemporary rhetoric: The use of reason in everyday life . Belmont, CA: Wadsworth Publishing Company.

Loucks, E. B., Buka, S. L., Rogers, M. L., Liu, T., Kawachi, I., Kubzansky, L. D., et al. (2012). Education and coronary heart disease risk associations may be affected by early life common prior causes: A propensity matching analysis. Annals of Epidemiology, 22 (4), 221–232.

Saposnik, G., Redelmeier, D., Ruff, C. C., & Tobler, P. N. (2016). Cognitive biases associated with medical decisions: A systematic review. BMC Medical Informatics and Decision Making, 16, 138. https://doi.org/10.1186/s12911-016-0377-1 .

Trowbridge, R. L. (2008). Twelve tips for teaching avoidance of diagnostic errors. Medical Teacher, 30, 496–500.

Walton, D. N. (1985a). Are circular arguments necessarily vicious? American Philosophical Quarterly, 22 (4), 263–274.

Walton, D. N. (1985b). Arguer’s Position . Westport, CT: Greenwood Press.

Walton, D. N. (1987). The ad hominem argument as an informal fallacy. Argumentation, 1 (3), 317–331.

Walton, D. N. (1991). Begging the question: Circular reasoning as a tactic of argumentation . New York: Greenwood Press.

Walton, D. N. (1992). Plausible argument in everyday conversation . Albany: SUNY Press.

Walton, D. N. (1996). Argumentation schemes for presumptive reasoning . Mahwah, NJ: Erlbaum.

Walton, D. N. (2010). Why fallacies appear to be better arguments than they are. Informal Logic, 30 (2), 159–184.

Weingart, S. N., Wilson, R. M., Gibberd, R. W., & Harrison, B. (2000). Epidemiology of medical error. Western Journal of Medicine, 172 (6), 390–393.

Woods, J. (1995). Appeal to force. In H. V. Hansen & R. C. Pinto (Eds.), Fallacies: Classical and contemporary readings (pp. 240–250). University Park: The Pennsylvania State University Press.

Woods, J. (2004). The death of argument: Fallacies in agent-based reasoning . Dordrecht: Kluwer Academic.

Woods, J. (2007). Lightening up on the ad hominem. Informal Logic, 27 (1), 109–134.

Woods, J. (2008). Begging the question is not a fallacy. In C. Dégremont, L. Keiff, & H. Rükert (Eds.), Dialogues, logics and other strange things: Essays in honour of Shahid Rahman (pp. 523–544). London: College Publications.

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Chapter Summary

Medicine and health have tended to be overlooked in the critical thinking literature . And yet robust critical thinking skills are needed to evaluate the large number and range of health messages that we are exposed to on a daily basis.

An ability to think critically helps us to make better personal health choices and to uncover biases and errors in health messages and other information. An ability to think critically allows us to make informed decisions about medical treatments and is vital to efforts to reduce medical diagnostic errors.

A key element in critical thinking is the ability to distinguish strong or valid reasoning from weak or invalid reasoning. When an argument is weak or invalid, it is called a ‘fallacy’ or a ‘fallacious argument’.

The informal fallacies are so-called on account of the presence of epistemic and dialectical flaws that cannot be captured by formal logic . They have been discussed by many generations of philosophers and logicians , beginning with Aristotle .

Historically, philosophers and logicians have taken a pejorative view of the informal fallacies. Much of the criticism of these arguments is related to a latent deductivism in logic , the notion that arguments should be evaluated according to deductive standards of validity and soundness . Against deductive standards and norms, many reasonable arguments are judged to be fallacies.

Developments in logic , particularly the teaching of logic, forced a reconsideration of the prominence afforded to deductive logic in the evaluation of arguments. New criteria based on presumptive reasoning and plausible argument started to emerge. Against this backdrop, non-fallacious variants of most of the informal fallacies began to be described for the first time.

Today, some argument analysts characterize non-fallacious variants of the informal fallacies in terms of cognitive heuristics . During reasoning , these heuristics function as mental shortcuts, allowing us to bypass knowledge and come to judgement about complex health problems.

Suggestions for Further Reading

Sharples, J. M., Oxman, A. D., Mahtani, K. R., Chalmers, I., Oliver, S., Collins, K., Austvoll-Dahlgren, A., & Hoffmann, T. (2017). Critical thinking in healthcare and education. British Medical Journal, 357 : j2234. https://doi.org/10.1136/bmj.j2234 .

The authors examine the role of critical thinking in medicine and healthcare, arguing that critical thinking skills are essential for doctors and patients. They describe an international project that involves collaboration between education and health. Its aim is to develop a curriculum and learning resources for critical thinking about any action that is claimed to improve health.

Hitchcock, D. (2017). On reasoning and argument: Essays in informal logic and on critical thinking . Cham: Switzerland: Springer.

This collection of essays provides more advanced reading on several of the topics addressed in this chapter, including the fallacies, informal logic , and the teaching of critical thinking . Chapter 25 considers if fallacies have a place in the teaching of critical thinking and reasoning skills.

Hansen, H. V., & Pinto, R. C. (Eds.). (1995). Fallacies: Classical and contemporary readings . University Park: The Pennsylvania State University Press.

This edited collection of 24 chapters contains historical selections on the fallacies, contemporary theory and criticism, and analyses of specific fallacies. It also examines fallacies and teaching. There are chapters on four of the fallacies that will be examined in this book: appeal to force; appeal to ignorance ; appeal to authority; and post hoc ergo propter hoc .

Diagnostic errors are a significant cause of death and serious injury in patients. Many of these errors are related to cognitive factors. Trowbridge ( 2008 ) has devised twelve tips to familiarize medical students and physician trainees with the cognitive underpinnings of diagnostic errors. One of these tips is to explicitly describe heuristics and how they affect clinical reasoning . These heuristics include the following:

Representativeness —a patient’s presentation is compared to a ‘typical’ case of specific diagnoses.

Availability —physicians arrive at a diagnosis based on what is easily accessible in their minds, rather than what is actually most probable.

Anchoring —physicians may settle on a diagnosis early in the diagnostic process and subsequently become ‘anchored’ in that diagnosis.

Confirmation bias —as a result of anchoring, physicians may discount information discordant with the original diagnosis and accept only that which supports the diagnosis.

Using the above information, identify any heuristics and biases that occur in the following scenarios:

Scenario 1: A 60-year-old man has epigastric pain and nausea. He is sitting forward clutching his abdomen. He has a history of several bouts of alcoholic pancreatitis. He states that he felt similar during these bouts to what he is currently feeling. The patient states that he has had no alcohol in many years. He has normal blood levels of pancreatic enzymes. He is given a diagnosis of acute pancreatitis. It is eventually discovered that he has had acute myocardial infarction.

Scenario 2: A 20-year-old, healthy man presents with sudden onset of severe, sharp chest pain and back pain. Based on these symptoms, he is suspected of having a dissecting thoracic aortic aneurysm. (In an aortic dissection, there is a separation of the layers within the wall of the aorta, the large blood vessel branching off the heart.) He is eventually diagnosed with pleuritis (inflammation of the pleura, the thin, transparent, two-layered membrane that covers the lungs).

Many of the logical terms that were introduced in this chapter also have non-logical uses in everyday language. Below are several examples of the use of these terms. For each example, indicate if the word in italics has a logical or a non - logical meaning or use:

University ‘safe spaces’ are a dangerous fallacy —they do not exist in the real world ( The Telegraph , 13 February 2017).

The MRI findings beg the question as to whether a careful ultrasound examination might have yielded some of the same information on haemorrhages ( British Medical Journal: Fetal & Neonatal , 2011).

The youth justice system is a slippery slope of failure ( The Sydney Morning Herald , 26 July 2016).

The EU countered with its own gastronomic analogy , saying that “cherry picking” the best bits of the EU would not be tolerated ( BBC News , 28 July 2017).

As Ebola spreads, so have several fallacies ( The New York Times , 23 October 2014).

Removing the statue of Confederacy Army General Robert E. Lee no more puts us on a slippery slope towards ousting far more nuanced figures from the public square than building the statue in the first place put us on a slippery slope toward, say, putting up statues of Hitler outside of Holocaust museums or of Ho Chi Minh at Vietnam War memorials ( Chicago Tribune , 16 August 2017).

We can expand the analogy a bit and think of a culture as something akin to a society’s immune system—it works best when it is exposed to as many foreign bodies as possible ( New Zealand Herald , 4 May 2010).

The Josh Norman Bowl begs the question : What’s an elite cornerback worth? ( The Washington Post , 17 December 2016).

The intuition behind these analogies is simple: As a homeowner, I generally have the right to exclude whoever I want from my property. I don’t even have to have a good justification for the exclusion. I can choose to bar you from my home for virtually any reason I want, or even just no reason at all. Similarly, a nation has the right to bar foreigners from its land for almost any reason it wants, or perhaps even no reason at all ( The Washington Post , 6 August 2017).

Legalising assisted suicide is a slippery slope toward widespread killing of the sick, Members of Parliament and peers were told yesterday ( Mail Online , 9 July 2014).

In the Special Topic ‘What’s in a name?’, an example of a question-begging argument from the author’s recent personal experience was used. How would you reconstruct the argument in this case to illustrate the presence of a fallacy?

On 9 July 2017, the effect of coconut oil on health was also discussed in an article in The Guardian entitled ‘Coconut oil: Are the health benefits a big fat lie?’ The following extract is taken from that article. (a) What type of reasoning is the author using in this extract? In your response, you should reconstruct the argument by presenting its premises and conclusion . Also, is this argument valid or fallacious in this particular context?

When it comes to superfoods, coconut oil presses all the buttons: it’s natural, it’s enticingly exotic, it’s surrounded by health claims and at up to £8 for a 500 ml pot at Tesco, it’s suitably pricey. But where this latest superfood differs from benign rivals such as blueberries, goji berries, kale and avocado is that a diet rich in coconut oil may actually be bad for us.

The article in The Guardian also makes extensive use of expert opinion. Two such opinions are shown below. (b) What three linguistic devices does the author use to confer expertise or authority on the individuals who advance these opinions?

Christine Williams, professor of human nutrition at the University of Reading, states: “There is very limited evidence of beneficial health effects of this oil”.

Tom Sanders, emeritus professor of nutrition and dietetics at King’s College London, says: “It is a poor source of vitamin E compared with other vegetable oils”.

The author of the article in The Guardian went on to summarize the findings of a study by two researchers that was published in the British Nutrition Foundation’s Nutrition Bulletin. The author’s summary included the following statement: There is no good evidence that coconut oil helps boost mental performance or prevent Alzheimer’s disease . (c) In what type of informal fallacy might this statement be a premise ?

Scenario 1: An anchoring error has occurred in which the patient is given a diagnosis of acute pancreatitis early in the diagnostic process. The clinician becomes anchored in this diagnosis, with the result that he overlooks two pieces of information that would have allowed this diagnosis to be disconfirmed—the fact that the patient has reported no alcohol use in many years and the presence of normal blood levels of pancreatic enzymes. By dismissing this information, the clinician is also showing a confirmation bias —he attends only to information that confirms his original diagnosis.

Scenario 2: A representativeness error has occurred. The patient’s presentation is typical of aortic dissection. However, this condition can be dismissed in favour of conditions like pleuritis or pneumothorax on account of the fact that aortic dissection is exceptionally rare in 20-year-olds.

(2) (a) non-logical; (b) non-logical; (c) non-logical; (d) non-logical; (e) non-logical; (f) logical; (g) logical; (h) non-logical; (i) logical; (j) logical

(3) The fallacy can be illustrated as follows. The head of department asks the question ‘Why did so many of these students get ‘A’ grades’? He receives the reply ‘Because they did very well’. But someone might reasonably ask ‘How do we know that they did very well?’ To which the reply is ‘Because so many students got ‘A’ grades’. The reasoning can be reconstructed in diagram form as follows:

The author is using an analogical argument , which has the following form:

P1: Blueberries, goji berries, kale, avocado and coconut oil are natural, exotic, pricey and surrounded by health claims.

P2: Blueberries, goji berries, kale and avocado have health benefits.

C: Coconut oil has health benefits.

This is a false analogy , or a fallacious analogical argument , because coconut oil does not share with these other superfoods the property or attribute < has health benefits >.

The author uses academic rank, field of specialization, and university affiliation to confer authority or expertise on individuals who advance expert opinions.

This statement could be a premise in an argument from ignorance .

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Cummings, L. (2020). Critical Thinking in Medicine and Health. In: Fallacies in Medicine and Health. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-28513-5_1

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Critical Thinking in medical education: When and How?

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Critical thinking in healthcare and education

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Critical thinking is an essential cognitive skill for the individuals involved in various healthcare domains such as doctors, nurses, lab assistants, patients and so on, as is emphasized by the Authors. Recent evidence suggests that critical thinking is being perceived/evaluated as a domain-general construct and it is less distinguishable from that of general cognitive abilities [1].

People cannot think critically about topics for which they have little knowledge. Critical thinking should be viewed as a domain-specific construct that evolves as an individual acquires domain-specific knowledge [1]. For instance, most common people have no basis for prioritizing patients in the emergency department to be shifted to the only bed available in the intensive care unit. Medical professionals who could thinking critically in their own discipline would have difficulty thinking critically about problems in other fields. Therefore, ‘domain-general’ critical thinking training and evaluation could be non-specific and might not benefit the targeted domain i.e. medical profession.

Moreover, the literature does not demonstrate that it is possible to train universally effective critical thinking skills [1]. As medical teachers, we can start building up student’s critical thinking skill by contingent teaching-learning environment wherein one should encourage reasoning and analytics, problem solving abilities and welcome new ideas and opinions [2]. But at the same time, one should continue rather tapering the critical skills as one ascends towards a specialty, thereby targeting ‘domain-specific’ critical thinking.

For the benefit of healthcare, tools for training and evaluating ‘domain-specific’ critical thinking should be developed for each of the professional knowledge domains such as doctors, nurses, lab technicians and so on. As the Authors rightly pointed out, this humongous task can be accomplished only with cross border collaboration among cognitive neuroscientists, psychologists, medical education experts and medical professionals.

References 1. National Research Council. (2011). Assessing 21st Century Skills: Summary of a Workshop. J.A. Koenig, Rapporteur. Committee on the Assessment of 21st Century Skills. Board on Testing and Assessment, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press. 2. Mafakheri Laleh M, Mohammadimehr M, Zargar Balaye Jame S. Designing a model for critical thinking development in AJA University of Medical Sciences. J Adv Med Educ Prof. 2016 Oct;4(4):179–87.

Competing interests: No competing interests

Critical Thinking in Healthcare and Medicine: A Crucial Skill for Improved Outcomes

Critical thinking is a crucial skill for individuals working in various healthcare domains, such as doctors, nurses, lab assistants, and patients. It serves as the foundation for evidence-based practice in healthcare and education and is essential for making informed decisions while evaluating research findings, which may sometimes be mixed or even conflicting [ The BMJ ].

In healthcare and medicine, critical thinking facilitates a more in-depth understanding of patients’ situations, complex clinical scenarios, and the ability to integrate various sources of information to make informed decisions. Professionals with strong critical thinking skills can better evaluate options, weigh potential risks and benefits, and ultimately choose the most appropriate course of action for their patients [ NurseJournal ].

Developing critical thinking skills in the healthcare sector is vital not only for patient safety but also for the professional development and career advancement of clinical and administrative nursing leaders. Ensuring that these skills are continuously nurtured and improved is critical for the ongoing success of the healthcare industry and for delivering the highest quality of patient care [ PubMed ].

Critical Thinking in Healthcare and Medicine

Critical thinking in healthcare and medicine involves the application of evidence-based practices and analytical skills to make informed decisions about patient care. This process often requires healthcare professionals to reflect on their knowledge, collaborate with colleagues, and evaluate the validity of various sources of information, including medical research, clinical experience, and patient preferences.

Some key components of critical thinking in healthcare and medicine include:

The Role of Critical Thinking in Decision-Making

Critical thinking plays a pivotal role in healthcare and medicine, affecting every aspect of the decision-making process. In clinical practice, it serves a key function in assessing patients’ symptoms, interpreting diagnostic results, and choosing appropriate interventions. This cognitive skill involves questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity to guide professional judgments and actions ( source ).

In many medical situations, such as triage, critical thinking can be crucial to ensure appropriate prioritization of patients based on their medical needs. Healthcare professionals must quickly adapt and process an influx of information to efficiently make critical decisions ( Rasmussen University ). Some practical examples of critical thinking in decision-making include:

Developing Critical Thinking Skills in Healthcare Professionals

Education and training.

Formal education and specialized training programs play a vital role in developing critical thinking skills among healthcare professionals. These programs should emphasize the importance of honing these skills as an essential component of their professional growth. Incorporating interactive learning methods, such as case studies, group discussions, and problem-solving exercises, can encourage participants to engage in reflective and analytical thinking. Courses on clinical reasoning and decision making can further strengthen these abilities.

Continuing Professional Development

Critical thinking tools and techniques.

Critical thinking in healthcare and medicine is an essential skill for professionals to make well-informed decisions and provide quality care to patients. This process combines cognitive abilities with strategic skills to achieve specific objectives. This section will explore some common tools and techniques used to promote critical thinking in healthcare professionals.

2. Analysis : Critical thinking in healthcare requires professionals to assess the quality and relevance of information, such as research findings or clinical guidelines. By breaking down information into its constituent parts and evaluating its strengths and weaknesses, professionals can make informed decisions that are based on evidence and best practices (The BMJ) .

4. Inference : Drawing conclusions from available information is a crucial aspect of critical thinking in healthcare. Professionals must infer the best course of action, considering all relevant variables and factors, such as patient preferences, clinical guidelines, and ethical considerations. Inference requires professionals to weigh the potential benefits and harms and use their judgment to make sound decisions (Critical Thinking in Critical Care) .

Challenges in Implementing Critical Thinking in Healthcare

Another challenge is the risk of conflicting metrics. Healthcare professionals often need to balance various metrics and targets to provide the best possible care to patients. Sometimes, success in one area may come at the expense of another, making it difficult to find a balance conducive to critical thinking ( International Journal for Quality in Health Care ).

In terms of education, there is an ongoing need to identify the most effective strategies for teaching critical thinking in healthcare. A scoping review of critical thinking literature in healthcare education highlights the broad range of methods used to teach critical thinking, as well as the variability in research methodologies ( PubMed ). This suggests a need for further research and consensus to develop the most effective critical thinking educational methods for healthcare professionals.

The Impact of Critical Thinking on Patient Outcomes

Another impact of critical thinking on patient outcomes is seen through proper planning and administration of care. A healthcare professional who utilizes critical thinking skills can carefully examine all aspects of patient care and make informed decisions that minimize harm and improve outcomes (ScienceDirect) .

Furthermore, critical thinking skills can also enhance communication and collaboration among healthcare professionals. This can lead to more effective teamwork and coordinated care, ultimately benefiting the patient and improving their overall experience in the healthcare system.

Future Perspectives

Furthermore, the integration of new technologies like artificial intelligence (AI) and machine learning will necessitate a greater emphasis on critical thinking. Healthcare practitioners will need to adapt and learn how to effectively use these tools while maintaining their ability to think critically about diagnoses and treatment plans.

In summary, the future of critical thinking in healthcare and medicine holds promise for enhancing patient care and improving medical education. By fostering a culture of collaboration and embracing new technologies, healthcare professionals can leverage their critical thinking skills to navigate complex challenges and drive innovation in their field.

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

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

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

• Critical Thinking

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Critical Reflection, Critical Reasoning, and Judgment

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

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

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

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

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

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

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

Techne and Phronesis

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

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

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

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

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

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

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

Thinking Critically

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Intuition and Perception

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

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

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

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

• Applying Practice Evidence

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

Evaluating Evidence

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

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

Sources of Evidence

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

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

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

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

Evidence-Based Practice

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

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

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

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

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

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

When Evidence Is Missing

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

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

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

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

The Three Apprenticeships of Professional Education

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

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

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

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

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

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

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

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

Clinical Grasp *

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

Making Qualitative Distinctions

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

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

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

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

Recognizing Changing Clinical Relevance

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

Developing Clinical Knowledge in Specific Patient Populations

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

Clinical Forethought

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

Future think

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

Clinical forethought about specific diagnoses and injuries

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

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

Anticipation of crises, risks, and vulnerabilities for particular patients

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

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

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

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

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

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

Seeing the unexpected

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

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

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

• Cite this Page Benner P, Hughes RG, Sutphen M. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 6.
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How Critical Thinking Skills Apply to Healthcare

Critical Thinking Includes

• The skill to draw conclusions.
• The skill to troubleshoot and problem-solve.
• The capability to use skills or knowledge in a variety of situations.

Examples of Everyday Critical Thinking

• Thinking about what steps should to be taken to avoid an accident.
•  Creating a list that gives ability to accomplish every task efficiently and effectively.
• Thinking through the process and dealing with issues that might arise. (missing an ingredient needed for a dish or finding out that the vacuum cleaner is broken)

Examples of Work-Related Critical Thinking

• Deciding how to deal with a customer who is upset over service or bill to ensure a happy customer.
• Handling a disagreement with another coworker.
• Presenting an issue or proposal to the supervisor.

Examples of Work-Related Critical Thinking Situations

• If you have worked in customer service then the same critical thinking skills that are used to deal with customers will be used to deal with patients in the medical field .
• If you have worked in a fast-paced environment requiring prioritizing then you will carry that skill over to the medical field.

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Tips for Online Students , Tips for Students

Practical Things You Study in College

Published: June 20, 2024

College is a transformative time where you gain not only academic knowledge but also essential skills that will benefit you in the real world. The process of learning new skills or improving existing ones to advance in your current role or prepare for new opportunities is known as “upskilling.”

Upskilling can involve gaining deeper knowledge in a specific area, acquiring new technical abilities, or enhancing soft skills such as communication and leadership. College is an excellent place to upskill because it provides a structured environment where students can access a wide range of resources and learning opportunities. 

Whether you’re a traditional student fresh out of high school or a non-traditional student returning to education, the skills you develop in college are crucial. Below, we’ll take a closer look at the skills you will learn while earning a college degree.

Why Should I Upskill in College?

The benefits of upskilling are numerous. For employees, it can lead to increased job satisfaction, higher productivity, and better career advancement opportunities. Upskilling can also make you more adaptable to changes within your industry, thus future-proofing your career. 

Employers value candidates who demonstrate a commitment to lifelong learning and continuous improvement, as these individuals are better equipped to drive innovation and contribute to organizational growth. By acquiring additional skills during your college years, you position yourself as a versatile asset in the workforce. This combination of academic achievement and practical expertise makes you more attractive to potential employers and sets the stage for a successful and rewarding career.

While earning your college degree, you will have the opportunity to master both technical and soft skills. Technical skills refer to specific, teachable abilities required for particular tasks, often involving specialized training from your major program of study. Soft skills are interpersonal attributes like communication and teamwork that are essential for effective collaboration and problem-solving in the workplace. Employers look for college students with a solid mix of technical and soft skills when recruiting for jobs.

What Are the Best Technical Skills to Learn in College?

Technical skills are specific abilities or knowledge required to perform specialized tasks within your job sector. Choosing a college major that delivers the appropriate technical skills for your career aspirations is critical. 

Business management, computer science, and health science are among the most popular majors to study in college due to their relevance and demand in the modern workforce. 

Business Management Skills

Business management programs offer technical skills in areas such as financial analysis, project management, and strategic planning, preparing students for leadership roles in diverse industries. 

Computer Science Skills

Computer science is a powerhouse for upskilling, providing in-depth knowledge of software development, algorithms, and network security, making graduates highly sought after in the tech industry. 

Health Science Skills

Health science delivers technical skills related to healthcare practices, medical technologies, and patient care, essential for those aiming to advance in the medical field. These majors not only provide a solid foundation in their respective fields but also offer numerous opportunities for continuous learning and professional growth.

What Are the Best Soft Skills to Learn in College?

The best skills to learn in college are soft skills, including critical thinking, communication, and time management. Mastering these skills will enable you to succeed both academically and professionally. Below, we’ll take a closer look at these soft skills and how you can improve them.

Critical Thinking

One of the most important skills to develop is critical thinking, which involves analyzing information, evaluating evidence, and making reasoned decisions. Critical thinking is crucial not only for success in school but also for navigating complex real-world issues. This skill is particularly valued by employers, as it demonstrates an individual’s ability to handle challenging situations and make informed decisions in the workplace. 

Your mastery of critical thinking will come from active engagement with your course material. You can hone your observational skills, ask questions to deepen your understanding and break complex problems into smaller parts.

Communication

Another essential skill to learn in college is effective communication . This includes both verbal and written communication, which are vital for collaborating with peers, presenting ideas, and writing reports or research papers. Good communication skills enable students to express their thoughts clearly and persuasively. Furthermore, strong communication skills facilitate better teamwork and collaboration, as students learn to listen actively, provide constructive feedback, and work together towards common goals. 

To improve your communication skills, focus on both verbal and written communication. Participate in group projects and presentations to practice speaking clearly and confidently. Enhance your writing by organizing your thoughts logically and using appropriate grammar and vocabulary. Your college likely has a writing center that will assist you with composing reports and papers.

Time management

Time management is also a critical skill that students must master in college. Balancing coursework, extracurricular activities, part-time jobs, and personal responsibilities requires effective time management strategies. Students who can prioritize tasks set realistic deadlines, and avoid procrastination are more likely to achieve their academic and personal goals. Employers look for candidates who can manage their time efficiently, as this skill directly impacts an individual’s ability to meet deadlines and handle multiple projects.

To refine your time management skills, set clear, achievable goals and prioritize your tasks based on deadlines and importance. Use tools like planners, calendars, or time management apps to organize your schedule and track your progress. Break larger tasks into smaller, manageable steps to avoid feeling overwhelmed. Allocate specific time slots for studying, attending classes, and participating in extracurricular activities. 

How Can I Improve My Study Skills While in College?

Improving your study skills while you are in college will help you achieve academic success. Good study habits, such as active recall, note-taking, self-explanation, and creating a study routine, can greatly enhance your ability to understand and retain complex information. 

Create a Study Routine

Establishing a consistent study routine helps to develop a habit of regular studying. It includes setting specific times for studying each day, breaking down study sessions into manageable chunks, and sticking to the schedule. A well-structured routine ensures that you cover all necessary material and maintain a balanced approach to your studies.

Practice Active Recall

Active recall is a study technique where you actively stimulate your memory during the learning process . Instead of passively reading or highlighting text, test yourself on the material to enhance your retention and understanding. This method helps to identify gaps in your knowledge and solidify your learning.

Take Effective Notes

Effective note-taking involves summarizing key concepts, ideas, and information during lectures or reading assignments. This skill helps you retain and comprehend the material better and provides a useful resource for review before exams. Good note-taking techniques include using bullet points, headings, and highlighting important information.

Use the Self-Explanation Technique

The self-explanation technique involves explaining the material you are studying in your own words, which helps deepen your understanding and retention of the subject. When you rephrase concepts and teach them to yourself or others, it forces you to process the information more thoroughly, identify gaps in your knowledge, and reinforce learning. 

As we have seen, mastering both technical skills and soft skills during your college years is crucial for standing out in today’s competitive job market. Employers increasingly seek candidates who not only possess the specialized knowledge required for specific roles but also demonstrate strong interpersonal abilities such as communication, teamwork, and problem-solving . These skills combined make you more versatile and adaptable, enhancing your employability across various industries.

As you embark on your college journey, remember that developing these skills is an ongoing process that will serve you well beyond your academic years. By embracing these practices, you will be well-equipped to tackle challenges and seize opportunities in both your academic and professional endeavors.

At UoPeople, our blog writers are thinkers, researchers, and experts dedicated to curating articles relevant to our mission: making higher education accessible to everyone.

Related Articles

• Open access
• Published: 22 June 2024

Public involvement in UK health and care research 1995–2020: reflections from a witness seminar

• Marisha Emily Palm 1 , 2 ,
• David Evans 3 ,
• Sophie Staniszewska 4 ,
• Louca-Mai Brady 5 ,
• Bec Hanley 6 ,
• Kate Sainsbury 7 , 8 ,
• Derek Stewart 7 , 9 &
• Paula Wray 7  

Research Involvement and Engagement volume  10 , Article number:  65 ( 2024 ) Cite this article

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Public involvement is important to the relevance and impact of health and care research, as well as supporting the democratisation of research. In 2020, the National Institute for Health Research (NIHR) reorganized and eliminated INVOLVE, an internationally recognised group that had played a central role in public involvement in the UK since 1996. Its remit was subsumed within a new center tasked with public involvement, participant recruitment, and evidence dissemination. A year later, in 2021, interested parties came together to discuss the evolution of INVOLVE and consider how to retain some of the important historical details and learn lessons from its long and important tenure.

We hosted a witness seminar in 2022 that was one of four work groups and brought together public involvement leaders that had been part of the conception, development, and evolution of INVOLVE between 1995 and 2020. Witness seminars are a method used to capture the complexity and nuance of historical events or initiatives. They support critical thinking and reflection rather than simple commemoration. We identified those who had played a role in INVOLVE history, ensuring diversity of perspective, and invited them to attend and speak at the seminar. This took place during two sessions where witnesses provided their recollections and participated in a facilitated discussion.

Across the two online sessions, 29 witnesses attended and contributed thoughts and recollections. Two authors (SS, MP) identified six themes that were described in the witness seminar report and have been discussed, elaborated, and illustrated with witness quotations. These are: the importance of historical perspective; INVOLVE as a social movement; how INVOLVE worked (e.g. its hospitality, kindness, and inclusivity); INVOLVE as a quiet disruptor; public involvement evidence, knowledge, and learning; the infrastructure, processes, and systems developed by INVOLVE; and the demise and loss of INVOLVE as an internationally recognized center of excellence.

The authors of this commentary reflected on the discussions that took place during the witness seminar and the themes that emerged, and share six broad learnings for future practice; (1) it is important to create and nurture public involvement communities of practice; (2) collaborative ways of working support open discussion amongst diverse groups; (3) be aware of the tensions between activism and being part of the establishment; (4) continued efforts should be made to build an evidence base for public involvement practice; (5) there are both benefits and drawbacks to having a centralized organization leading public involvement; and (6) support for public involvement in research requires a fit-for-purpose tendering process that embeds robust public involvement.

Plain Language Abstract

Involving members of the public in research can improve the way that research is planned, managed, and shared. Between 1996 and 2020 an organization in the UK called INVOLVE had an important role in public involvement in research. When INVOLVE lost this role, some people who had been part of the group got together to think about how to save some of the important information and learn lessons from the time it had existed.

A meeting was arranged where people who have been part of an event or topic get together to share what it was like for them. This was called a witness seminar and it took place online over two days in 2022. Twenty-nine people attended and spoke about their experiences.

The people who attended the witness seminar had different ideas about why INVOLVE was important and agree that it is now missed. People talked about INVOLVE as part of a certain time in history and said it was a social movement. They felt that it was kind and caring, brought together lots of people with different ideas, and supported changes in thinking. INVOLVE had a focus on evidence and learning and created structure and systems to support public involvement in research. Losing INVOLVE was difficult because a lot of people within the UK and beyond looked to them as a leader in public involvement. We share quotes on all of these topics.

In this article we looked at how people remembered INVOLVE and thought about what information could be saved. We share lessons that will support thinking about the future of public involvement. These include things like how important it is for there to be spaces for people to come together to learn, discuss, and share, and that we have more work to do to understand public involvement and fully include it in research.

Peer Review reports

Health research is essential to improving individual and public health, and public involvement can improve the quality and impact of this research. In England, beginning in the 1990s there was emerging recognition of the importance of involving the public in health care research. The 1991 National Health Service (NHS) Research and Development Strategy was the first government document to note the relevance of public involvement [ 1 ]. In 1996, England’s Department of Health (DH) established the Standing Advisory Group on Consumer Involvement in the NHS Research and Development Programme, a group to support public involvement in research that was later rebranded as Consumers in NHS Research, and then as INVOLVE in 2003 [ 2 ]. The mention of involvement within NHS Research and Development policy, and the establishment of a national centre focused on public involvement, meant that the UK was at the forefront of a move towards inclusive involvement in health research. The NHS supported and funded public involvement, producing policies, research deliverables, and maintaining the INVOLVE Centre. When the National Institute for Health Research (NIHR), England’s largest funder of health and social care research, was established in 2006, INVOLVE became part of its portfolio. In the same year, newly published Department of Health guidance stated that “patients and public must be involved in all stages of the research process” [ 2 ].

The first decades of the twenty-first century were a time of expansion, where public involvement in health and care research became more established. The involvement of public members in health research was adopted by many other research and funding organizations, including the Medical Research Council [ 3 ]. The NIHR integrated public involvement policies and practices within the Central Commissioning Facility, the Research Design Services, and some of the large grant schemes (e.g., Research for Patient Benefit, Health and Social Care Delivery Research). The public involvement zeitgeist went beyond the UK policy and funding climate, with Australia, Denmark, Canada, and the United States, and other countries, establishing support systems for public involvement in research [ 4 , 5 , 6 , 7 , 8 ]. Throughout this time INVOLVE was a centralized national home for public involvement in research, answering queries, developing resources to support involvement, and acting as a convener of academics, practitioners, and public members. Its inclusion in the NIHR meant that it worked in partnership with the NHS, UK universities, and local government, and collaborated widely through active outreach and Advisory Group membership. Many Advisory Group members were affiliates of UK-based patient organisations with a focus on health, some were NHS clinicians, and others were university academics with strong links to the NHS. INVOLVE primarily operated in England, and despite not having the same reach or authority, it worked closely with colleagues in the devolved nations of Wales, Scotland, and Northern Ireland. INVOLVE was not only well known in the UK, it also become internationally recognised for its leadership in public involvement.

Support for INVOLVE was maintained through an NIHR tendering process that included a funding application, a contract, and regular renewal cycles. In 2019, a call was put out for a new incarnation to support public involvement within the NIHR. The NIHR Centre for Engagement and Dissemination (CED), launched in 2020, subsumed the remit of INVOLVE. In addition to public involvement, the CED was tasked with responsibilities related to participant recruitment and evidence dissemination. The CED is still a relatively new organization, and it is unclear whether and how INVOLVE materials, processes, and learnings will be retained, though some materials have been reviewed and updated. As the CED was established, the Advisory Group was disbanded, the INVOLVE name, in use for nearly two decades, was removed, and the website fell into disuse.

A group of those who had been engaged in the work of INVOLVE, as co-founders, Advisory Group chairs and members, and Centre staff came together in 2021 to discuss the evolution of INVOLVE and consider how to retain this historical knowledge and distill lessons learned. Work groups were formed, with one group compiling INVOLVE documents, another developing a timeline, a third discussing the eternal struggle of democratising research, and the fourth hosting a witness seminar (Table  1 ).

In this paper we describe the witness seminar methodology, present a synthesis of the themes, provide illustrative quotations, and distill some of the key learnings that we hope will inform the future of public involvement. The full witness seminar report with a brief introduction, approved transcripts, a synthesis of themes, the chronology, and references, is included as an appendix to this article.

Witness seminars have been used to document significant events and historical developments, particularly in medicine and politics [ 9 , 10 , 11 , 12 ]. The methodology has been developed to be flexible and fit-for-purpose; however, it often includes (1) mapping people who have been involved in a particular event, initiative, or development and inviting them to speak, (2) a facilitated discussion where invited guests, or ‘witnesses,’ share memories and reflections of the event or initiative, and (3) transcription and publication of the discussion. This method of collecting reflections allows for a full and nuanced capture of complex activities that are influenced by the environmental and social context. Experiences and perceptions are gathered from key vantage points to provide a rich understanding and lay the groundwork for considering lessons learned and next steps. Although this method is not well known, it was chosen because of its contextual and nuanced approach, which includes voices from different perspectives and is aligned with the ethos of public involvement in research.

Witness identification

We began the witness seminar process by identifying potential witnesses. INVOLVE’s governance structure included an Advisory Group of between 13 and 17 members, with a mix of public members, health professionals, and researchers. We aimed to identify former INVOLVE Advisory Group members with a range of perspectives, Advisory Group chairs, directors and staff members. The second work group (see Table  1 ), who had developed the INVOLVE timeline, shared this information, including notation that highlighted key players in the public involvement field as it evolved over the quarter century from 1995 to 2020. We reviewed this list of names, then added to it, intentionally taking an inclusive approach to engage a diversity of perspectives. We further supplemented this list via outreach to the full group of 20 individuals who had begun meeting in 2021. We shared the names of those we intended to invite to the seminar and asked the group for additional people and perspectives.

Witness invitation

After mapping the list of witnesses across time and perspective, we used our personal contacts and the internet to find publicly available email addresses for as many of the witnesses as possible. Two dates were set a week apart and a formal invitation was sent to potential witnesses. Those organizing the witness seminar (DE, SD, MP, SS) set the agenda so that the first session of the event would cover the first decade of INVOLVE and the second session would cover the second decade of INVOLVE. We invited two chairs for each session, all four of whom were in the public involvement field and had significant expertise in facilitation of diverse groups. It was important to have a balance of professional and public members of the involvement community guiding the discussion, therefore we invited one professional and one public member to share the facilitation work of each session.

Practices and procedures

Formal ethical review was not required as this was a seminar that involved a group of contributors working toward a common goal. Contributors had full ownership and control of their own text, with the opportunity to edit or withdraw text up to final approval for publication. However, the editors were mindful of ethical considerations including power inequalities between professionals and public members and sought to follow INVOLVE good practice guidance at all times [ 13 ]. The invitation sent to witnesses included notice that the online seminars would be recorded and transcribed, and that the transcriptions would be reviewed by all those participating before being published. The transcripts of both three-hour sessions were reviewed by the team organizing the witness seminar and errors were corrected. They were then sent to witnesses for their review and approval.

The transcripts were reviewed by two authors (SS, MP) to identify key themes and sub-themes. They iterated on the themes and co-developed descriptions for inclusion in the full witness seminar report (see appendix ). These themes were shared with the authors of this commentary, who discussed them in detail, shaping and adding nuance to their description. Authors met once to agree the framing of the manuscript and to discuss the themes in detail, and then again to share thoughts about recommendations arising from the witness seminar. After each virtual meeting a draft of the manuscript was circulated for review and comment.

We identified 45 potential witnesses and found contact details for 36 (80%); of those contacted, 29 witnesses agreed to participate in the seminar, 13 in the first session and 16 in the second. Four of the witnesses were asked to chair and/or facilitate the discussion. All witnesses were invited to attend both sessions but given a speaking slot at one, and many people attended and contributed to the discussion in both sessions.

The witnesses who attended included many UK public involvement leaders with a diversity of roles within health care organisations, research institutions, user-led organisations, governmental organisations, and the community and voluntary sector. There were also public involvement leaders in attendance who were experts through experience with the health and/or social care system and were not part of a wider organisation. Brief biographical details of the witnesses are included in the full report, where the broad range of skills and perspectives represented are apparent.

Qualitative themes

The themes that were identified and discussed are captured in Table  2 and appear as numbered headers below. These are explained briefly in the final pages of the witness seminar report. In this paper we share quotes that illustrate the themes and showcase the mixed history of INVOLVE. The quotes are long but their length has largely been maintained to protect the rich and detailed information provided by witness accounts.

The importance of historical perspective

Witnesses talked about the historical context and its impact on the development of INVOLVE. There were references to the context and wider government and political changes, changes in the health research climate, and their influence on INVOLVE and its remit. There was recognition of the mixed history and the importance of this nuanced perspective. The quotations here showcase some of the historical shifts that witnesses experienced, from changes in the political climate, to structural transformation in the organizational environment surrounding INVOLVE, to the widening of INVOLVE’s remit.

One witness talked about the shift away from the hierarchical medical model common before the mid-90 s and towards a flattened hierarchy or shared approach that has supported progress in health research and health care.

“You go back to the mid-'90s, and it's not gone now entirely, but there was still that feeling that scientists invented, doctors prescribed, patients took and were grateful, whether it worked or not. Shifting away from that cascade, that hierarchical model, to a more, sort of, matrix-based approach where there was an expectation of, to a certain extent at least, a negotiated approach to planning and delivering research and development, to service provision and so on, was actually very important. I think that then translated through into the developments that we've seen since.” – Alistair Kent (Advisory Group Member)

The history of the contextual structures, remit, and priorities of INVOLVE was also discussed, with expansion leading to an evolution of INVOLVE’s organizational role over time.

“The budget involved did increase over time quite considerably, certainly from the very early days, but the remit and priorities of the group continued to expand, because when we started off it was very much just NHS and it moved towards public health and social care and other work. The other issue in terms of when the NIHR was established, that in one way the expertise and involvement grew across the NIHR, there were a lot more people involved who were able to support and work with people and develop ideas. The INVOLVE role in developing and providing shared resources also needed to expand because there were more people needing to think about these issues and talking about it.” – Sarah Buckland (Director)

“I was in the staff unit for seven and a half years and it was an immense period of change in itself, of expansion. I do remember feeling that towards the end it-, it's almost like the environment around us was changing very rapidly, and the rhetoric was changing rapidly in the wider environment. It wasn't just about INVOLVE, what it had become. It wasn't just about the group. We were beginning to work more and more in an environment where other organisations had their own patient public involvement units and staff, and so on... So, I felt that there was becoming an increasing tension with it as well, in the sense that INVOLVE having, sort of, broken through institutionalisation was maybe becoming a bit of an institution as well.” – Roger Steel (Staff member)

The political context and government actions were also mentioned by witnesses, with one witness reflecting on how changes in political climate affected the work of INVOLVE.

“There seems to be a distinct arc for me, from about 2006 to when INVOLVE morphed into the Centre for Engagement. And that begins with some very heady days around 2010, 2011, 2012, when we were seeing things like the NHS Constitution come forward, the research mandate in the Health and Social Care Act of 2013. You know, it seemed to be that people's idea may not be what we would class as public involvement but people's idea of public involvement was spawning everywhere and that felt a very, very exciting time. Even though that was against a very clear, difficult agenda around austerity. And then, I think around 2016, 2017, things became very much more difficult. The political environment changed. There was a change in government with Cameron and Brexit and all those things and things became a lot harder if you had anything to do with the Citizen Agenda. And so, I would say that became the next phase that was very, very difficult to navigate.” – Simon Denegri (Advisory Group Chair)

INVOLVE as a social movement

The theme of INVOLVE as a social movement emerged strongly through both days of the witness seminars. INVOLVE brought together people who sought change and it was described as having persuasive storytellers, champions, and people who led the way toward democratisation of health and social care research. The quotes below capture what it felt like to be part of that movement, pushing boundaries, campaigning for change, growing the movement, and eventually becoming a powerful force not only nationally but internationally. In many ways it was the loss of this social movement that caused concern and distress for some.

A sub-theme within the idea of INVOLVE as a social movement was the importance of public involvement leaders and champions, which was mentioned by many of the witnesses. The early champions spoken about in the first quote below led to a movement that created future champions and inspired others to promote public engagement, as expressed in the final three quotes.

“The key thing I wanted to pick up was about the importance of leadership in all this. So, leadership of Ruth [Evans], and Nick [Partridge], and Iain [Chalmers], and Harry [Cayton], of what was then the Standing Advisory Group, and then Consumers in NHS Research, but also leadership of a number of researchers who, as Nick [Partridge] said, really stuck their neck on the block to champion involvement, and other people who were leaders in their own field, so other members of the Standing Advisory Group who were leaders, who pushed for involvement in research in their own ways-, that, I think, has been key to what's happened.” – Bec Hanley (Director)

“I know that, at national, local, and international level, members of INVOLVE, or people who used our resources, came to the conferences, were inspired by what the Support Unit was doing, what INVOLVE was publishing, went out and made extraordinary contributions, and challenged people, across health and social care, to ensure much greater patient and public engagement in the whole of the research cycle.” – Nick Partridge (Advisory Group Chair)

“At the beginning, there were these strong people that were willing to say what they thought, and come up with new ideas, and really push for public and patient involvement to become the norm, sort of, laid the ground for us that were going to come in later. I've always been known as a bit of a revolting peasant, so it's great that there were some revolting peasants before me.” – Amander Wellings (Advisory Group Member)

“And I think I would say that all of the INVOLVE members, they were all great ambassadors for going out and telling that story. And that's, I think, one of the ways-, we weren't armed with lots of money to communicate, actually, we were just armed with an awful lot of very good people who are excellent communicators and, and really good at telling a story.” – Simon Denegri (Advisory Group Chair)

One of the quotes above mentions ‘revolting peasants’, a metaphor for those experiencing oppression rising up against their oppressors, and the quote below refers to campaigning and power differentials. This vocabulary echoes the language of social movements, with collective efforts to seek change and a shift in power.

"I think there's also something really important…about dress, and costume, and title. I came along as a representative-, as a mother, somebody without the formal role. I came along as a mother who knew that there weren't services, and was campaigning, and had come through a background of campaigning, for the lack of services, not that one service should be measured against another. I remember that the first conference I attended, and participated, and took the soapbox-, I actually changed into a nightdress and dressing gown to go on stage, because it always felt to me really important that we embodied, and actually modelled, what it was to be powerless, and you don't get much more powerless than wearing a nightdress and a dressing gown in front of a professor in a suit." – Kate Sainsbury (Advisory Group Chair)

The growth of the movement and the increased recognition that it received over time was also mentioned, with INVOLVE's reach starting in the UK but eventually becoming international as it was as the forefront of change.

“Both the extent to which greater public involvement was beginning to spread across the globe, literally, but the degree to which, at the front of that movement, whatever you want to call it, was the INVOLVE name. Everywhere you went people talked about INVOLVE. They talked about the resources. They talked about it as their North Pole. You know, everybody looked at INVOLVE as providing the leadership and the hope and the aspiration that they were all looking to embed in their own nation. And I think it's quite difficult to describe just how strong that was and continues… So, so that international, global, reach was incredible.” – Simon Denegri (Advisory Group Chair)

The importance of how INVOLVE worked

INVOLVE was positioned as a convener and witnesses described the importance of how it brought people together in meetings, work groups, and at biannual conferences. There was an intentional flattening of hierarchies and a recognition of the importance of language and its use. Witnesses talked about the hospitality and kindness of the INVOLVE support staff and members. There was a deliberate inclusivity and support for a diversity of voices to speak respectfully. This was described as building a community, supporting trust and leading to INVOLVE becoming a respected brand.

Witnesses spoke about how INVOLVE brought people together, created community and a forum for discussion, supported networking, and empowered active involvement.

“Bringing together such a wide range of people and the fact that everybody was supported to be heard, to feel comfortable, to be valued, I think was really, really important. And I think--, that was both through the advisory group, but I think also through things like the conferences and the events. I think the INVOLVE conference was absolutely critical in bringing together the wider public involvement community. And, you know, I think I always came away from those things really enthused, really inspired, but also with new information, new networks, new contacts. And there feels like a real gap in the public involvement world now, particularly without the conferences. There's been nothing else that's replicated that. And I think physically bringing people together in that way, was so, so important.” – Louca-Mai Brady (Advisory Group Member)

“It’s important to say that INVOLVE was, I think, the most significant force in enabling the voices and experiences of patients and the public to have a voice and a presence in what we know as patient public involvement in research. It created a forum to talk about involvement, produced guidance and guidelines, held conferences and developed a community, and we who are here today were all there, and are still there in this.” – Derek Stewart (Advisory Group Member)

The word humanity was used by a few of the witnesses to describe how INVOLVE supported the public involvement community.

“I think the humanity of INVOLVE was really, really important and I think it didn't get clouded by lots of jargon and words and all sorts of stuff, it just ended up being something we all understood for a very long time.” – Rachel Purtell (Advisory Group Member)

Examples of what is meant by humanity are captured in the quotes below, with one witness talking about how INVOLVE staff and the Advisory Group modelled good practice in making sure everyone felt important, another witness talking about demonstrations of kindness and compassion, and a third talking about feeling part of a family.

“What Roger [Steel] and I were trying to do is model what we saw as good practice, which is the opposite of the bad practice of the people with all the titles, with the big table in Leeds Castle, making people feel small. Actually, there's no place in this world…for making somebody else feel small and as Goethe said, only everyone knows the truth. I think we were there to bear witness to that.” – Kate Sainsbury (Advisory Group Chair)

“That culture that was engendered by the organisation, the way in which all of the staff involved in that showed and demonstrated kindness and compassion. And that's really important for everybody. It was important for me, too… You were made to feel special, and that, I think, made all of us feel the ability to stand up and speak and say what you felt…Probably my last point would be the diversity of what INVOLVE was about. And I don't mean that just in the sense of people being different, but people's opinions being different. It was wonderful to be involved in something where I could sit in a room and hear people with vehemently different views, but a sense that they were all accepted. And it was okay that there was disagreement. And that was special, and it's unusual to, to, to experience that and see that and be a part of it.” – Stuart Eglin (Advisory Group Member)

“In terms of personal contribution, I actually felt like I was part of a family. And that's quite difficult to find in this day and age. It was lovely to be a part of that community. And at the time, some of you may remember, I was fairly introverted in, in the classic way of difficulty speaking up in a group. And I held my idea 'til the end and sometimes missed the moment, but with facilitation, people generally brought that out of me. I'm not so introverted now, I hasten to add. And I have no problem challenging or questioning, because I know some of you around the table now. But seriously, I honed some of those skills through INVOLVE.” – Tracey Williamson (Advisory Group Member)

The last two quotes related to how involved worked go beyond talking about the kindness of INVOLVE and also touch on how this supported the expression of a diversity of views and encouraged people to speak up and share their ideas and questions.

INVOLVE as a quiet disruptor

There was a theme of INVOLVE as a "quiet disruptor" that witnesses talked about as a strategic way to challenge the status quo and push for change. These forms of influence were described as sometimes subtle and calculated to work from within and to balance “challenge and encouragement” as one witness described. Depending upon perspective, these softer efforts to influence may have complemented some of the activist elements of INVOLVE or perhaps dulled them.

One witness talked about the work done by INVOLVE members and the staff centre using discussion, conversation, and presentation, to support public involvement in various venues.

“I know INVOLVE members would often, through the work they were doing, by those conversations and discussions with people, could often change how things might then develop and how people might think about things, also through the conferences, the opportunities of people to come together and have those conversations or workshops and discuss things. Some of it from the INVOLVE Coordinating Centre, we were often chipping away by going and talking to people, giving presentations or being part of advisory groups, just trying to influence alongside members doing some of that as well. Sometimes it felt we got somewhere, sometimes we were still carrying on trying to knock at the door.” – Sarah Buckland (Director)

This influence, using passion and persuasion rather than authority, caused a spreading awareness and allowed those in patient communities to be more assertive in their attempts to influence health research and service delivery.

“That core group, the influence, the awareness spread out into the patient community, the family community, and gave confidence to support organisations for those supporting families with particular conditions to be more assertive in the way in which they were able to approach the research community, the clinical community, to shape the nature of the research that was being undertaken, where that was possible, and also to influence beyond that into the way in which services were delivered within the context of the NHS.” – Alistair Kent (Advisory Group Member)

The witness quotations below recognise the importance of choosing battles carefully and knowing when to be disruptive and when not to push boundaries.

“I remember having discussions with Harry [Cayton], with Bec [Hanley], and with Sarah [Buckland] about making sure that we chose the battles that we could win, and getting the balance right between challenge and encouragement, and giving the resources and the push and the lift to those researchers and research funders who really wanted to embrace this.” – Nick Partridge (Advisory Group Chair)

“One of my reflections is knowing when to be disruptive and when to play the system is actually quite an important awareness to have as a change facilitator.” – David Evans (Advisory Group Member)

However, there was acknowledgement of the limits of quiet disruption, and the distinction between acceptable and unacceptable forms of disruption. This tension between activism and being part of an institution is also reflected in the demise and loss of INVOLVE theme described below.

“I wonder if there was always this idea, and I think it exists even now, of acceptable people outside the system that could be invited in, and people that were just so unacceptable that they weren't.” – Lynn Laidlaw (Advisory Group Member)

Evidence, knowledge and learning

Witnesses spoke of the importance that INVOLVE placed on evidence, knowledge, and learning, and how public involvement practice was supported via collective learning and building an evidence base. INVOLVE’s sub-group ‘Evidence, Knowledge and Learning’ engaged in thinking about evidence and knowledge from different perspectives, and INVOLVE created resources and evidence syntheses that helped to inform practice as well as convince others of the importance and impact of public involvement. While the quotes below capture important progress, they also reflect concern that the work fell short and there were missed opportunities to be the driver of a change in research culture, especially around methodology development.

One witness talked about the evolution of evidence collection and synthesis that was supported by INVOLVE.

“I think Nick [Partridge] referred to the database of research projects that was first established very early on, which developed into the evidence library, studies of consumers involved in NHS regions, and then moving on later to impact of involvement and examples of public involvement, but building a background knowledge and issues that people could understand about what has gone on and what difference public involvement is making for some organisations and some individuals was hugely important.” – Sarah Buckland (Director)

Another spoke about the evidence synthesis being a tool in successfully convincing those outside of the public involvement community of its important contributions to research.

“One of the things I think INVOLVE gave me was the resources to tackle the entrenched culture which was not inclusive and involving. And it was partly the confidence that having the experience of being part of the group gave me. It was partly things like the evidence synthesis work, which was really, really important. That was a very useful tool in convincing people that there was something of substance in public involvement, that it really did contribute to research. – David Evans (Advisory Group Member)

Witnesses also spoke about the nature of the evidence collection and synthesis, which was inclusive and diverse, and the role that it played in future developments, like the launch of an international journal that has been co-developed with a patient editor in chief.

"I always felt really proud of the work that Evidence, Knowledge and Learning [Advisory Committee Sub-group] did, and I think we were really careful to value different forms of knowledge, and different forms of evidence and learning, and it wasn't just about academic knowledge and publication. It was about a whole range of perspectives, including the tacit knowledge people have as practitioners, which is hugely important. So, the work we did was vital and from that group came our journal, Research Involvement and Engagement, and lots of people inputted into that, and it's still the only journal, international journal, with a patient as co-editor in chief." – Sophie Staniszewska (Advisory Group Member)

Although witnesses acknowledged the importance of the tools and resources developed by INVOLVE, this was tempered by a feeling that there was a limit to INVOLVE’s remit that meant that it could promote change but did not have the power to drive that change forward.

“I think it did an absolutely brilliant job and I've always been a huge fan of everything that's been done but it always felt that it didn't have the executive power to drive and support, and make the change happen. It just had to do things, it produced lots of the tools but couldn't actually be the driver. Everybody who was part of it wanted it to do but it wasn't given the remit to do and it wasn't given the high level support.” – Jim Elliott (Advisory Group Member)

There was also acknowledgement of where INVOLVE did not achieve its aims; despite leading the synthesis of evidence and building resources, witnesses spoke about a failure to change the culture in research, and particularly the hierarchy of methods and evidence production.

"I think that something that we have really failed to do is change the culture in research, where actually we're still just, tolerated, 'we'll put patients at the centre', but actually what does that mean? We tinker around at the edges, and we have frameworks, and we have tick boxes, and whatever. But unless we fundamentally change the culture of what evidence, or what knowledge, is valued then I think we're stuck." – Lynn Laidlaw (Advisory Group Member)

“I think all of those things that particularly we didn't crack…like the hierarchy of methods - the hierarchy of evidence is not a hierarchy of evidence, it's a hierarchy for producing evidence, a hierarchy of methods and we didn't manage to crack it.” – Diana Rose (Advisory Group Member)

Infrastructure, processes, and systems

INVOLVE played an important role in developing infrastructure to support public involvement. Witnesses mentioned the development of guidance documents and standards, as well as how these resources laid the foundation for network building and collaboration. In addition, INVOLVE played a key role in development of NIHR public involvement infrastructure, including its embedding in peer review and the setting of research priorities.

Witnesses spoke about the practical guidance documents that were developed early in INVOLVE’s tenure and remain relevant.

“The work of INVOLVE, I would say, was absolutely hugely valuable. Numerous guidance documents, so for me, the, the biggest benefit and then, I believe, impact is through the guidance documents that were developed that are still largely relevant today. And obviously, some got refreshed. The Briefing Notes for Researchers was, I personally think, the best thing they ever did.” – Tracey Williamson (Advisory Group Member)

INVOLVE also acted as a convenor of public involvement priority working groups where diversity and inclusion were prioritized.

“All of our working groups, everything we did, we looked at all the diverse stakeholders, anyone that wanted to be a part, could be a part in shaping what we were doing, and it was about the common purpose. Standards [ 14 , 15 ] was a fantastic example of that, representatives of the devolved nations and Northern Ireland, and Ireland, and public contributors, where you didn't know who was who around the table.” – Paula Wray (Staff Member)

The development of resources and networks was described by one witness as creating a positive environment for patient and public involvement (PPI) that allowed new collaborative partnerships to develop.

“I was trying to set up a network of people across the west of England because I was aware that every institution, every university, every research centre had a part time somebody …sometimes funded and sometimes unfunded, to do a bit of PPI. And it was really, really difficult to get resource together to do things on a more collaborative basis and everybody was reinventing the wheel… Becoming a member of INVOLVE and getting really into the INVOLVE world, and understanding all the resources and understanding the networks enabled me, with others, to build a real network of people and… get the different bits of NIHR, in the west of England, to work together and pool their resource and ended up having a team which has been… working collaboratively across the universities and the bits of NIHR. And develop a, a real infrastructure and resource and memory and really good practice and so on. And so, for me, this is one of the key things that INVOLVE contributed to, was creating this much more positive environment for PPI in our region and it wouldn't have happened without INVOLVE.” – David Evans (Advisory Group Member)

The embedding of public involvement in the NIHR was described by a witness as including a role for patients and the public in commissioning and peer reviewing of research, in setting research priorities, and in selection of senior investigators.

“Throughout this time, public involvement in research did become firmly embedded in what became NIHR, rather than CDRC [Central Research and Development Committee], NIHR systems, strategy and structures. We ought to recognise the importance, and how fortunate we were, with the different medical officers of health that we had. They were hugely important in helping us be able to do this. Members of public became routinely involved as members of NIHR programme boards commissioning research, and as peer reviewers of research bids, in a way that was almost unimaginable in 1999. Patients and the public also became involved in a range of strategic activities, including setting research priorities, and in selection of NIHR senior investigators. I do wonder if that still happens. The INVOLVE Coordinating Centre became an integral part of NIHR.” – Nick Partridge (Advisory Group Chair)

The demise and loss of INVOLVE as an internationally recognised centre of excellence

There was a lot of discussion amongst witnesses about how INVOLVE’s role and remit changed over time, and the move from relative independence to more constraint. Witnesses reflected on INVOLVE’s link to the DH and NIHR, increases in bureaucracy, decreases in transparency and influence, and a tendering process that some felt did not include adequate consultation with members of the public and was not fit for purpose. There was great sadness and disappointment around the loss of INVOLVE as an important international leader in public involvement and a desire to consider lessons learned. The demise and loss of INVOLVE was a substantive theme with interconnected elements that we wanted to highlight via the subheadings of: changes in INVOLVE’s role and remit; a decrease in independence and an increase in bureaucracy; and the loss of INVOLVE after a long tenure.

Changes in INVOLVE’s role and remit

The growth of INVOLVE’s remit over time and the increase in public involvement across the NIHR were described by witnesses.

“Over a period of time INVOLVE seemed to get busier and busier and trying to respond to a whole range of expectations as we went through the years. It was almost becoming a victim of its own success and had to think about reconfiguring.” – Roger Steel (Staff Member)

There were challenges related to this growth and evolution that were discussed, with one witness acknowledging the lack of resources and the difficulty navigating expansion over time, and other witnesses talking about what was perceived as an inherent conflict in INVOLVE’s remit growing to include engagement and participation/recruitment.

“Suddenly there was involvement spawning everywhere across this family. It needed to be the centre of gravity for that, but it was never really well-resourced enough to do that. It could never actually-, it was probably set up for failure. Not deliberately set up for failure in that sense and I think they found it very, very difficult to understand, navigate, think about its relationship, its position, in relation to that growth and spread of an idea and ideals and quite what its best role should be.” – Simon Denegri (Advisory Group Chair)

“I felt at the time and still do that involvement needed to be kept separate because bringing in engagement and participation both confused people and diverted resources away from involvement alone, the other two being bigger enterprises in terms of people and likely to need more input.” – Jim Elliott (Advisory Group Member)

“It seemed to me that INVOLVE was about research by the public, not on the public, by the public and with the public, by patients and with patients, not on patients and on the public, but now all of a sudden we're into recruitment. We're into getting more and more people into research as subjects or participants, as they laughingly like to call them. I think that was a bit of an undoing and that tension ran through things for quite a long time. So, we had, ‘It's okay to ask,’ it was very much persuading people to come and participate in trials. At the same time we're talking about co-production and research being done by the public and research being done by patients, it was a conflict I felt and it wasn't well-handled.” – Diana Rose (Advisory Group Member)

These changes over time led to perceived differences over the underlying purpose of involvement, which one witness described as the tension between “propping up the neoliberal state and…challenging it”.

“I see the time of INVOLVE as us moving from feeling we're all on the same road together, to a gradual realisation, amongst us as service users, that those who talk PPI actually are often concerned with something rather different. And those of us concerned with user involvement, from a perspective of disabled people, mental health services users and so on are about liberatory democratisation. And that one is concerned with propping up the neo-liberal state and the other is with challenging it. This realisation of a growing gap, perhaps, making the role of INVOLVE untenable, I think was very important. Also, I began to feel, maybe it's because I was hanging around, a lack of transparency in the direction of travel of the unit of INVOLVE. A sense of diminishing influence.” – Peter Beresford (Advisory Group Member)

A decrease in independence and increase in bureaucracy

Witnesses talked about the relationship between INVOLVE, England’s Department of Health, and the NIHR. The first witness in this section describes INVOLVE’s closeness to the Department of Health.

“The first dilemma, I think, for INVOLVE was its closeness to the Department of Health. It's been touched on a lot. I think INVOLVE played that role brilliantly. It was incredibly influential and central to success with governments and civil servants. I think some days it meant there was a caution, that instead of just going, 'just get on with it', or 'just do it', meant that they stopped and thought what it might mean to the Department. I think that was right and proper, but I think sometimes it had a frustration attached to it.” – Derek Stewart (Advisory Group Member)

Another witness talked about changes over time from an initial position of relative independence to progressively more constraint and management by the NIHR.

“I think a key strength of the Standing Group and then INVOLVE, in its early days, was its relative independence compared to when it was more directly-managed, and increasingly directly-managed by National Institute for Health Research, because it could constructively criticise what the Department of Health did, and what NHS R&D did, and that was very effective. That did bring about change… But actually it's been much more difficult in the second half of the history when it's been, kind of, managed out-, the independence has been felt like it's been managed out, and I think everybody's contributions so far have really brought that out, the really important element of that relative independence and the ability to be very vocal and say what we think and not be afraid of that, and it really makes me feel that the second half of it was quite constrained, and actually that was one of the reasons why I let my tenure on the Advisory Group end sooner than it might have done.” – Jim Elliott (Advisory Group Member)

One witness described INVOLVE as playing the role of a critical friend and outsider before the links between NIHR grew and the role became more about process and standards.

“I think, I'd say, reflecting what people said about how INVOLVE changed, I agree. Certainly, at the beginning, it felt a lot more open, a lot more exciting. A lot more of a collaborative process where things were up for grabs. And obviously that may be because I was younger then and a bit more enthusiastic and less cynical. But I think there was also the sense of being a critical friend to NIHR, but also having a wider remit. Being an outsider. And I think that was really important, and I think over the time, it became increasingly more about a focus on process, about standards, about how involvement is done. And a lot more, as people have said, a lot more closely linked to the NIHR.” – Louca-Mai Brady (Advisory Group Member)

The decrease in independence was also experienced as an increase in bureaucracy that made it more difficult to achieve things.

“So, I'd started off in INVOLVE that was really, really active and really good at achieving something, to INVOLVE that was strangled by bureaucracy and politics, and funding cuts, and, and changes of contracts, and all that. And I was just in the middle of that, like a swan. You couldn't see how much my feet were going under the water to try and actually get things to be achieved, and that, as an autistic person, was really hard for me, because I wanted to see things being produced. I didn't want to sit in a group where they talked about a strategy that may not happen, and business models. That wasn't me. I just needed to get out there, work with people and produce things. That was my passion.” – Amander Wellings (Advisory Group Member)

Loss of INVOLVE after its long tenure

Many witnesses reflected on the last years of INVOLVE and its loss. The first witness quoted in this section acknowledged its long tenure and strength over time.

“INVOLVE actually had a remarkable continuity and a longevity, compared to other patient and public involvement structures in the early 2000s. I think that's really important to remember. So, of the ones I can remember, we saw the abolition of the community health councils, the establishment and then, in quick succession, the abolition of patient forums, local involvement networks or LINKs, the Commission for Patient and Public Involvement in Health, and the NHS National Centre for Involvement, among others. INVOLVE, though, survived and thrived.” – Nick Partridge (Advisory Group Chair)

One witness described feeling a sadness about the final years of INVOLVE as public involvement became more mainstream and those championing it became less well positioned to agitate for change.

“The last few years of INVOLVE's life, I just felt, were really, really deeply saddening, because the system in some ways had accepted involvement and engagement as an important issue, but was sucking it into itself to swallow it up and make it part of the mainstream. And as soon as it becomes part of the mainstream, it loses its ability to, I've used the word already, agitate to do something to keep changing things.” – Stuart Eglin (Advisory Group Member)

There was surprise about the move away from INVOLVE, with one witness feeling that it came “out of the blue” without sufficient consultation, and another mourning the loss of the INVOLVE reputation and brand.

“INVOLVE becoming part of the Centre for Engagement and Dissemination came as a big surprise to me as somebody who'd been involved. It just came out of the blue. There was no consultation about it within the PPI world and I think that was a very big missed opportunity, and in a way it was related to tendering, obviously, but the government seems to want to do consultations all the time so I don't know why there wasn't a consultation about this change.” – Mary Nettle (Advisory Group Member)

“The credibility and respect that INVOLVE had both nationally and indeed internationally for its work on patient and public involvement and it had a really, really great reputation. So, it was always slightly sad to see the INVOLVE brand, the name, actually go and that was something that we all fought very hard for at the end. At one stage I think we thought we had got it agreed that it would keep the name, but, but hey, it, it didn't and we move on.” – Gary Hickey (Staff member)

It is an indication of the importance of INVOLVE that a large number of those who had worked in and around the organization over the years gave their time to engage in the witness seminar. One limitation of the commentary is that, though a wide range of public members, health professionals, and researchers were able to join the witness seminar, it was an unfunded project and we were not able to offer any support to join in dissemination efforts. This meant that not all public members who we initially invited to be part of the commentary writing group were able to join as some had to prioritize paid opportunities. Another limitation was the close involvement of all witnesses in the development and evolution of INVOLVE. While this is common in witness seminars, it can mean a bias toward insider perspectives while neglecting perspectives that are further removed. To address this, a retired senior manager at NIHR who would have had oversight of the tendering process was invited to participate, but they declined, so unfortunately this perspective was not able to be included.

A clear message from the seminar is that there is historical knowledge that should be maintained and the themes can inform future efforts to build communities of practice around public involvement in research. The theme of INVOLVE as a social movement is an important consideration for the field. Social movements are agents of change that work through collective behaviour and typically sit outside of organizational constraints [ 16 ]. INVOLVE began as the efforts of a minority who saw the importance of involving public members in shaping health care research. From the early days of INVOLVE through the expansion of the early 2010s some of the social movement ethos was maintained. The foothold in the NIHR gave INVOLVE a voice within the traditional structures of health and care research and research funding. This was seen as a useful lever, a way to have influence, and a seat at the table where decisions were being made. However, this was counter-balanced by the institutionalization of the Centre, with early freedom to act as a critical friend later seen as subsumed by strictures of inflexible systems.

The description of the evolution of INVOLVE as the development of a social movement exists as a backdrop to much of the conversation within the witness seminar. With this as context, and the feeling there are many things that can be learned from the recollections of those who were part of the emergence, evolution, and demise of INVOLVE, the authors of this commentary report six important lessons based on the conversations that occurred as part of the witness seminar. The witness seminar report provides a nuanced and detailed account that we encourage others to read in full, conducting further analyses and parsing the information for additional lessons and specific recommendation for groups that develop, support, and fund public involvement in health and care research. We have included below what we believe are broad learnings for future practice nationally and internationally, framed in a way that we intend to be useful for all those interested in the future success of public involvement in health and care research.

It is important to create and nurture public involvement communities of practice

The early days of public involvement saw small numbers of committed individuals working together to inspire others and eventually accessing levers of power that provided funding, structure and support. The expansion of public involvement meant that there was an ongoing need to convene groups of like-minded people to share learnings, support each other, and build knowledge and evidence. The bi-annual INVOLVE conference and centralized web space, listing groups supporting public involvement around the country and housing a database of evidence, supported and grew the community of practice in essential ways. The loss of INVOLVE as a hospitable convener has meant fragmentation and fewer opportunities for collaboration and shared learning.

Collaborative ways of working support open discussion amongst diverse groups

There was a lot of conversation about INVOLVE’s ways of working, which included transparency, responsiveness, openness, and respect. In order to bring a diverse range of voices into the room, forethought and understanding of accommodation, dietary, and access needs, were essential. Good facilitation and an intentional approach were crucial to witness reports of growing confidence and the ability to voice ideas. Hospitality, awareness and celebration of differences, and platforms to speak and be heard, all came together to open discussions. Healthy disagreement and productive tension were part of this open discussion, and a culture of respect meant that ideas could be challenged and iterated upon in an arena where many people felt understood.

Be aware of the tensions between activism and being part of the establishment

Public involvement, with its roots in a social movement of activists for change, maintains the spirit of collective action, pushing boundaries and supporting the embedding of involvement and the importance of power-sharing. The first iterations of INVOLVE were composed of those outside of the mainstream agitating for change and achieving a platform within existing structures. The subtle shifts as the role of INVOLVE was shaped not only from the inside but also by the structures it existed within led to the tension that was described by the witnesses who spoke at the seminar. While some of activist ideas and approaches were maintained, over the years the Centre was asked to take on a wider remit and the tendering process for the Centre budget became more opaque. The work of INVOLVE began to be focused on process rather than leadership and this evolution limited its range of motion and access to power. While the tension was experienced as essential and positive at times, eventually the balance was tipped and there was the perception that the work was becoming less activist and more institutionalized.

Continued efforts should be made to build an evidence base for public involvement practice

INVOLVE championed building an evidence base for public involvement. This meant supporting an understanding of where, when, and how public involvement in research is being carried out and what makes it successful for members of the public, researchers, and the scientific community. INVOLVE supported scoping reviews, literature reviews, identification of gaps, and filling of those gaps. They created a repository of peer reviewed literature as well as a database of public involvement activity across the country so that local and regional groups could interact and learn from one another. These efforts to join thinking, support prioritization of literature and practice gaps, and highlight existing evidence were important to the growth of the field. A bibliometric review of the literature on public involvement that looked at literature between 1995 and 2009 found that the UK publication by population was by far the highest, with those in the UK contributing significantly to the evidence base [ 17 ]. The loss of INVOLVE as an advocate for building evidence, and as a force for ensuring the capture and centralized sharing of this information, may mean a longer road to change and impact.

There are both benefits and drawbacks to having a centralized organization leading public involvement

The national progress made to involve the public in health research was supported by INVOLVE in many ways. They had a seat at the table by virtue of being embedded into structures of power and were seen as the experts and therefore could be part of shaping policy and practice. Researchers interested in involving the public in their work were directed to INVOLVE for advice and support, including materials, templates, and links to relevant literature. The longevity of INVOLVE acting as a centralised home for public involvement expertise benefited health care funders, researchers, and public members who were interested in getting involved. A ‘home’ for public involvement meant easy access to cutting edge research and practice in the area. However, these benefits came alongside less flexibility and challenges related to institutionalization. Having one central voice rather than many can risk dampening dialogue and feel constraining to those who are agitating for change in different ways. It is likely that future iterations of the organised work of public involvement will experience a similar balancing act – with benefits to centralised organising being tempered by the restrictions inherent in institutionalised efforts.

Support for public involvement in research requires a fit-for-purpose tendering process that embeds robust public involvement

There was discussion amongst the witnesses about the evolution of INVOLVE and the tendering process. While the early tendering process was collaborative, with some flexibility and interaction between those with expertise in public involvement, as time went on tendering became more prescriptive and was developed by people who were perceived as having less understanding of the work and how it sits within the wider landscape. The INVOLVE brand had been built over decades, took an inclusive approach, and had a particular remit. The remit, stretched initially to include public health and social care, was then grouped with participation in research, and dissemination of research. The most recent tender had the widest remit, with less focus on building on earlier successes and a requirement to do more with fewer staff and less funding. The developers of the tender were seen as sitting outside of the public involvement sphere and not sufficiently engaging those with expertise in the area. Public involvement was bundled with other issues and the priority and focus shifted. The changes did not feel informed, and left the witnesses feeling that a fit-for-purpose model would have better avoided losing momentum and historical knowledge.

Conclusions

This paper illustrates some of the themes and sub-themes that arose in the INVOLVE witness seminar using quotations from the witnesses who attended. After attending the seminars and reviewing the transcripts, we developed lessons that may inform future efforts to support public involvement. The tension between activism and the institutionalisation of public involvement is something that is likely to continue. Thoughtful discussion about this balance will be important, and the tightrope walk between agitating for change and becoming part of the establishment may be inherently difficult. The lesson around matching process to fit and function bears repeating. Witnesses talked about the context and confluence of events that led to the dissolution of INVOLVE, and there was agreement regarding the difficulty of the tendering process and the fact that it was disruptive, opaque, and ultimately led to a change in course that meant the end of the INVOLVE tenure.

The witness seminar provided a “mixed history” of INVOLVE spoken by a diverse group of people who were a key part of its development and evolution. Individuals with lived experience played leadership roles in INVOLVE, and their independence served to hold it to account. True to this spirit, there was a sense that the witnesses wanted to engage in a critical review rather than a simple celebratory history. The full transcript, an appendix to this paper, showcases problems and tensions as well as celebrating the growth of an inclusive movement. The constructive reflection shown by witnesses, as well as the open and respectful conversation, make us feel hopeful that we can use some of the difficult lessons to support reflective thought and action, inform future efforts, and continue the push toward democratisation of research.

Availability of data and materials

Our commentary relates to the Witness Seminar, which was written up as a report and published on the International Patient and Public Involvement Network website. All of the data is available in full, with reviewed and approved transcripts included as part of the report.

Abbreviations

Central Research and Development Committee

NIHR Centre for Engagement and Dissemination

Department of Health

National Health Service

• National Institute for Health and Care Research

Patient and Public Involvement

Research and Development

Peckham M. Research and development for the National Health Service. The Lancet. 1991;338(8763):367–71. https://doi.org/10.1016/0140-6736(91)90494-A .

Article   CAS   Google Scholar  

Department of Health. Duty to Involve Patients Strengthened: Briefing on Section 242 of NHS Act 2006. Gateway Reference 9138. London: DH, 2007. Available at: https://webarchive.nationalarchives.gov.uk/ukgwa/20130123192901/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081089

Medical Research Council. Public involvement and engagement – Medical Research Council. https://www.ukri.org/what-we-do/public-engagement/public-engagement-mrc/ .

Clancy C, Collins FS. Patient-Centered Outcomes Research Institute: The Intersection of Science and Health Care. Sci Transl Med. 2010;2(37). https://doi.org/10.1126/scitranslmed.3001235 .

Canadian Institutes of Health Research. Canada’s Strategy for Patient-Oriented Research. Canadian Institutes of Health Research; 2012. https://cihr-irsc.gc.ca/e/44000.html .

Staley K, Sandvei M, Horder M. “ A Problem Shared...” The Challenges of Public Involvement for Researchers in Denmark and the UK. TwoCan Associates; April 2019: 22. https://www.twocanassociates.co.uk/wp-content/uploads/2017/05/A-problem-shared_forskningsrapport_A4.pdf

Consumer and Community Engagement. National Health and Medical Research Council https://www.nhmrc.gov.au/about-us/consumer-and-community-involvement/consumer-and-community-engagement .

Consumers Health Forum of Australia. Statement on Consumer and Community Involvement in Health and Medical Research, National Health and Medical Research Council . ; 2006. https://www.nhmrc.gov.au/about-us/publications/statement-consumer-and-community-involvement-health-and-medical-research .

Jones EM, Tansey EM, eds. Human Gene Mapping Workshops c.1973-c.1991: The Transcript of a Witness Seminar Held by the History of Modern Biomedicine Research Group, Queen Mary, University of London, on 25 March 2014. Queen Mary University of London; 2015. https://doi.org/10.1016/j.gene.2016.02.030

Crowson NJ, Hilton M, McKay J, Marway H. Witness Seminar: The Voluntary Sector in 1980s Britain. Contemp Br Hist. 2011;25(4):499–519. https://doi.org/10.1080/13619462.2011.626658 .

Article   Google Scholar  

Nicholls EJ. The witness seminar: A research note. Qual Res. 2022;22(1):166–73. https://doi.org/10.1177/1468794120974153 .

Doel RE, Söderqvist T, eds. The Historiography of Contemporary Science, Technology, and Medicine: Writing Recent Science. 1. publ. Routledge; 2006. ISBN: 0415272947

INVOLVE. Briefing Notes for Researchers: Involving the Public in NHS, Public Health and Social Care Research. INVOLVE; 2012. ISBN 978-0-9557053-7-3

UK Standards for Public Involvement. National Institute for Health and Care Research; Public Health Agency Northern Ireland; Health and Care Research Wales; Chief Scientist Office Scotland; 2016. https://sites.google.com/nihr.ac.uk/pi-standards/standards .

Crowe S, Adebajo A, Esmael H, et al. ‘All hands-on deck’, working together to develop UK standards for public involvement in research. Res Involv Engagem. 2020;6(1):53, s40900–020–00229-y. https://doi.org/10.1186/s40900-020-00229-y .

Della Porta D, Diani M. Social Movements: An Introduction. 2nd ed. Blackwell Publishing; 2006 ISBN-13: 978-1-4051-0282-7.

Boote J, Wong R, Booth A. ‘Talking the talk or walking the walk?’ A bibliometric review of the literature on public involvement in health research published between 1995 and 2009. Health Expect. 2015;18(1):44–57. https://doi.org/10.1111/hex.12007 .

Article   PubMed   Google Scholar  

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Acknowledgements

We would like to thank all of the witnesses who gave their time, dug into their filing cabinets, email inboxes, and memories, and provided such a rich historical account from a variety of perspectives. In addition to the authors of this paper, the witnesses were: Ade Adebajo, Peter Beresford, Sarah Buckland, Iain Chalmers, Simon Denegri, Stuart Eglin, Jim Elliott, Ruth Evans, Zoe Gray, Gary Hickey, Alastair Kent, Mary Nettle, Nick Partridge, Stan Papoulias, Rachel Purtell, Holly Rogers, Diana Rose, Patsy Staddon, Roger Steel, Amander Wellings, and Tracey Williamson. The witness seminar would not have been possible without the help of the Academy of Medical Sciences and its staff, who arranged and hosted the two virtual sessions. The idea to capture the lessons learned during INVOLVE’s tenure came from a group brought together in 2021 by Bec Hanley and Derek Stewart. We are also indebted to this group, including Peter Beresford, Jonathan Boote, Louca-Mai Brady, Eleni Chambers, Shoba Dawson, Simon Denegri, Stuart Eglin, Jim Elliott, David Evans, Alison Faulkner, Amanda Farwell, Helen Hayes, Gary Hickey, Thomas Kabir, Meerat Kaur, Lynn Laidlaw, Elspeth Mathie, Marisha Palm, Stan Papoulias, Rachel Purtell, Sophie Staniszewska, Maryrose Tarpey, and Amander Wellings.

The Witness Seminar event as well as the report and this commentary were all unfunded and relied on the commitment of individuals who care about the future of public involvement and were willing to give up their time to capture lessons from the INVOLVE tenure.

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Marisha Emily Palm

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University of the West of England, Bristol, UK

David Evans

University of Warwick, Coventry, UK

Sophie Staniszewska

University of Hertfordshire, Hertfordshire, UK

Louca-Mai Brady

Former Director, INVOLVE, Eastleigh, UK

University of Oxford, Oxford, UK

Kate Sainsbury, Derek Stewart & Paula Wray

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MP drafted a manuscript outline, which was reviewed and shaped by all authors (DE, SS, LMB, BH, KS, DS, PW). MP, DE, and SS reviewed transcripts, edited, and wrote the related report, which is attached as an appendix. MP drafted the manuscript text, which was again reviewed by all authors (DE, SS, LMB, BH, KS, DS, PW), who met and provided thoughts on the manuscript content, title, illustrative quotations, and lessons learned. All authors (DE, SS, LMB, BH, KS, DS, PW) also provided track changes and comments for the early draft and a final draft revised according to discussions and suggested amendments.

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Correspondence to Marisha Emily Palm .

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As stated in the manuscript, formal ethical review was not required as the witness seminar involved a group of contributors working toward a common goal. All contributors had full ownership and control of their own text, with the opportunity to edit or withdraw text up to final approval for publication.

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The manuscript authors and the witnesses who have been quoted in the manuscript have all given their consent for publication.

Competing interests

S.S. has a competing interest as Co-Editor in Chief of Research Involvement and Engagement and excludes herself from the handling or review of this manuscript. S.S. is part funded by NIHR ARC WM, NIHR HPRU GI, NIHR HPRU GED, NIHR ESG Warwick, and NIHR HDRC Coventry.

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Palm, M.E., Evans, D., Staniszewska, S. et al. Public involvement in UK health and care research 1995–2020: reflections from a witness seminar. Res Involv Engagem 10 , 65 (2024). https://doi.org/10.1186/s40900-024-00598-8

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Received : 12 March 2024

Accepted : 07 June 2024

Published : 22 June 2024

DOI : https://doi.org/10.1186/s40900-024-00598-8

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