PURPOSE OF CRITICAL THINKING Critical thinking involves the differentiation of statements of fact, judgment… Mastery of the theory and research findings that relate to the problem or issue to be addressed is critical, but this is not something that nurses always take time to achieve. “Critical thinking is that mode of thinking—about any subject, content, or problem—in which the thinker improves the quality of his or her thinking by skillfully taking charge of the structures inherent in thinking and imposing intellectual standards upon them.” In the situation just mentioned, if the patient told the nurse, “I feel like a rock is crushing my chest,” the subjective data would substantiate the nurse’s observations (objective data) that the patient is having chest pain. An unstructured interview is commonly used in situations in which the nurse wishes to elicit information from the client’s perspective or gain insight to the client’s understanding of a problem. All of these changes have emphasized the need for professional nurses to think critically in order to provide safe and effective client care to diverse populations. • Describe the components and characteristics of critical thinking. CHAPTER 8 The nursing process serves as a tool for applying critical thinking to nursing practice. An early definition, proposed by Watson and Glaser (1964), described critical thinking as the combination of abilities needed to define a problem, recognize stated and unstated assumptions, formulate and select hypotheses, draw, Discriminating among use and misuse of language, Analyzing arguments and issues into premises and conclusions, Making and checking inferences based on data, Verifying, corroborating, and justifying claims, beliefs, conclusions, decisions, and actions, Giving relevant reasons for beliefs and conclusions, Formulating and clarifying value judgments, Seeking reasons, criteria, and principles that justify value judgments, Conflicting viewpoints exist regarding whether critical thinking is subject specific or generalizable (U.S. Department of Education, 1995). When you learn that the only seats available are near the back of the venue and cost $105.00 each, you decide to stay home, get a good night’s sleep before the big exam, and make a 98%. Your diagnosis is that Mr. Stevens has dysfunctional gastrointestinal motility. This expert statement, still widely used, was the culmination of 3 years of work by Facione and others who synthesized the work of numerous persons who had defined critical thinking. Meyers (1991) and McPeck (1990) believe that mastery of basic terms, concepts, and methodologies must occur before critical thinking skills can be developed. The interrelationships among these concepts are illustrated in Figure 9-1. In the practice of nursing, the nursing process represents a universal intellectual standard by which problems are addressed and solved. Care should be taken to record data factually and to avoid personal or biased interpretations. Easy-to-understand language and a "how-to" approach equip you to become a sensible, resilient critical thinker with the clinical reasoning skills you need to think think through complex issues … Subjective data are obtained from patients as they describe their needs, feelings, strengths, and perceptions of the problem. Mark a plus sign (+) next to those you now possess, mark IP (in progress) next to those you have partially mastered, and mark a zero (0) next to those you have not yet mastered. At the same time, the critical thinker monitors, corrects, and improves the judgment. Suspending judgment Identifying specific steps makes the process clear and concrete but can cause nurses to use them rigidly. OBJECTIVES Subjective data should include physical, psychosocial, and spiritual information. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. When it is in place, it is wonderful. In clinical settings, time to engage in deliberative critical thinking is even more difficult to attain. Rather, blind, noncritical obedience is the order of the day. According to Allen, Rubenfeld, and Scheffer (2004), the dimensions of creativity, intuition, and transforming knowledge that are so crucial to effective clinical practice were not included in the Delphi Report definition. The assurance that critical thinking will be truly woven into the fabric of our profession will depend on our ability to recruit and retain intelligent, interested, and committed nurses; to provide challenging educational opportunities that develop the requisite competencies; and to provide and sustain the kinds of environments in which critical thinking is valued and demanded. The nursing process is a systematic, problem-solving approach used extensively in the United States and Canada for the delivery of nursing care. Assessment usually begins by taking a nursing history and, Surgical and (if appropriate) obstetrical history, Genetics and Genomics in Professional Nursing, Ethical Dimensions of Nursing and Health Care, Historical Development of Professional Nursing in the United States, Health Policy and Planning and the Nursing Practice Environment, Conceptual Foundations The Bridge to Professional Nursing Practice, Combination of abilities needed to define problems, recognize assumptions, formulate and select hypotheses, draw conclusions, and judge validity of inferences, Reasonable reflective thinking focused on deciding what to believe or do, Process of self-disciplined, self-directed, rational thinking that verifies what we know and clarifies what we do not know, Purposeful, self-regulatory judgments resulting in interpretation, analysis, inference, evaluation, and explanation, Rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs, and actions, Informed, purposeful, and outcome-focused thinking that uses evidence to make clinical judgments. The current model closely resembles the Yura and Walsh model, but with the addition of a diagnostic component. Her approach was built around three interrelated spheres of nursing activity: care, core, and cure. Are comfortable with rethinking a procedure if patient needs require modification of the procedure, Have a better idea of suspected problems, allowing them to question more deeply and collect more relevant and in-depth data, Analyze standards and policies, looking for ways to improve them, Are challenged by novices’ questions, clarifying their own thinking when teaching novices, Critical thinking is a complex, purposeful, disciplined process that has specific characteristics that make it different from run-of-the-mill problem solving. Critical thinking in nursing is undergirded by the standards and ethics of the profession. • Understand the relationship of critical thinking to clinical judgment and the nursing process. This involves paying attention to how you think and making thinking itself a focus of concern. It combines developing CT skills with nurturing those dispositions that consistently yield useful insights and that are the basis of a rational and democratic society. So it is with critical thinking: novices think differently from experts. The unstructured interview allows the nurse to use active listening skills while building rapport with the client through the use of an open-ended interview format. Paul and Elder, 2012 Many clinical areas have developed nursing history and physical forms specific to the type of agency and the clients served. Brenda Morris, EdD, RN, CNE All of these changes have emphasized the need for professional nurses to think critically in order to provide safe and effective client care to diverse populations. Keep in mind that this is a process, that progression through the process may not be linear, and that it is a tool to use, not a road map to follow rigidly. ______ Willing to revise judgment when new evidence warrants During the past 20 years we have talked increasingly about critical thinking in nursing, but that wasn’t always the case. Defining “critical thinking” is a complex task that requires an understanding of how people think through problems. Her temperature remains at 37.8° C, and her pulse is 120. Introduction • Assessment—gathering and validating client health data, strengths, risks, and concerns CRITICAL THINKING AND THE NURSING PROCESS Based on my experience, I believe that two essential types of learning provide the basis for critical thinking. You listen to her chest and note that it is difficult to appreciate breath sounds due to the patient’s body habitus. For example, if a newly hospitalized patient is experiencing a great deal of pain, a novice nurse might proceed by asking family members to leave so that he or she can provide a quiet environment in which the patient may rest. The expert nurse, in addition to assessing the patient, is willing to consider alternative explanations and interventions, enhancing the possibility that the patient’s pain will be relieved. ], St. Louis: Mosby.) An example of subjective data occurs when the client states that he is having pain in his right ear. Bandman and Bandman (1995) Most of us don't think about how we think. It was hard work, but invigorating. Clearly, if one’s role is defined as handmaiden, rather than as colleague or independent decision maker, critical thinking is not deemed particularly important or even desirable. CT is essential as a tool of inquiry. Although many areas overlap with the American Philosophical Association’s (1990) Delphi Report definition of critical thinking, some important differences also exist. Data collection centers on the use of multiple sources and types of data, a variety of data collection techniques, and the use of reliable and valid measurement instruments. An unstructured interview is commonly used in situations in which the nurse wishes to elicit information from the client’s perspective or gain insight to the client’s understanding of a problem. You then realize that with such a good grade on this exam, you will have much less pressure when studying for the final exam at the end of the semester. Contrast the characteristics of “novice thinking” with those of “expert thinking.”. Nurses also use their critical thinking skills to reduce health care errors and improve client safety (Fero, Witsberger, Wesmiller, Zullo, & Hoffman, 2008). Regardless of the format, the nursing database should include the following categories of information (Edelman & Mandle, 1994): • Surgical and (if appropriate) obstetrical history, Only gold members can continue reading. Objective data are often called signs. When you are finished, make a plan for developing the areas that need improvement. • Define critical thinking. A nurse’s ability to think critically about a patient’s particular needs and how best to meet them will determine the extent to which a patient benefits from the nurse’s care. This model is consistent with the concept of critical thinking as a continuous reflective process. The answer is very simple: excellent critical thinking skills are required for you to make good clinical judgments. • Verifying, corroborating, and justifying claims, beliefs, conclusions, decisions, and actions Analyzing and integrating information across an increasing number of sources of knowledge requires that you have flexible intellectual skills. We understand critical thinking (CT) to be purposeful, self-regulatory judgment that results in interpretation, analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment is based. Tend to store knowledge in a highly organized and structured manner, making recall of information easier. The nursing process was first described in the literature in 1955 by Lydia Hall. The second type of learning involves the process of critical thinking itself. Objective data are often called signs. One of my most exciting opportunities to engage in intense and prolonged critical thinking occurred when a group of four colleagues and I were “freed up” from many of our routine responsibilities to plan a doctoral program “from scratch.” In weekly full-day sessions we argued, debated, challenged, cajoled, compromised, and created. A nurse who is exercising critical thinking asks the following questions: “What assumptions have I made about this patient?” “How do I know my assumptions are accurate?” “Do I need any additional information?” and “How might I look at this situation differently?” The Delphi project produced the following consensus definition from its panel of experts: We understand critical thinking (CT) to be purposeful, self-regulatory, judgment which results in interpretation, analysis, evaluation, and inference, as well as explanation of evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment is based. Commonalities in definitions include an emphasis on knowledge, cognitive skills, beliefs, actions, problem identification, and consideration of alternative views and possibilities (Daly, 1998). The nursing process as a method of clinical problem solving is taught in schools of nursing across the United States, and many states refer to it in their nurse practice acts. Keywords clinical reasoning, critical thinking, simulation, undergraduate, nursing students, nursing education, clinical judgment The demands of contemporary nursing practice necessitate clinical reasoning and decision making at a level never before experienced within the profession ( del Bueno, 2005 ; Shinnick, Woo, & Mentes, 2011 ). Data collection centers on the use of multiple sources and types of data, a variety of data collection techniques, and the use of reliable and valid measurement instruments. Understand the relationship of critical thinking to clinical judgment and the nursing process. Focuses on what to believe and do The expert nurse, in addition to assessing the patient, is willing to consider alternative explanations and interventions, enhancing the possibility that the patient’s pain will be relieved. ______ Honest about personal biases/self-aware Certainly the nursing process can be taught, learned, and used in a rigid, mechanistic, and linear manner. • Have a better idea of suspected problems, allowing them to question more deeply and collect more relevant and in-depth data For example, professional nurses apply critical thinking skills to client care situations in order to make sound clinical judgments, whereas engineers apply critical thinking skills to business or industrial situations in order to make sound decisions. The Delphi research project used an expert panel of theoreticians representing several disciplines from the United States and Canada to develop a conceptualization of critical thinking from a broad perspective (Facione, 1990). • Analysis/diagnosis—processing client data and identifying appropriate nursing diagnoses The American Nurses Association (ANA), in its publication Nursing: Scope and Standards of Practice (2004), parallels the steps of the nursing process and supports its use. To strengthen the overall assessment and validate client data, it is important to use primary and secondary data sources. You must be able to describe how you came to a conclusion and support your conclusions with explicit data and rationales. In the early 1960s, when I was entering the profession, serious efforts to change the “handmaiden” image of nursing were only just beginning. (Modified from Christensen, P. J., & Kenney J. W. [1995]. Assessment is the initial phase or operation in the nursing process. So what does this have to do with nursing? A nurse’s ability to use a reliable cognitive approach is crucial in determining a patient’s priorities for care and in making sound clinical decisions in addressing those priorities. The focal point in the core sphere was on the therapeutic use of self in providing nursing care, whereas nursing activities related to the cure sphere centered on the administration of treatments and therapies, as well as supporting the patient and family during the treatment process. Although critical thinking skills are important components of the nursing process and problem solving, these are not synonymous terms. Explain the differences between independent, interdependent, and dependent nursing actions. You will be responsible and accountable for your own decisions as a professional nurse. Nurses obtain two types of data about and from patients: subjective and objective. She is to be discharged home on postoperative day 2, as per the usual protocol. To function effectively in complex, rapidly changing health care environments, nurses must use higher-order thinking skills and apply content knowledge to clinical practice. • Allergies For example, if a newly hospitalized patient is experiencing a great deal of pain, a novice nurse might proceed by asking family members to leave so that he or she can provide a quiet environment in which the patient may rest. Her approach was built around three interrelated spheres of nursing activity: care, core, and cure. Qualitative studies have shown that the use of intuition in making clinical nursing judgments is an important part of the critical thinking process. Defining “critical thinking” is a complex task that requires an understanding of how people think through problems. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Nursing process: A critical thinking approach (2nd ed.). As a nurse, what areas of the nursing process do you think might be more challenging to you given the critical thinking and clinical judgment skills you have now? Not inconsequentially, the school was in a small liberal arts institution, where we were exposed on a daily basis to a wide range of points of view and disciplinary perspectives and assumptions. The clinical environment in which I have seen critical thinking encouraged most effectively was one in which the expectations were explicit, critical thinking was measured routinely in the practice context, relevant learning and growth opportunities were provided, and critical thinking was taken into account in performance evaluation. Identifying arguments This model is consistent with the concept of critical thinking as a continuous reflective process. Examples of subjective data are statements such as, “I am in pain” and “I don’t have much energy.” The only source for these data is the patient. Ennis (1987) agrees that some familiarity with subject matter is necessary for the development of critical thinking; however, some principles of critical thinking bridge many disciplines and can transfer to new situations. Critical thinking in nursing which includes clinical reasoning and clinical judgment is purposeful, informed, outcome-focused thinking that is guided by standards, policies, ethics codes, and laws. Are you SUPER confused on what critical thinking means in nursing school? Process of self-disciplined, self-directed, rational thinking that verifies what we know and clarifies what we do not know Oct 26, 2016 | Posted by admin in NURSING | Comments Off on Critical Thinking, Clinical Judgment, and the Nursing Process. Being a good critical thinker makes you more adaptable in this new economy of knowledge (Lau and Chan, 2012). However, the difference lies in how the critical thinking processes are applied to specific disciplines. Most authors agree that the critical thinking processes are not discipline specific but, rather, are generalizable (Ennis, 1987; Facione, 1990; Paul, 1992; Watson & Glaser, 1964). These four steps are: It is important to note that based on Tanner’s model, the nurse must be able to USE knowledge in order to NOTIC… You are faced with weighing a number of factors that will influence your decision about whether to go see the band: your grade going into the exam; how late you will be out the night before the exam; how far you will have to drive to see the band; and how much study time you will have to prepare for the exam in advance. • Define clinical judgment in nursing practice and explain how it is developed. • Current medications So what does this have to do with nursing? That study resulted in the identification of 17 dimensions of critical thinking and agreement on the definition of critical thinking for nursing as: … an essential component of professional accountability and quality nursing care. Involves conceptualization An excellent website on critical thinking can be found at philosophy.hku.hk/think/ (OpenCourseWare on critical thinking, logic, and creativity). Critical thinking skills provide you with a powerful means of determining patient needs, interpreting physician orders, and intervening appropriately. These activities are embedded in the critical thinking process in both nursing education and nursing practice. Upper Saddle River, NJ: Prentice-Hall. The variety of definitions helps provide insight into the myriad dimensions of critical thinking. Unfortunately, we have been less successful than other professions (namely, medicine) in socializing our practitioners to value learning as a career-long pursuit; yet pursuit of the most state-of-the-science information is an essential ingredient of critical thinking. Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Click to share on Google+ (Opens in new window) This is known as reflective thinking. Planning Categorizing data Box 8-2 presents an example of the importance of critical thinking in the provision of safe care. Overview of Critical Thinking Throughout the Nursing Process, Distinguishing relevant from irrelevant data, Distinguishing important from unimportant data, Transferring knowledge from one situation to another, Making criterion-based evaluations and judgments. This organization, which recently celebrated its 40th year, is now known as. Bonnie M. Wivell, MS, RN, CNS; 2 Defining Critical Thinking. The focal point in the core sphere was on the therapeutic use of self in providing nursing care, whereas nursing activities related to the cure sphere centered on the administration of treatments and therapies, as well as supporting the patient and family during the treatment process. Although an argument can be made that the nursing process constrains critical thinking because of its structured format, general agreement exists that critical thinking skills and subskills are evident throughout the nursing process (Alfaro-LeFevre, 2006). • Evaluate the utility of the nursing process as a systematic framework for the delivery of nursing care. When it is in place, it is wonderful. The nursing process was first described in the literature in 1955 by Lydia Hall. Continuing one’s education through lifelong learning is an excellent way to maintain and enhance your critical thinking skills. To get a clearer picture of the patient’s situation, the nurse should use the best communication skills he or she possesses to increase the patient’s trust, which will result in more openness. Making clinical nursing judgements is central to the practice of nursing, and critical thinking skills are essential to making clinical judgments. Bandman and Bandman (1995) describe critical thinking for nursing as “the rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs, and actions” (p. 7) and include the following functions: • Discriminating among use and misuse of language, • Analyzing arguments and issues into premises and conclusions, • Making and checking inferences based on data, • Verifying, corroborating, and justifying claims, beliefs, conclusions, decisions, and actions, • Giving relevant reasons for beliefs and conclusions, • Formulating and clarifying value judgments, • Seeking reasons, criteria, and principles that justify value judgments, • Evaluating the soundness of conclusions. Defining Critical Thinking Almost every encounter a nurse has with a patient is an opportunity for the nurse to assist the patient to a higher level of wellness or comfort. Without labeling the goal as such, we were consistently encouraged, groomed, and enabled to be critical thinkers. The variety of definitions helps provide insight into the myriad dimensions of critical thinking. A nurse who is exercising critical thinking asks the following questions: “What assumptions have I made about this patient?” “How do I know my assumptions are accurate?” “Do I need any additional information?” and “How might I look at this situation differently?”. At first frightened by that kind of candor during my doctoral studies in sociology, I later came to value greatly the critical input of my peers. The answer is very simple: excellent critical thinking skills are required for you to make good clinical judgments. Upper Saddle River, NJ: Prentice-Hall.) Consciously developed to improve patient outcomes, critical thinking by the nurse is driven by the needs of the patient and family. To get a clearer picture of the patient’s situation, the nurse should use the best communication skills he or she possesses to increase the patient’s trust, which will result in more openness. Lack knowledge gained from actually doing (e.g., listening to breath sounds). ______ Open-minded You are faced with weighing a number of factors that will influence your decision about whether to go see the band: your grade going into the exam; how late you will be out the night before the exam; how far you will have to drive to see the band; and how much study time you will have to prepare for the exam in advance. A less prescriptive definition was offered by Ennis (1989), who characterized critical thinking as “reasonable reflective thinking focused on deciding what to believe or do” (p. 4). Observation provides a variety and depth of data that may be difficult to obtain by other methods. What elements converge to produce a good critical thinker? Such time away from the routine is rarely available in today’s environment, but the model is certainly not without merit. • Physical assessment This diagnosis is based on NANDA-I’s taxonomy because you have determined that the risk factors and physical signs and symptoms associated with this diagnosis apply to him. An example of objective data that a nurse might gather includes the observation that the patient, who is lying in bed, is diaphoretic, pale, and tachypneic, clutching his hands to his chest. As you move from novice to expert, your ability to think critically will improve with practice. Educators and philosophers struggled with definitions of critical thinking for several decades. From Wilkinson, J. M. (2001). Outcome identification, which follows the nursing diagnosis phase and precedes the planning phase, is identified as a separate step in the ANA model. Although she describes herself as “not feeling well at all,” the physician writes the order for discharge and you, as the nurse who does postoperative discharge planning for the surgery practice, prepare Ms. George to go home with her new dietary guidelines and encouragement for her successful weight loss. Nursing has reached the point in its evolution in which a consistent and continuous pattern of critical thinking by its practitioners is a mandate—a, The ability to process information from multiple sources and make decisions is a fundamental ability of professional nursing practice. Suppose your favorite band is performing in a nearby city the night before your big exam in pathophysiology. These activities are embedded in the critical thinking process in both nursing education and nursing practice. Thus educating good critical thinkers means working toward this ideal. Currently, NANDA-I has more than 200 diagnoses approved for clinical testing and has recently added 16 new diagnoses and 8 revised diagnoses. Measurement is used to determine the dimensions of a given indicator (e.g., blood pressure) or to ascertain characteristics such as quantity, size, or frequency. Nurses are critical thinkers. You note that Ms. George does not seem as comfortable or pleased with her surgery as most patients with whom you have worked in the past. Subjective data are often referred to as symptoms. Making criterion-based evaluations and judgments It’s basically stopping, looking at a situation, identifying a solution and trying it out. A less prescriptive definition was offered by. Nursing has reached the point in its evolution in which a consistent and continuous pattern of critical thinking by its practitioners is a mandate—a sine qua non. The interactive nature of the model with its feedback mechanism permits the nurse to reenter the nursing process at the appropriate stage to collect additional data, restructure nursing diagnoses, design a new plan, or change implementation strategies. A less prescriptive definition was offered by Ennis (1989), who characterized critical thinking as “reasonable reflective thinking focused on deciding what to believe or do” (p. 4). ______ Diligent in seeking information Overview of Critical Thinking Throughout the Nursing Process Objective data are the other types of data that the nurse will collect through observation, examination, or consultation with other health care providers. She instructs you to have Ms. George force fluids to the extent that she can tolerate it, and to take mild pain medication for postoperative pain.

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