Is it 4 Attributes of Critical Thinking or 5 Rights of Clinical Reasoning?
Is it 4 Attributes of Critical Thinking or 5 Rights of Clinical Reasoning?
Does it matter?
This post is meant to be a continuation of our discussion about promoting critical thinking throughout the clinical experience.
I am wondering about your thoughts as they relate to Sound Clinical Judgement as discussed in Manetti’s article.
Specifically, I am wondering about your opinion of the clarity of her article and the model cases that she presented?
The 4 Attributes of Critical Thinking
After reading the article written by Von Colln-Appling & Guiliano (2017), I developed a diagram to better visualize the critical thinking process as presented by them. What they were talking about seemed to make sense but I needed to see it.
The four primary characteristics or “attributes” described in their article are “knowledge and application, analysis of information, informed decision making, and reflection” (Von Colln-Appling & Guiliano, 2017. p. 107).
Here are my Take-aways
What we need first is knowledge and then the ability to apply it to the particular situation.
It is extremely important that an individual have a foundation of knowledge in order to be able to apply it (Von Colln-Appling & Guiliano, 2017). In our case as nurses, this knowledge needs to be about what is going on with our patients.
The foundation needs to include the condition or disease process, the appropriate care, medications associated with the condition, as well as, how other health conditions and medications can and do impact the patient’s condition and the current situation. This list is not all inclusive, you may think of other need-to-know items to begin one’s foundation of knowledge. It is impossible for one to think of every variable within a hypothetical situation.
Wouldn’t you agree that is a lot to expect of beginning students?
In reality, how can one have any deep thoughts about anything without some basic knowledge and application experience with the knowledge!
This is where the clinical nursing instructor comes in.
The instructor must make sure that the students have a really good sense of what is going on with the patient first since it is going to be very hard (next to impossible) for them to continue with the next steps of critical thinking if they do not have a firm foundation of knowledge. It is also important for the instructor to remember that as a beginner it is difficult to see the bigger picture. Therefore, this is where high-level questioning can be used to assist the student with putting together the knowledge they may have but have not quite gotten all of the pieces put together.
As the student moves through the process of thinking, the student must be able to analyze patient care data, such as, lab data, status changes, as well as, considering the natural progression of the condition or disease as it relates to this particular patient.
Next, the student begins to sort through the data looking for pertinent data and considering if more is needed, as well as, what is not needed in order to make decision about patient care. Finally, the student reflects upon their own actions, decisions, and thinking, which could require them to seek out more foundational information and moving back through this thinking cycle again.
While it is the job of the clinical instructor to assist students in moving through this process, it is also the job of the instructor to encourage the student to build their own independent thinking, as well as, their personal reflection upon the nursing care rendered, their thinking, and their actions.
The Five Rights of Clinical Reasoning by T. Levett-Jones et al. (2010).
After writing up the previous summary, I came across another article that I would like to share. While it is an older article (published in 2010) it is still relevant today, especially since they use some of the same verbiage in the article that I am hearing used today in regards to the next generation of NCLEX.
This article makes clinical reasoning easy to understand. This educational model makes it easy to think through “critical thinking, reasoning, and clinical judgement” and just feels right.
Because just like the rights of medication administration the authors’ model is called “The Five Rights of Clinical Reasoning: …” They also developed a diagram of the “Clinical Reasoning Cycle” (T. Levett-Jones et al., 2010, p. 517). I’ll post a screenshot of the diagram here but to get a full appreciation of the diagram, I suggest you download the article and take a closer look: The 5 Rights of Clinical Reasoning
The “five rights of clinical reasoning” according to the authors are “the ability to collect the right cues and take the right action for the right patient at the right time and for the right reason” (T. Levett-Jones et al., 2010, p. 517). The authors found that both expert and novice nurses use the same thinking strategies, however as you would expect the expert is much better at picking up on all the various cues when thinking as well as knowing the action to take (T. Levett-Jones et al., 2010).
The authors listed the thinking strategies used by nurses as; “describe the patient situation, collect new patient information, review information, relate information, recall knowledge, interpret information, make inferences, discriminate between relevant and irrelevant information, match and predict information, synthesise information to diagnose or identify a problem, establish goals, choose a course of action and evaluate” (T. Levett-Jones et al., 2010, p. 516).
My sarcastic first thought about all the necessary thinking strategies is: Really? Is that all?
In all seriousness: This gives me such an appreciation for the awesome processes nurses go through during each patient care encounter!
Do you agree that we should give the “5 Rights of Clinical Reasoning” to the students along with the thinking strategies of nurses in the form of a handout?
It seems like a great list of expectations for the students. I bet we already have some or all of these thinking strategies in “our” minds as expectations for students to learn. However, if the students had them written down in the form of a handout they could use it as a “cheat sheet” or guide (see Table 1).
It seems to me that if they began practicing these thinking strategies now, they will become the thinking habits that they take with them as graduates (Bristol, 2019).
Next, I looked at their definition of “cues”. Remember, experts are better at picking up on the cues. Therefore, students should be given specific examples of the cues and directed to use them habitually. According to T. Levett-Jones et al., (2010),
“Cues refer to available patient information (for example, hand- over reports, patient history, patient charts, results of investigations and nursing/medical assessments previously undertaken), current clinical assessment data, and also the recall of knowledge. This includes a broad and deep knowledge of physiology, pathophysiology, pharmacology, epidemiology, therapeutics, culture, context of care, ethics and law etc. as well as an understanding of evidence-based practice” (p. 517).
Yes, I agree. This is the area where all nurses can struggle depending on their depth of knowledge in all of these areas.
There is no doubt that the ability to pick up on all of the cues regarding a patient care encounter is especially difficult for a student.
This is why I am concerned for our students as they approach the NEXT generation of the NCLEX.
From what I understand, the student will be tested on their ability to demonstrate their clinical judgement, which will encompass their ability to function (at least on an exam) at the level of clinical judgement as described by T. Levett-Jones et al. (2010).
Therefore, it is incumbent upon the nursing instructor to continuously seek out effective clinical reasoning, critical thinking, and clinical judgement teaching strategies.
Specific Teaching Strategies to Promote and Improve Critical Thinking
Through specific assignments the instructor can assist students in developing and deepening their critical thinking skills. Suggested strategies are high-level questioning, reflective journaling, concept-mapping, simulation, and case-based exercises (Hoffman (2008); Popil (2011); Von Coln-Appling & Giuliano (2017). The teaching strategies of high-level questioning and reflection could be rolled together into post-clinical day conferences and post-clinical written assignments.
Interestingly, after sending out part one of this series of blog posts on critical thinking, I received a response from one of the course participants. In her email she shared a great example of using an unfolding case study. I have asked her permission to share her strategy. I hope to share it with you in part 3. Real-Life case studies help students build habits of clinical judgement (Bristol, 2019). In the mean-time I found an example of unfolding case study on the QSEN website.
Brenda Moench, (2019) developed an unfolding case study called “Develop Clinical Forethought in Novice Nursing Students”. You can find the QSEN unfolding case using this link: http://qsen.org/using-unfolding-case-studies-to-develop-clinical-forethought-in-novice-nursing-students/ . I reached out to her and asked if she would be willing to share the KEY to her teaching strategy. She agreed and sent it to me but asked that I NOT make it available on the internet. Therefore, if you would like the KEY please contact me directly and I will share it with you.
I would be interested in hearing your feedback on this strategy and if you have any cases that you like to use with your student groups. It would be nice if we could share strategies. I look forward to hearing your ideas. Please let me know if I can use your case(s) or other strategies, as well as, sharing your name and contact information to enable others to contact you directly with questions or feedback.
Writing your own case study
After looking at several case studies, I developed a basic template that one could consider using when putting together a case study as a teaching strategy. The basic components of the case should include a description of the patient, a brief history to include a list of problems. Next present the case, which should include the information from admission, the physical assessment both on admission and the current assessment to include ALL current data, not just the pertinent data. It is important for students to be able to sort through all the available data to discern “what” is necessary or what further information is needed. The next section should include questions to consider about additional information needed, concerns retrieved from the patient assessment and data, as well as, the hospital course. Finally, what are the take-a-ways from the case?
Have you found a format that works for you? I created one that you can consider (Table 2). Please consider sharing your thoughts with other course participants.
Until next time.
Student Expectations Patient Care
Building Clinical Reasoning
1. Describe the patient situation.
2. Collect new patient information.
3. Review patient information and then relate it to additional patient information.
4. Recall knowledge the about the patient’s condition, next interpret the information (patient data) then make inferences.
5. Discriminate between relevant and irrelevant information, match and predict information.
o As you collect data from both the patient through the assessment and the medical record start putting data together and consider what information you will need or what you expect to see (in the patient assessment or other data as the patient progress through their healthcare course.)
6. Synthesize all patient care information to develop a care plan-nursing diagnose and/or identify a problem(s), establish goals, choose a course of action then evaluate.
Where should you look for the patient care information and what should you consider?
Hand-over reports, patient history, patient medical record, results of … nursing/medical assessments previously undertaken), current clinical assessment data, and also the recall of knowledge. This includes…(YOUR) knowledge of physiology, pathophysiology, pharmacology, epidemiology, therapeutics, culture, context of care, ethics and law..., as well as (YOUR) understanding of evidence-based practice” (p. 517).
o Adapted from (T. Levett-Jones et al., 2010, p. 516).
Case Study Outline & Format
· Describe the patient
· Brief History
· Upon Admission
· Physical Assessment
o Laboratory findings/trends
· Questions to address pertaining to the specific case.
· Possible questions:
o What additional information is needed?
o What concerns do we have based on the patient’s assessment?
o Is there anything about the patient’s assessment that supports or makes us want to look at both the current and pending Data findings?
· Hospital course
· Take home points
Bristol, T. (2019). Next Gen learning for the new national council licensure examination for
registered nurses. Teaching and Learning in Nursing, 14(4), 309-311.
Hoffman, J. (2008). Teaching strategies to facilitate nursing students’ critical thinking. Annual
Review of Nursing Education. Chapter 12. 225-236.
Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S., Noble, N., Norton, C.A., Roche, J., & Hickey, N.(2010). The ‘five rights’ of clinical reasoning: An educational model to
enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today, 30. 515-520. Retrieved from https://study.sagepub.com/sites/default/files/Levett-Jones%20et%20al%202009.pdf
Manetti, W. (2019). Sound clinical judgment in nursing: A concept
analysis. NursForum, 54(1).102– 110. https://doi.org/10.1111/nuf.12303
Moench, B. (2019). Using unfolding case studies to develop clinical forethought in novice
nursing students. QSEN Institute. Retrieved from
Popil, I. (2010). Promotion of critical thinking by using case studies as a teaching method. Nurse
Education Today, 31(2), 204-207. doi: 10.1016/j.nedt.2010.06.002. (*this article can be downloaded by searching the entire name and doi)
Von Colln-Appling, C.V., & Giuliano, D. (2017). A concept analysis of critical thinking: A
guide for nurse educators. Nurse Education Today, 49, 106-109. doi:10.1016/j.nedt.2016.11.007