Critical Thinking Versus Clinical ReasoningVersus Clinical JudgmentDifferential DiagnosisJoyce Victor-Chmil, MS, RN-BC, MHA

Concepts of critical thinking, clinical reasoning, and clinical judgment are often used interchangeably. However, they are notone and the same, and understanding subtle difference among them is important. Following a review of the literature fordefinitions and uses of the terms, the author provides a summary focused on similarities and differences in the processes ofcritical thinking, clinical reasoning, and clinical judgment and notes suggested methods of measuring each.

The terms critical thinking, clinical reasoning, andclinical judgment are interrelated concepts. Eachrepresents an important set of processes leading the

nurse to sound, evidence-based practice. Critical thinking isthe cognitive processes used for analyzing knowledge.2 Clin-ical reasoning is the cognitive and metacognitive processesused for analyzing knowledge relative to a clinical situation orspecific patient.9 Clinical nursing judgment is the cognitive,psychomotor, and affective processes demonstrated throughaction and behaviors.3 Together, these processes lead to com-petent nursing practice.

In both education and practice, nurses must demonstratecompetency through measurable outcomes. To ensure thatmeasurements of critical thinking, clinical reasoning, and clin-ical judgment are both valid and reliable, nurses must firstdifferentiate what each of these key processes is and whattools are available for the measurement of each.

Literature Search StrategyTo better understand these related concepts, multiple data-bases and search strategies were used to review the literature.A search for each key term critical thinking, clinical reasoning,and clinical judgment AND nursing was conducted using theCINAHL, PubMed, Academic Search Premier, and the archivesof the Clinical Simulation in Nursing online journal. Addi-tional definitions were obtained via Google with no year lim-itations to obtain a sense of nonnursing definitions of theseconcepts. An initial search of the key terms critical thinking,clinical reasoning, and clinical judgment yielded more than10 000 results. Because for this review, the author was inter-ested only in the application of these terms to nursing, ‘‘AND

nursing’’ was added to the search criteria. This yielded 3207publications.

Because of the volume of the data retrieved, a filter tolimit sources to English language was added. This decreasedthe number of publications yielded to 946. Because these dataincluded a large number of poster and presentation abstracts,a filter for full-text articles was added. This reduced the dataretrieved to 95 publications. Search findings were scanned forrelevancy. Clinical trials using the terms, but not primarilyaddressing the concepts of, critical thinking, clinical reason-ing, and clinical judgmentwere found in the retrieved data. Afilter was added to eliminate clinical trials from the search,which reduced the findings to 29. Three articles dated 1984,1988, and 1995 were found to be relevant and were accessedfor use in this literature review prior to adding a filter forpublications within the last 10 years. This final filter yielded12 additional relevant articles, which were also used in thisliterature review. Nine of these 12 articles were publishedwithin the last 5 years.

Critical ThinkingAccording to the Foundation for Critical Thinking,1 criticalthinking is a way of ‘‘imposing intellectual standards’’ in theapproach to any subject, content, or problem.1(p.e1) Criticalthinking is a cognitive process used to analyze empirics. It isknowledgebased and is not dependent on the situation at hand,but rather on the knowledge about the subject that the nursepossesses.2 Theprocess of critical thinking is basedonevidenceand science rather than ‘‘assumptions and/or conjectures.’’3(p.S4)

A thorough literature review by Simpson and Courtney4

included an examination of 78 publications on the topic ofcritical thinking. The publications ranged from Dewey in 1916to current literature in 2000. The majority of the literature re-viewed was published in the 1990s and included a discus-sion of the tools available as of 2000 to evaluate critical-thinkingskills. Their review was based largely on the 1990 DelphiProject by Facione,4 which concluded that critical thinking isa cognitive process that is not discipline specific.

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Author Affiliation: Director, Clinical Nursing Simulation Center.School of Nursing, Wilkes University, Wilkes-Barre, Pennsylvania.The author declares no conflict of interest.Correspondence: Ms Victor-Chmil,WilkesUniversity School ofNursing,84 West South St, Wilkes-Barre, PA 18766 (joyce.chmil@wilkes.edu).DOI: 10.1097/NNE.0b013e318276dfbe

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Simpson and Courtney4 noted that instruments beingused to evaluate critical thinking, such as the Watson-GlasserCritical Thinking Assessment Tool, California Critical ThinkingTest, and UNCG Critical Thinking Skills Evaluation Instrument,were not specific to nursing. In their summary, they recom-mended development of a tool to measure critical thinkingspecific to nursing.4 This, however, seems futile because theirreview noted a consensus in the literature that critical thinkingis not discipline specific. Thus, if critical thinking is not disci-pline specific, the tools noted in this article can be used toevaluate critical thinking as long as validity and reliability forthe tool have been established. A discipline-specific tool is notnecessary.

Clinical ReasoningSimpson and Courtney’s4 analysis of critical thinking laid theground work for the concept of clinical reasoning. Kuiper andPesut5 noted that critical thinking is one of the key factors inthe cognitive processes of clinical reasoning.

Clinical reasoning is defined in practice-based disciplinesas the application of critical thinking to the clinical situation.6

In nursing literature, Jones6 defines clinical reasoning as acognitive process used by healthcare practitioners to addresspatient issues. According toBenner,2 clinical reasoning involvessynthesis of knowledge and experience, as well as engagementin the social relationships of the caregiving situation. Clinicalreasoning requires both a background of scientific knowledgeand a general case or a particular instance in which to apply thisknowledge.7 Clinical reasoning refers to a set of cognitive pro-cesses used to discern the relevance of the evidence and sci-entific knowledge as it applies to a particular patient.8

A concept analysis by Banning9 reviewed and analyzed71 nursing and nonnursing publications dated 1964 to 2005,with the majority of the literature dated in the late 1990s andearly 2000s. Banning’s analysis (1) identified a consensus thatthe processes of clinical reasoning are both cognitive and meta-cognitive, (2) provided a definition of clinical reasoning as theapplication of knowledge and experience to a clinical situa-tion, and (3) concluded there is a need to develop tools to mea-sure clinical reasoning in nursing practice in order for it to bebetter understood.9

Many of the difficulties surrounding the measurementof clinical reasoning in nursing practice were related to thelack of a definition. This may have been due to the blurringof lines between the defining attributes of critical thinkingand clinical reasoning which existed prior to the publicationof Banning’s concept analysis of clinical reasoning in 2008.

A search for valid and reliable tools to measure the devel-opment of clinical reasoning did not yield any results; however,current literature suggests that the cognitive and metacogni-tive processes of clinical reasoning can be developed withinthe practice of nursing through the use of decision trees andalgorithms,8 thinking aloud,9 and reflective journaling.10

Clinical JudgmentAlfaro-LeFevre11 emphasized the imperativeness of devel-oping both critical thinking and clinical reasoning skills inorder to practice sound clinical judgment. In her definitionof clinical judgment, Alfaro-LeFevre suggests clinical judg-ment is the application of critical thinking in clinical practice.

Judgments are necessary for clinical practice that is based onevidence rather than conjecture.2,11

At first glance, Alfaro-LeFevre’s definition of clinical judg-ment is no different than the definitions found in the literaturefor clinical reasoning. Clinical judgment, however, is not limitedto cognitive or metacognitive processes. In her conceptualmodel of Clinical Judgment in Nursing, Tanner12 defines clin-ical judgment as ‘‘an interpretation or conclusion about a pa-tient’s needs, concerns, or health problems, and/or the decisionto take action (or not), use or modify standard approaches, orimprovise new ones as deemed appropriate by the patient’sresponse.’’12(p204)

Tanner12 also identified 5 assumptions of clinical judgmentin nursing. They are (1) clinical judgments are more influencedby what nurses bring to the situation than the objective dataabout the situation at hand; (2) sound clinical judgment rests tosomedegree on knowing the patient andhis/her typical patternof responses, as well as an engagement with the patient andhis/her concerns; (3) clinical judgments are influenced bythe context in which the situation occurs and the culture ofthe nursing care unit; (4) nurses use a variety of reasoningpatterns alone or in combination; and (5) reflection on prac-tice is often triggered by a breakdown in clinical judgmentand is critical for the development of knowledge and im-provement in clinical reasoning.12(pp205-207)

Tanner’s12 key concepts of clinical judgment differentiatedit from other definitions of clinical judgment and from theconcepts of both critical thinking and clinical reasoning. First,Tanner’s definition focuses not only on the cognitive andmetacognitive processes of thinking and reasoning, but alsoon the psychomotor processes of actions and the affectiveprocesses of the caregiver. Second, Tanner’s 5 assumptionstake into account not only the knowledge and application toa specific patient, but also the affective aspects of the caregiverand the environment.

Clinical judgment can only be evaluated comprehen-sively when there are observable behaviors that allow for theevaluation of level of mastery in not only cognitive domains,but also the psychomotor and affective domains.13 The devel-opment and evaluation of clinical judgment come not onlyfrom observable behaviors but also from self-reflection onthese behaviors.10

Clinical judgment encompasses cognitive, psychomotor,and affective skills. Clinical judgment is specific to the indi-vidual. It is rooted in actions based on the ability to analyzeempirical information in relation to both the specific situationand the aesthetic and reflective aspects of the nurse and theenvironment of practice. The most comprehensive concep-tual framework for defining clinical judgment in nursing andits philosophical underpinnings are presented in Tanner’s12

Model for Clinical Judgment in Nursing. Tanner’s conceptualmodel illustrates the subcategories or 4 aspects of clinicaljudgment: noticing, interpreting, responding, and reflecting,anddiscusses the cognitive, psychomotor, and affective aspectsof ‘‘thinking like a nurse.’’12(p204)

The Lasater Clinical Judgment Rubric14 (LCJR) opera-tionalizes Tanner’s Model of Clinical Judgment in Nursing byfurther breaking down each of Tanner’s phases of clinical judg-ment into 11 dimensions. The rubric provides a consistent lan-guage that can be used to evaluate performance within eachdimension and categorize it into a developmental phase of

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beginning, developing, accomplished, or exemplary.14 TheLCJR thus provides a framework for both self-assessmentand formal evaluation of clinical judgment development.13

Although the LCJR has been shown to be a valid andreliable tool for the assessment of clinical judgment develop-ment in nursing students when used in the simulation envi-ronment,15 there is no evidence to suggest it reflects the specificmeasurement of critical thinking or clinical reasoning. In astudy by Mann16 using the LCJR and the Assessment Tech-nologies Institute Critical Thinking Assessment to evaluateclinical judgment and critical thinking before and after simu-lation, there was no significant relationship established betweencritical thinking and clinical judgment. The LCJR is designed toevaluate development within the 4 phases of clinical judg-ment in nursing14 but not the cognitive, metacognitive, psy-chomotor, and affective skills specifically applied in clinicaljudgment. Also, the validity and reliability for the LCJR outsidethe simulation environment and for the evaluation of popu-lations other than nursing students have not been established.

SummaryThe terms critical thinking, clinical reasoning, and clinicaljudgment are interrelated concepts. Each represents an impor-tant set of processes leading the nurse to sound, evidence-based practice.

Critical thinking is the cognitive processes used for analyz-ingknowledgebasedonevidenceand science1,3 Critical thinkingis a key skill or process integral for clinical reasoning.5 Criticalthinking can be measured through valid and reliable stan-dardized examinations not specific to the discipline of nursing.4

Clinical reasoning is the cognitive and metacognitiveprocesses used for analyzing knowledge relative to a clinicalsituation or specific patient.9 Clinical reasoning is a necessarycognitive and metacognitive component of clinical judgmentin nursing.7,8,10 Although there are currently no valid and reli-able tools for measurement, clinical reasoning can be developedwithin the practice of nursing through the use of decision treesand algorithms,8 thinking aloud,9 and reflective journaling.10

Clinical judgment in nursing is the cognitive, psycho-motor, and affective processes demonstrated through actionandbehaviorswithin the 4phases of clinical judgment: noticing,interpreting, responding, and reflecting.12 Development ofclinical judgment in nursing students within its 4 phases canbe evaluated using the LCJR in the simulation environment.13

Together, application of cognitive, metacognitive, psy-chomotor, and affective processes leads to sound and com-petent nursing practice. Although the concepts of criticalthinking, clinical reasoning, and clinical judgment are inter-related, there is no one way to measure their development,but rather a variety of tools and processes to facilitate and

assess their development. Measurable outcomes to assessthe development of critical thinking, clinical reasoning, andclinical judgment in nursing can only be achieved throughstrategies appropriately designed to individually evaluateeach of the processes used by the nurse to analyze (criticallythink), apply (clinically reason), and act (clinically judge).

Acknowledgment

The author thanks Dr Joan Such Lockhart, professor and asso-ciate dean for Academic Affairs, School of Nursing, DuquesneUniversity, for her guidance in preparing this article.

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11. Alfaro-LeFevre R. Critical Thinking in Nursing: A PracticalApproach. Philadelphia, PA: WB Saunders; 1995.

12. Tanner CA. Thinking like a nurse: a research-based model ofclinical judgment in nursing. J Nurs Educ. 2006;45(6):204-211.

13. Mariani B, Cantrall MA, Meakim C, Prieto P, Dreifuerst KT. Struc-tured debriefing and students’ clinical judgment abilities. ClinSimulat Nurs. 2012:e1-e9. PII: S1876-1399(11)00266-0. doi: 10.1016/j.ecns.2011.11.009.

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