By Saiya Marshall
Professors all throughout nursing school talk endlessly about critical thinking and how
important it is to develop it as we become nurses. But rarely do they describe just exactly what
it is and the exact steps to get good at it. They are correct in saying that it truly is an important
part of the work we do as nurses. So, let’s talk break it down. In this post we talk about the first
foundational skill to start developing your critical thinking skills.
The central skill in critical thinking is having clinical grasp.
By the end of this article, you will be able to:
- Understanding what clinical grasp is
- Why you care about it
- Ways to start strengthening your clinical grasp
Put plainly, wrapping your mind around the clinical picture is called Clinical Grasp. It really is
that simple. But in real life, “Getting a Grip” isn’t always so straight forward, and that is why it’s
a skill that must be developed.
So why do we care about it? Because it orients you- think of it as your compass. Having clinical
grasp means you understand what is happening. And when you understand what is happening,
you can initiate interventions and act appropriately. Having clinical grasp will make or break
everything you do for that patient. That is why getting a grip is the first priority.
An expert nurse enters a clinical situation with the goal of gaining a good grasp on the situation.
Besides it being a safe thing to do, there are three main reasons why gaining clinical grasp
before you do anything else is imperative:
1) It gives you an understanding of the patient’s baseline, so that any deviation from that baseline can guide you to have clinical inquiry.
2) It puts your priorities into place, and makes your actions appropriate.
3) It will help you identify or predict/prevent problems (AKA having clinical forethought).
Those skills mentioned above are future skills that will be built on this foundation. What you
need to know is that they all require you to have a grasp on what is happening.
Pre-reqs for Gaining Clinical Grasp
What parts make up the skill of clinical grasp?
- Having theoretical background- Everything you are learning in nursing school
- Your mindset: Openness to being wrong and to change course of action as new things
develop
Three ways to start strengthening your clinical grasp
1) Get your story; your baseline.
Understanding the story of your patient is like reading a recipe for something you are
about to bake. You must get familiar with all the ingredients to start understanding how they
make up the big picture.
When you get report at the beginning of your shift, that will be the first story you come to
understand. Once you have that, personalize the story. That means take that story and go look
at your patient. Does what you were told make sense when you look at them in the bed, at the
machinery around them, at the vital signs on the monitor?
You may have had some questions or thoughts during report. Take a few minutes, if you can, to
dig around the chart to get things straight in your mind.
As you do your first assessment, actively think about everything you observe, and WHY its
present (crackles, murmurs, etc). Does that fit into your understanding of the story? Or is that
something new?
Getting report and doing your first assessment is very important, because the rest of your shift
will be based on your understanding of what is normal for this patient, and what isn’t.
2) Be present and apply yourself.
Sometimes we get into a bad habit of coasting through our shift. If you ever find yourself doing
that, STOP! Never, ever be on autopilot. We must get away from seeing our job as observers,
and to start interacting with the clinical picture.
To do that, train yourself to apply your senses (touch, sight, smell, sound, etc). Every detail
counts, especially in high-acuity settings like the ICU. And instead of gathering data for charting
purposes, gather it to create an understanding of the picture (both big and small).
Every occurrence or finding can point you in the right direction, if only you recognize it and
think about it. And to recognize it, you have to be aware, to be present. Has your urine output
dropped? Are your patient’s vital signs trending in the wrong direction? Are the lung sounds
changing? These subtle clues can lead to big discoveries- so put yourself in a position to see
them.
At the beginning, it might be overwhelming to think about all these things, but keep in mind:
critical thinking develops as your experience. Don’t worry about everything else. If you can SEE
and identify, the rest will follow.
3) Become a detective
Clinical grasp is not static: it is something you have to constantly CREATE in yourself as things
evolve. Going hand in hand with being present, train yourself to recognize when you don’t
understand something you are seeing.
The number one red flag that you have lost your clinical grasp is that you will realize something
doesn’t make sense, or does not align with your expectations. (“Hmm, his O2 Sats are dropping-
he’s never done that before…” or “I expected by now she would be more awake but she is still
hard to arouse…”).
This is a great thing to happen, because it will wake you up to look at something closer, to ask
questions, to figure out why something has changed or isn’t changing. Don’t ever take for
granted that something is transient or a one-time occurrence. There is a reason why that thing
happened. And it is your job to figure out why. From the time you get report at the beginning,
to when you give it at the end, you should always be asking questions, to be trying to
understand WHY, WHAT, and HOW.
Pro-Tip #1-
Think it out- When there is a change in clinical relevance, think it through and reason yourself
to an understanding. It may seem silly at first to sit there and tell yourself “Well, of course he is
acidotic: he is breathing 9 times a minute” But do it ANYWAY. You may start making
connections to other pictures of the puzzle as you talk it through with yourself.
For example, he isn’t breathing up to parr, he is acidotic and now you are seeing a lot more
ectopy on the monitor. Why is this happening? Is there a link to these things? Once you get a
clinical grasp of what is occurring, you will be able to act. Perhaps his respiratory rate needs to
be increased on the ventilator, perhaps his ectopy is from having a low potassium level because
of the acidosis, etc… These hypotheses will guide you to act and to address the acidosis and
hopefully prevent complications that are occurring (or will occur) as a result.
Pro-Tip #2-
Recognizing changing clinical Relevance-
It has happened to us all: one minute you think everything is just dandy, the next minute, the
whole world just fell apart. Sometimes changes for the worse do not have warnings. But a lot of
the times, they do.
Recognizing changing clinical relevance is built on the skill of being present and applying
yourself (as mentioned above). It also has to do with knowing what to expect from your patient
(both in specific patient populations AND your particular patient.) Having an expected clinical
trajectory AND being an astute observer, you will begin to recognize when something is going
well and when it isn’t.
For example: you gave 2 units of PRBCs for your patient with a Hgb of 6.3. You EXPECT that his
post-infusion Hgb will be around 8.3. So if it comes back at 5.8- that should be a red flag that
there has been a change in clinical relevance: If it comes back that low, he is likely having an
active bleed somewhere. Coming to that realization will switch all your priorities around
because now you have an actively bleeding patient with a pretty low hgb.
As you can see, having a clinical grasp is the anchor to your craft and expertise as a nurse. Your
ability to hone in on this skill is where we have immense impact, where we save lives and where
we can shape positive outcomes for our patients.
TL;DR-
Wrap your mind around the situation because otherwise you’re blind. This is called having
Clinical Grasp.
You need a good theoretical background and an open, attentive mind to get this grasp.
Three ways to get your grip on:
1) Know your patient’s story inside-and-out. Become the expert on your patient through you understanding of the evolving story.
2) Be present and attentive, don’t go on autopilot.
3) Channel your inner Sherlock Holmes and get answers to every question/confusion that arise in you as you observe the patient or situation.
BIO:
Saiya Marshall is a registered nurse turned freelance medical writer who loves helping future
nurses succeed. She holds a Bachelor of Science in Nursing and brings over a decade of hands-
on experience to her writing. Saiya now uses her clinical background to create helpful content
for nursing students and professionals. She balances writing with traveling, parenting her
energetic four-year-old and exploring new coffee shops. Saiya believes nursing is both a science
and an art—and she’s here to cheer you on every step of the way.