By Nicole Fauteux
"Most people use critical thinking to
mean our best thinking," says Dr. Patricia E. Benner, Professor
Emerita, Department of Social and Behavioral Sciences at the
University of California, San Francisco. "That's not a bad thing,"
she adds. "They usually mean being sharp and not just making snap
judgments or acting in a rote way."
Nevertheless, she believes that critical thinking is just one of
several modes of thinking that skilled clinicians need. She would
add formal reasoning, diagnostic reasoning, clinical reasoning,
creative thinking, and deliberative rationality to the list. She
draws precise distinctions between these different modes of
"Does it help to be this picky and philosophical in the
education process?" she asks rhetorically. "I think it
does help," she replies. "I think clarifying all these
things is very helpful to students and sharpens their
Having spent decades as a professor of nursing, Dr. Benner has
given considerable thought to what's involved in teaching
clinicians how to think. Her experience is reflected in Educating Nurses: A Call for Radical Transformation,
part of the Preparation for the Professions series commissioned by
Foundation for the Advancement of Teaching. The report
recommends four fundamental shifts in how nursing is taught,
including a shift "[f]rom an emphasis on critical thinking to an
emphasis on clinical reasoning and multiple ways of thinking."
As lead author of the report, Dr. Benner took responsibility for
developing the rationale for this recommendation. It reads:
Critical thinking alone cannot develop students' perceptual
acuity or clinical imagination; and cynicism and excessive doubt
are often the by-product of the over-use of critical thinking.
Nurses need multiple ways of thinking, including clinical
reasoning-the ability to reason as a clinical situation changes,
taking into account the context and concerns of the patient and
family-helping nurses to capture a patient's trends and
trajectories. Clinical imagination, which requires students to
grasp the nature of patients' needs as they change over time, is
also needed, as well as critical, creative, and scientific
"In the Carnegie study, we looked at how people were teaching
critical thinking," Dr. Benner recalls. "We found they were really
very fuzzy about the language."
Not so Dr. Benner, who defines critical thinking as "the main
mode of thought in the scientific and enlightenment traditions-to
question the received view, to deconstruct what is given to you,
and rethink it and create something new."
This type of thinking can be invaluable, she points out, in
novel situations when the clinician encounters something that he or
she has never seen before or where the treatments applied are
giving substandard results. "Then you have to step back and rethink
the whole situation and engage in a very broad search of what this
could be," Dr. Benner explains. "You have to consciously leave
behind your usual assumptions. That's a really good use of critical
She also sees a place for critical thinking in evidence-based
practice, stressing its utility in helping students assess the
value of scientific research. Yet despite its importance, Dr.
Benner argues that critical thinking is not the mode of thinking
clinicians use regularly in their day-to-day practice.
"The real crux of all of this is that critical reasoning demands
a kind of stepping back from the situation and considering all the
elements and deconstructing what's going on," she says. "Well,
that's a bit of a problem in practice. You really need situated
thinking and engagement with the situation so you're very present
Dr. Benner advocates achieving situated thinking by placing more
emphasis on clinical reasoning in health professions curricula. She
defines this mode of thinking as "reasoning across time about
changes in the patient's condition or in the clinician's
understanding of the patient's condition."
She says that nursing education, like dental education, has room
to grow in drawing these distinctions and effectively training
students to engage in these various modes of thought. That said,
she reports that the Carnegie study has prompted discussion of
these issues among her colleagues. "They're working on it," she
says, "and they're beginning to see distinctions."
She is especially excited about the
new curriculum in place at the University
of Pennsylvania School of Nursing. The
curriculum emphasizes situated learning, meaning learning that
occurs in the context (or the simulated context) in which it will
be applied. For example, students are given unfolding case studies
that call on their knowledge of science and engage them in the
clinical reasoning over time that they will use every day in
"The agenda in higher education has been critical thinking,
questioning, sometimes to the point of cynicism," Dr. Benner
concludes. She hopes that soon the kind of situated contextual
thinking students need to develop as clinicians will be given
equal-if not more-time.