Clarifying Definitions and Measures of Clinical Thinking: A Systematic Review

• In Event: Clarifying Assessment and Measurement Issues Across Disciplines and Professions

Abstract

Purpose
This research examines the definitions of terms and the instruments used to measure clinical thinking of health care providers.

Perspectives
The Institute of Medicine and the National Academics of Practice have urged health care providers to work collaboratively in the delivery of patient care. Evidence-based practice requires that education function with the same rigor of research as clinical practice. With this increased focus on evidence-based practice and interprofessional collaboration during education and clinical practice, an examination of recent research on terms and measurement instruments is needed.

Methods
A systematic review was conducted to answer the following question: What definitions and instruments to measure clinical thinking of nurses and doctors during patient care have been used in recent education research? Inclusion criteria were peer-reviewed, empirical journal articles published between 2006-2011 using the terms clinical reasoning(CR), problem solving(PS), critical thinking(CT), and case-based reasoning(CBR), searching the PsycInfo database. To focus on the evaluation of clinical thinking in practice, selection criteria required that included articles studied direct patient care, or education to provide patient care, in the health sciences and concerned the thinking of individual human health professionals (not computers), and that the research directly measured thinking, not dispositions, confidence or self-efficacy. The resulting pool of articles was the data source for this systematic review. IRB approval was not applicable.
Outcomes
In the studies reviewed, researchers examined practitioners at the student, newly licensed, and practicing providers levels of expertise. Teaching methods used included classroom assessment techniques, case studies, questions, group discussion, writing assignments, simulation, and clinical rounds. None of the studies conducted analysis of nurses and doctors in the same study. Analysis of the definitions used revealed differences in patterns of use. Nursing research studies tended to use “critical thinking” to describe clinical thinking, whereas studies of doctors or medical students tended to use the terms “clinical reasoning” or “problem solving”. No nursing studies using case-based reasoning were identified, and few in medicine. Many studies in both professions used the terms CT, CR, and PS interchangeably, and definitions were coded as explicit or implicit. More medical studies tended to use instruments that were with previously validated. Instruments used by the two professions included the California Critical Thinking Skills Test, the Health Sciences Reasoning Test, the Script Concordance Test, and teacher-researcher made instruments. The studies were rated for quality and wide variation was found.

Significance
This review showed that nursing studies of clinical thinking analyzed some aspects of care that are vital to patient-centered care, whereas the strength in medical studies was the robustness of instruments. Both suffered from definitional conflation. Poor communication and lack of respect have been identified as a barriers to interprofessional education. More consensus and transparency in term definition can lead to increased communication among health care educators and providers. Increased sharing of instruments and techniques could help break down this barrier. In conclusion, an understanding of differences in approaches to evaluating clinical thinking in different health professions is vital to the improvement of patient outcomes.

Author

• Lily Fountain, University of Maryland