Critical Thinking and the Nursing Process LEARNING OUTCOMES After completing this chapter, you will be able to: 1. Discuss the skills and attitudes of critical thinking. 2. Describe the significance of developing critical-thinking abilities in order to practice safe, effective, and professional nursing care. 3. Discuss the relationships among the nursing process, critical thinking, the problem-solving process, and the decision-making process. 4. Explore ways of demonstrating critical thinking. KEY TERMS creativity, 163 critical analysis, 164 critical thinking, 163 decision making, 168 deductive reasoning, 164 inductive reasoning, 164 intuition, 168 nursing process, 167 problem solving, 167 Socratic questioning, 164 INTRODUCTION Although critical thinking has many definitions, one of the most useful for nursing is from the National League for Nursing (2000): "Critical thinking in nursing practice is a discipline specific, reflective reasoning process that guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns" (p. 2). Nurses are expected to use critical thinking to solve client problems and make better decisions. Thus, critical thinking, problem solving, and decision making are interrelated processes, with creativity enhancing the result. CRITICAL THINKING Critical thinking is essential to safe, competent, skillful nursing practice. The amount of knowledge that nurses must use and the continuing rapid growth of this knowledge prevent nurses from being effective practitioners if they attempt to function with only the information acquired in school or outlined in books. Decisions that nurses must make about client care and about the distribution of limited resources force them to think and act in areas where there are neither clear answers nor standard procedures and where conflicting forces turn decision making into a complex process. Nurses therefore need to embrace the attitudes that promote critical thinking and master criticalthinking skills in order to process and evaluate both previously learned and new information. Box 101 lists some reasons supporting the importance of critical thinking. Nurses use critical-thinking skills in a variety of ways: • Nurses use knowledge from other subjects and fields. Because nurses deal holistically with human responses, they must draw meaningful information from other subject areas (i.e., make interdisciplinary connections) in order to understand the meaning of client data and to plan effective interventions. Nursing students take courses in the biologic and social sciences and in the humanities so that they can acquire a strong foundation on which to build their nursing knowledge and skill. For

example, the nurse might use knowledge from nutrition, physiology, and physics to promote wound healing and prevent further injury to a client with a pressure ulcer. • Nurses deal with change in stressful environments. Nurses work in rapidly changing situations. Treatments, medications, and technology change constantly, and a client's condition may change from minute to minute. Routine actions may therefore not be adequate to deal with the situation at hand. Familiarity with the routine for giving medications, for example, does not help the nurse deal with a client who is frightened of injections or with one who does not wish to take a medication. When unexpected situations arise, critical thinking enables the nurse to recognize important cues, respond quickly, and adapt interventions to meet specific client needs. • Nurses make important decisions. During the course of a workday, nurses make vital decisions of many kinds. These decisions often determine the well-being of clients and even their very survival, so it is important that the decisions be sound. Nurses use critical thinking to collect and interpret the information needed to make decisions. Nurses must use good judgment, for example, to decide which observations must be reported to the primary care provider immediately and which can be noted in the client record for the primary care provider to address later, during a routine visit with the client. Creativity is a major component of critical thinking. When nurses incorporate creativity into their thinking, they are able to find unique solutions to unique problems. Creativity is thinking that results in the development of new ideas and products. Creativity in problem solving and decision making is the ability to develop and implement new and better solutions. Creativity is required when the nurse encounters a new situation or a client situation in which traditional interventions are not effective. For example, a pediatric home health nurse is caring for a 9-year-old girl who has ineffective respirations following abdominal surgery. The primary care provider has ordered incentive spirometry (a treatment device that promotes alveolar expansion). The child is frightened by the equipment and tires quickly during the treatments. The nurse offers her a bottle of blow bubbles and a blowing wand. She is delighted with blowing bubbles. The nurse knows that the respiratory effort in blowing bubbles will promote alveolar expansion and suggests that she blow bubbles between incentive spirometry treatments.

BOX 10-1

Top 10 Reasons to Improve Thinking

10. Things aren't what they used to be or what they will be. 9. Patients are sicker, with multiple problems. 8. More consumer involvement (patients and families). 7. Nurses must be able to move from one setting to another. 6. Rapid change and information explosion requires us to develop new learning and workplace skills. 5. Consumers and payers demand to see evidence of benefits, efficiency, and results. 4. Today's progress often creates new problems that can't be solved by old ways of thinking. 3. Redesigning care delivery and nursing curricula is useless if students and nurses don't have the thinking skills required to deal with today's world. 2. It can be doneit doesn't have to be that difficult. 1. Your ability to focus your thinking to get the results you need can make the difference between whether you succeed or fail in this fast-paced world. Note: Reprinted from Critical Thinking in Nursing: A Practical Approach 3rd ed., R. Alfaro-LeFevre, Copyright 2004, with permission from Elsevier.

Creative thinkers must have knowledge of the problem. They must have assessed the present problem and be knowledgeable about the underlying facts and principles that apply. For example, in the previous situation, the nurse knows the anatomy and physiology of respiratory function and is aware of the purpose of incentive spirometry. The nurse also understands pediatric growth and development.

In trying to assist the child, the nurse builds on this knowledge and comes up with a creative solution. Using creativity, nurses • Generate many ideas rapidly. • Are generally flexible and natural; that is, they are able to change viewpoints or directions in thinking rapidly and easily. • Create original solutions to problems. • Tend to be independent and self-confident, even when under pressure. • Demonstrate individuality. SKILLS IN CRITICAL THINKING Complex mental processes such as analysis, problem solving, and decision making require the use of cognitive critical-thinking skills. These skills include critical analysis, inductive and deductive reasoning, making valid inferences, differentiating facts from opinions, evaluating the credibility of information sources, clarifying concepts, and recognizing assumptions. Critical analysis is the application of a set of questions to a particular situation or idea to determine essential information and ideas and discard superfluous information and ideas. The questions are not sequential steps; rather, they are a set of criteria for judging an idea. Not all questions will need to be applied to every situation, but one should be aware of all the questions in order to choose those questions appropriate to a given situation. Socrates (born about 470 BC) was a Greek philosopher who developed the Socratic method of posing a question and seeking an answer. Box 10-2 lists Socratic questions to use in critical analysis. Socratic questioning is a technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes. Nurses should employ Socratic questioning when listening to an end-of-shift report, reviewing a history or progress notes, planning care, or discussing a client's care with colleagues. Two other critical-thinking skills are inductive and deductive reasoning. In inductive reasoning, generalizations are formed from a set of facts or observations. When viewed together, certain bits of information suggest a particular interpretation. Inductive reasoning moves from specific examples (premises) to a generalized conclusionfor example, after touching several hot flames (premise), we conclude that all flames are hot. A nurse who observes a client who has dry skin, poor turgor, sunken eyes, and dark amber urine and who is otherwise determined to be dehydrated (premise) concludes that the presence of those signs indicate that other clients are dehydrated.

BOX 10-2

Socratic Questions

QUESTIONS ABOUT THE QUESTION (OR PROBLEM) • Is this question clear, understandable, and correctly identified? • Is this question important? • Could this question be broken down into smaller parts? • How might ___________ state this question? QUESTIONS ABOUT ASSUMPTIONS

• You seem to be assuming ___________; is that so? • What could you assume instead? Why? • Does this assumption always hold true? QUESTIONS ABOUT POINT OF VIEW • You seem to be using the perspective of ___________. Why? • What would someone who disagrees with your perspective say? • Can you see this any other way? QUESTIONS ABOUT EVIDENCE AND REASONS • What evidence do you have for that? • Is there any reason to doubt that evidence? • How do you know? • What would change your mind? QUESTIONS ABOUT IMPLICATIONS AND CONSEQUENCES • What effect would that have? • What is the probability that will actually happen? • What are the alternatives? • What are the implications of that?

Deductive reasoning, by contrast, is reasoning from the general premise to the specific conclusion. If you begin with the premise that the sum of the angles in any triangle is always 180 degrees, you can then conclude that the sum of the angles in the triangle you happen to have is also 180 degrees. A nurse might start with a premise that all children love peanut butter sandwiches. If the client is a child, then the child will love peanut butter sandwiches. This is an example in which the premise is not always valid and, thus, the conclusion also may not be valid. Nurses use critical thinking to help analyze situations and establish which premises are valid. In critical thinking, the nurse also differentiates statements of fact, inference, judgment, and opinion. Table 10-1 shows how these may be applied to a client. Evaluating the credibility of information sources is an important step in critical thinking. Unfortunately, we cannot always believe what we read or are told. The nurse may need to ascertain the accuracy of information by checking other documents or with other informants. To comprehend a client situation clearly, the nurse and the client must agree on the meaning of terms. For example, if the client says to the nurse "I think I have a tumor," the nurse needs to clarify what this word means to the client medical definition of tumor (a solid mass) or the common lay the meaning of cancerbefore responding.

Persons also live their lives under certain assumptions. Some people view humans as having a basically generous nature whereas others believe that the human tendency is to act in their own best interest. The nurse may believe that life should be considered worth living no matter what the condition whereas the client believes that quality of life is more important than quantity of life. If they recognize that they make choices based on these assumptions, they can still work together toward an acceptable plan of care. Difficulty arises when people do not take the time to consider what assumptions underlie their beliefs and actions. ATTITUDES THAT FOSTER CRITICAL THINKING Certain attitudes are crucial to critical thinking. These attitudes are based on the assumption that a rational person is motivated to develop, learn, and grow. A critical thinker works to develop the following attitudes or traits: independence, fair-mindedness, insight, intellectual humility, intellectual courage, integrity, perseverance, confidence, and curiosity. Independence Critical thinking requires that individuals think for themselves. People acquire many beliefs as children, not necessarily based on reason but in order to have an explanation they comprehend. As they mature and acquire knowledge and experience, critical thinkers examine their beliefs in the light of new evidence. Critical thinkers consider seriously a wide range of ideas, learn from them, and then make their own judgments about them. Nurses are open-minded about considering different methods of performing technical skills just the single way they may have been taught in school. They are not not easily swayed by the opinions of others but take responsibility for their own views (Catalano, 2003). Fair-Mindedness Critical thinkers are fair-minded, assessing all viewpoints with the same standards and not basing their judgments on personal or group bias or prejudice (Catalano, 2003). Fair-mindedness helps one to consider opposing points of view and to try to understand new ideas fully before rejecting or accepting them. Critical thinkers strive to be open to the possibility that new evidence could change their minds. The nurse listens to opinions of all the members of a family, young and old. Insight into Egocentricity Critical thinkers are open to the possibility that their personal biases or social pressures and customs could unduly affect their thinking. They actively try to examine their own biases and bring them to awareness each time they think or make a decision. For example, a nurse spends extensive time trying to teach a client how to prevent a future recurrence of some problem but is mystified when the client appears uninterested and does not follow the nurse's advice. The nurse's egocentric tendency to assume that all clients are motivated and interested in preventive care (just because the nurse is) resulted in an inaccurate assessment of the client's desire to learn; both the nurse's and the client's time was wasted. Had the nurse assessed the client's background and beliefs about the problem and collected sufficient evidence, the nurse might have identified a problem more relevant to the client's priorities and, thus, developed a better care plan. Intellectual Humility Intellectual humility means having an awareness of the limits of one's own knowledge. Critical thinkers are willing to admit what they do not know; they are willing to seek new information and to rethink their conclusions in light of new knowledge. They never assume that what everybody believes to be right will always be right, because new evidence may emerge. A hospital nurse might be unable to imagine how the elderly wife will care for her husband who has recently had a stroke. However, the nurse also recognizes that it is not really possible to know what the couple can achieve.

Intellectual Courage to Challenge the Status Quo and Rituals With an attitude of courage, one is willing to consider and examine fairly one's own ideas or views, especially those to which one may have a strongly negative reaction. This type of courage comes from recognizing that beliefs are sometimes false or misleading. Values and beliefs are not always acquired rationally. Rational beliefs are those that have been examined and found to be supported by solid reasons and data. After such examination, it is inevitable that some beliefs previously held to be true will be found to contain questionable elements and that some truth will emerge from ideas considered dangerous or false. Courage is needed to be true to new thinking in such cases, especially if social penalties for nonconformity are severe. As an example, previously many nurses believed that allowing family members to observe an emergency (such as cardiopulmonary resuscitation) would be psychologically harmful to the family and that members would get in the health care team's way. Others felt that blanket exclusion of family members was unnecessary and extremely stressful for some of them. As a result, nurses initiated research that has demonstrated that family presence can be accomplished without detrimental effects to the nurse, the client, or the family. Integrity Intellectual integrity requires that individuals apply the same rigorous standards of proof to their own knowledge and beliefs as they apply to the knowledge and beliefs of others. Critical thinkers question their own knowledge and beliefs as quickly and thoroughly as they challenge those of another. They are readily able to admit and evaluate inconsistencies within their own beliefs and between their own beliefs and those of another. A nurse might believe that wound care always requires sterile technique. Reading a new article on the use and outcomes of clean technique for some wounds leads the critically thinking nurse to reconsider. Perseverance Nurses who are critical thinkers show perseverance in finding effective solutions to client and nursing problems. This determination enables them to clarify concepts and sort out related issues, in spite of difficulties and frustrations. Confusion and frustration are uncomfortable, but critical thinkers resist the temptation to find a quick and easy answer. Important questions tend to be complex and confusing and therefore often require a great deal of thought and research to arrive at an answer. The nurse needs to continue to address the issue until it is resolved. For example, the nurses on a unit have tried to establish a policy for selected clients to leave the hospital on a pass rather than have to be discharged and readmitted in the same day. The need for involvement of nursing, medical, administrative, and accounting staff gradually generates solutions to obstacles. The development of the policy moves forward, although very slowly. Confidence Critical thinkers believe that well-reasoned thinking will lead to trustworthy conclusions. Therefore, they cultivate an attitude of confidence in the reasoning process and examine emotion-laden arguments using the standards for evaluating thought, by asking questions such as these: Is that argument fair? Is it based on sufficient evidence? Consider nurses attempting to determine the best way to allocate holiday time off for staff. Should they go by seniority, use random selection (lottery), give preference to those who have children, use "first-come, first-served," or use another method? The critical thinker develops skill in both inductive reasoning and deductive reasoning. As the nurse gains greater awareness of the thinking process and more experience in improving such thinking, confidence in the process will grow. This nurse will not be afraid of disagreement and indeed will be concerned when others agree too quickly. Such a nurse can serve as a role model to colleagues, inspiring and encouraging them to think critically as well. Curiosity

The mind of a critical thinker is filled with questions: Why do we believe this? What causes that? Does it have to be this way? Could something else work? What would happen if we did it another way? Who says that is so? The curious nurse may value tradition but is not afraid to examine traditions to be sure they are still valid. The nurse may, for example, apply these questions to the issue of moving responsibility for a procedure such as the drawing of arterial blood samples among the nursing, respiratory therapy, or laboratory department staff. STANDARDS OF CRITICAL THINKING How can one know whether one's thinking is critical thinking? Paul and Elder (2005) proposed that thinkers can use universal standards, shown in Table 10-2. Explicitly stating the standards for critical thinking promotes the reliability and validity of the thinking and thus makes appropriate action more likely. Forneris (2004), building on the work of many modern educational theorists, described core attributes of critical thinking: reflection, context, dialogue, and time. Reflection involves determining what data are relevant and making connections between that data and the decisions reached. Context is an essential consideration in nursing since care must always be individualized, taking knowledge and applying it to real people. Dialogue, which need not involve other persons, refers to the process of serving as both teacher and student in learning from situations, questioning, making connections, and determining motivation. Finally, the attribute of time emphasizes the value of using past learning in current situations that then guide future actions. APPLYING CRITICAL THINKING TO NURSING PRACTICE Nurses function effectively some part of every day without thinking critically. Many small decisions are based primarily on habit with minimal thinking involved; examples include selecting what uniform to wear, choosing which route to take to work, and deciding what to eat for lunch. Psychomotor skills in nursing often involve minimal thinking, such as operating a familiar piece of equipment. However, the higher order skills of critical thinking are put into play as soon as a new idea is encountered or a less-than-routine decision must be made. The nursing process is a systematic, rational method of planning and providing individualized nursing care. The phases of the nursing process assessing, diagnosing, planning, implementing, and evaluatingare discussed in detail in the chapters that follow. The phases of the nursing process and application to a clinical example of critical thinking are shown in Table 10-3. This demonstrates the use of critical thinking with individual clients. In addition, a nurse employs critical thinking when setting priorities for the day. When analyzing a situation and planning strategies for conflict resolution or change, the nurse manager uses critical-thinking attitudes and skills. The nurse clinician and nurse manager seek awareness of their thinking as they are thinking, as they apply standards for thinking, and as their thinking progresses. Nurses use critical thinking in nursing practice primarily when solving problems and making decisions. These two processes are described in more detail. Problem Solving In problem solving, the nurse obtains information that clarifies the nature of the problem and suggests possible solutions. The nurse then carefully evaluates the possible solutions and chooses the best one to implement. The situation is carefully monitored over time to ensure its initial and continued effectiveness. The nurse does not discard the other solutions but holds them in reserve in the event that the first solution is not effective. The nurse may also encounter a similar problem in a different client situation where an alternative solution is determined to be the most effective. Therefore, problem solving for one situation contributes to the nurse' s body of knowledge for problem solving in similar situations. Commonly used approaches to problem solving include trial and error, intuition, the research process, and the scientific/modified scientific method.

Trial and Error One way to solve problems is through trial and error, in which a number of approaches are tried until a solution is found. However, without considering alternatives systematically, one cannot know why the solution works. Trial-and-error methods in nursing care can be dangerous because the client might suffer harm if an approach is inappropriate. However, nurses often use trial and error in the home setting where, due to logistics, equipment, and client lifestyle, hospital procedures cannot work as effectively (e.g., there may be no pole from which to hang an IV bag or no electricity to plug in a device).

REAL WORLD PRACTICE When you hear the words, "critical thinking" many things enter your mind. It is more than just having the knowledge or psychomotor skill to do a task. In client care, it is the ability to recognize deviations from normal, the ability to prioritize, manage those deviations, and justify your actions. Traditionally, technical skills were considered the only measure of competency. That is no longer true. The key to critical thinking is to use strategies that focus on your thought process to make decisions. Using critical thinking skills in the nursing process, you need to assess, identifying any risk factors; diagnose, including analyzing data, predicting any potential problems, and diagnosing any actual problems; plan your client care; and implement appropriate interventions; reassess, and finally evaluate each problem, determining if the interventions are effective to the desired outcome. Ask yourself the following questions: What are the potential problems for this client and why? What would you do about these problems if they should occur? How would you prioritize and why? Critical thinking ability is developed over time through many experiences. With the complexity of client care today and increasing all the time, the need to use critical thinking is crucial in the nursing world. The key area for development of new graduates is urgency and problem management. Both require coaching, mentoring and time for the development of critical thinking skills. Jan Knudsen MSN, RN, Saint Elizabeth Regional Medical Center Lincoln, NE

Intuition Intuition is the understanding or learning of things without the conscious use of reasoning. It is also known as sixth sense, hunch, instinct, feeling, or suspicion. As a problem-solving approach, intuition is viewed by some people as a form of guessing and, as such, an inappropriate basis for nursing decisions. However, others view intuition as an essential and legitimate aspect of clinical judgment acquired through knowledge and experience. The nurse must first have the knowledge base necessary to practice in the clinical area and then use that knowledge in clinical practice. Clinical experience allows the nurse to recognize cues and patterns and begin to reach correct conclusions. Experience is important in improving intuition because the rapidity of the judgment depends on the nurse having seen similar client situations many times before. Sometimes nurses use the words "I had a feeling" to describe the critical-thinking element of considering evidence. These nurses are able to judge quickly which evidence is most important and to act on that limited evidence. Nurses in critical care often pay closer attention than usual to a client when they sense that the client's condition could change suddenly.

Although the intuitive method of problem solving is gaining recognition as part of nursing practice, it is not recommended for novices or students, however, because they usually lack the knowledge base and clinical experience on which to make a valid judgment. Research Process and Scientific/Modified Scientific Method The research process, discussed in Chapter 2, is a formalized, logical, systematic approach to solving problems. The classic scientific method is most useful when the researcher is working in a controlled situation. Health professionals, often working with people in uncontrolled situations, require a modified approach to the scientific method for solving problems. For example, unlike experiments with animals, the effects of diet on health are complicated by a person's genetic variations, lifestyle, and personal preferences. Table 10-4 compares the research process or scientific method with the modified scientific method. Critical thinking is important in all problem-solving processes as the nurse evaluates potential solutions to a given problem and makes a decision to select the most appropriate solution for that situation. Decision Making Decision making is a critical-thinking process for choosing the best actions to meet a desired goal. Decisions must be made whenever several mutually exclusive choices are available or when there is an option to act or not. For example, the individual who wishes to become a nurse in the United States has several possible courses of action: a diploma program, an associate degree program, or a baccalaureate program. Prospective students must choose. Therefore, they must evaluate the different types of programs, as well as personal circumstances, to make a decision appropriate to their situations. Nurses make decisions in the course of solving problems. Decision making, however, is also used in situations that do not involve problem solving. Nurses make value decisions (e.g., to keep client information confidential), time management decisions (e.g., taking clean linens to the client's room at the same time as the medication in order to save steps), scheduling decisions (e.g., to bathe the client before visiting hours), and priority decisions (e.g., which interventions are most urgent and which can be delegated). Nurses must make decisions and assist clients to make decisions. When faced with several client needs at the same time, the nurse must prioritize and decide which client to assist first. The nurse may (a) look at advantages and disadvantages of each option, (b) apply Maslow's hierarchy of needs, (c) consider which tasks can be delegated to others, or (d) use another priority-setting framework. When a client is trying to make a decision about what course of treatment to follow, the nurse may need to provide information or resources the client can use in making a decision. Nurses must make decisions in their own personal and professional lives. For example, the nurse must decide whether to work in a hospital or community setting, whether to join a professional association, and whether to carry professional liability insurance. Here are sequential steps to the decision-making process: 1. Identify the purpose. The nurse identifies why a decision is needed and what needs to be determined. 2. Set the criteria. When the nurse sets the criteria for decision making, three questions must be answered: What is the desired outcome, what needs to be preserved, and what needs to be avoided? For example, for a client with pain, the criteria would be as follows: a. What is the desired outcome? Relief of pain.

b. What needs to be preserved? Physical functioning, cognitive functioning, psychologic functioning. c. What needs to be avoided? Central nervous system depression, respiratory depression, nausea. 3. Weight the criteria. In this step, the decision maker sets priorities or ranks activities or services from least important to most important as they relate to the specific situation. Because the weighting is specific to the situation, an activity may be ranked as most important in one situation and of less importance in another situation. For example, the nurse avoids medication that can cause sedation of a client with a head injury, but for a client with terminal cancer, pain relief may be more important than avoiding the sedative side effects of the pain medication. 4. Seek alternatives. The decision maker identifies possible ways to meet the criteria. In clinical situations, the alternatives may be selected from a range of nursing interventions or client care strategies. Pain may be treated with oral or injectable medications, as needed (prn) or on a schedule, or without pharmacologic intervention at all, instead using complementary alternative modalities (CAM). 5. Examine alternatives. The nurse analyzes the alternatives to ensure that there is an objective rationale in relation to the established criteria for choosing one strategy over another. For pain that results from a procedure (such as removal of a foreign object), CAM may not be strong enough relief, and oral medication may be effective but act too slowly, so an intravenous narcotic might be the better choice. 6. Project. The nurse applies creative thinking and skepticism to determine what might go wrong as a result of a decision and develops plans to prevent, minimize, or overcome any problems. If the intravenous narcotic is selected, what safety procedures need to be in place example, a narcotic for antidote and supplemental oxygen? 7. Implement. The decision plan is placed into action. The pain treatment is begun. 8. Evaluate the outcome. As with all nursing care, in evaluating, the nurse determines the effectiveness of the plan and whether the initial purpose was achieved. How does the client rate the level of pain following the procedure? The decision-making process and the nursing process share similarities, and the nurse uses decision making in all phases of the nursing process. Table 10-5 compares these processes. It is essential that the nurse use critical thinking in each step or phase of these processes so that decisions and care are well considered and delivered with the highest possible quality. DEVELOPING CRITICAL-THINKING ATTITUDES AND SKILLS After gaining an idea of what it means to think critically, solve problems, and make decisions, nurses need to become aware of their own thinking style and abilities. Acquiring critical-thinking skills and a critical attitude then becomes a matter of practice. Critical thinking is not an "either-or" phenomenon; people develop and use it more or less effectively along a continuum. Some people make better evaluations than others do, some people believe information from nearly any source, and still others seldom believe anything without carefully evaluating the credibility of the information. Critical thinking is not easy. Solving problems and making decisions is risky. Sometimes the outcome is not what was desired. With effort, however, everyone can achieve some level of critical thinking to become an effective problem solver and decision maker.

RESEARCH NOTE Are Education, Experience, and Critical-Thinking Ability Related to Clinical Decision Making?

This pilot study investigated the premise that there would be relationships between the education and experience of critical care nurses and their ability to make consistent clinical decisions. Criticalthinking ability, as measured by skills and dispositions tests, was also expected to correlate with decision making. Fifty-four nurses with a BSN or MSN working in adult critical care units in teaching hospitals were included in the study. Results showed that, overall, the more complex the clinical situation, the less consistent the nurses were in their decisions. Intuition, as a decision-making strategy, was most related to consistent decisions. No correlation was found between education or total years of experience and consistency in decision making. There was an association between years of experience in critical care and decision consistency. IMPLICATIONS This study reinforces that decision making and critical thinking are complex when applied in real clinical situations. That the results showed greater consistency in decisions when intuition was used and when the nurse had more years of critical care nursing experience (not just overall nursing experience) suggests that there is a type of nurse thinking in that clinical specialty that does not necessarily evolve with more global exposure to client care. It also suggests that the method of thinking used by nurses who choose critical care practice may be an inherent characteristic. Note: From "Critical Thinking and Clinical Decision Making in Critical Care Nursing: A Pilot Study," by F. D. Hicks, S. L. Merritt, & A. S. Elstein, 2003, Heart & Lung, 32, pp. 169-180.

Self-Assessment The nurse should consider some of the attitudes discussed earlier that facilitate critical thinking, such as curiosity, fair-mindedness, humility, courage, and perseverance. A nurse might benefit from a rigorous personal assessment to determine which attitudes he or she already possesses and which need to be cultivated. This could also be done with a partner or as a group. The nurse first determines which attitudes are held strongly and form a base for thinking and which are held minimally or not at all. The nurse also needs to reflect on situations where he or she made decisions that were later regretted, and analyzes thinking processes and attitudes or asks a trusted colleague to assess them. Identifying weak or vulnerable skills and attitudes is also important. Reflection, at every step of critical thinking and nursing care, helps examine the ways in which the nurse gathers and analyzes data, makes decisions, and determines the effectiveness of interventions. Reflection requires the nurse to pause in order to consider his or her beliefs, knowledge, values, and abilities in the particular situation at hand. The purpose of this reflection is to determine if the current course of action is the best one and to improve future actions. Figure 10-1, the Mind Map for Critical Thinking in Nursing, is a visual depiction of the interactive loops of concepts used in critical thinking. Note that the action of reflection appears as part of three of the steps shown: the starting points, processes, and outcomes. Tolerating Dissonance and Ambiguity The nurse needs to take deliberate efforts to cultivate critical-thinking attitudes. For example, to develop fair-mindedness, one could deliberately seek out information that is in opposition to one's own views; this provides practice in understanding and learning to be open to other viewpoints. It is a human tendency to seek out information that corresponds to one's previously held beliefs and to ignore evidence that may contradict cherished ideas. This perspective is true for both the nurse and the client. Elders may have great difficulty accepting the pervasiveness of technology or that people don't stay in the hospital as long as they did in the 1970s or that having a diagnosis of cancer doesn't always mean that one is going to die. On the other hand, elders have a wealth of knowledge and experience and often know better than the health care provider knows what will work well and be

acceptable to them. Nurses should increase their tolerance for ideas that contradict previously held beliefs, and they should practice suspending judgment. Suspending judgment means tolerating ambiguity for a time. If an issue is complex, it may not be resolved quickly or neatly, and judgment should be postponed. For a while, the nurse will need to say, "I don't know" and be comfortable with that answer until more is known. Although postponing judgment may not be feasible in emergency situations where fast action is required, it is usually feasible in other situations. Seeking Situations Where Good Thinking Is Practiced Nurses will find it valuable to attend conferences in clinical or educational settings that support open examination of all sides of issues and respect for opposing viewpoints. Cultivating a questioning attitude, using either Socratic questioning or another technique, is vital. Nurses need to review the standards for evaluating thinking and apply them to their own thinking. If nurses are aware of their own thinking while they are doing the thinking they can detect thinking errors. Creating Environments that Support Critical Thinking A nurse cannot develop or maintain critical-thinking attitudes in a vacuum. Nurses in leadership positions must be particularly aware of the climate for thinking that they establish, and they must actively create a stimulating environment that encourages differences of opinion and fair examination of ideas and options. Nurses must embrace exploration of the perspectives of persons from different ages, cultures, religions, socioeconomic levels, and family structures. As leaders, nurses should encourage colleagues to examine evidence carefully before they come to conclusions, and to avoid "group think," the tendency to defer unthinkingly to the will of the group.


Health Care Decisions

Parents most often make decisions about the health care of children. Growing children can participate in those decisions in age-appropriate ways. As described by Piaget, the ability of children to reason and critically think about themselves and their situation develops gradually (see Chapter 20). each stage, nurses should be aware of the ways children think and sensitive to how they can be involved in health care decisions: At

• Infants progress from reflexive behavior to simple, repetitive behavior and then to imitative behaviors, learning the concepts of cause and effect and object permanence. Though not involved in making decisions, they need to be comforted and secure as care is given. • Toddlers and preschoolers are very egocentric and engage in magical thinking. They cannot reason out the implications of care, but need explanations in language they can understand. Play therapy and use of dolls and toys can help them adjust to care, and they can sometimes be given options (e.g., do you want your dressing changed before breakfast or after?). • School-age children tend to be concrete thinkers. They benefit from simple, direct explanations; hands-on exploration of equipment and materials; and helping the care provider as appropriate during procedures. Involving these children in care can increase cooperation and decrease anxiety. • Adolescents are increasingly able to think abstractly and may make many of their own health care decisions. They should be actively consulted as a part of the family system.

ELDERS It is important to include all adult clients in decision making and planning nursing care, but it is especially difficult to do this when working with elders who have impaired cognitive abilities such as Alzheimer's disease. The nurse should allow them as much control and input as possible, keeping things simple and direct so they understand. Elders with impairments are usually unable to perform multiple tasks or even to think of more than one step at a time. The nurse must have patience and be willing to calmly repeat instructions if necessary. Presenting and discussing issues in basic terms helps to maintain respect and dignity and allows elders to participate in their own care for as long as possible. If the elder is unable to perform self-care activities such as bathing or health-related activities such as a dressing change, the nurse seeks appropriate alternative methods for assisting the elder with these.

Critical Thinking Checkpoint Mr. W. is a 53-year-old recently retired engineer with a history of irritable bowel syndrome that causes frequent diarrhea and rectal bleeding. His wife is a schoolteacher. It is mid-December when he comes to your clinic complaining about "not feeling good." You conclude he is having a reoccurrence of his intestinal problem. 1. What questions would you ask yourself to check this assumption? 2. How would you demonstrate that you are using the critical-thinking attitude of "confidence in reasoning" ? 3. Socrates might ask you about the consequences of your conclusion by posing the question "What are the implications of your thinking?" How would you answer? Consider the implications if you are correct and if you are incorrect in your assumption. 4. Critical thinkers look for subtle cues. Which cues in this situation require follow-up? See Critical Thinking Possibilities in Appendix A.

Figure 10-1. Mind Map for Critical Thinking in Nursing Note: Duphorne, P. & Giddens, J. (2004) Critical Thinking in Nursing Resource funded by intramural grant of College of Nursing, University of New Mexico. CHAPTER 10 REVIEW CHAPTER HIGHLIGHTS • Nurses need critical-thinking skills and attitudes to be safe, competent, skillful practitioners. • Critical thinking is a process that guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concepts (NLN, 2000). • Nurses use critical thinking as they apply knowledge from other subjects and fields to nursing practice, deal with change in stressful environments, and make important decisions related to client care. When nurses incorporate creativity into their thinking, they are able to find unique solutions to unique problems.

• Creativity enhances critical thinking. Creative nurses generate many ideas rapidly, are flexible and natural, create original solutions to problems, tend to be independent and self-confident, and demonstrate individuality. • Critical-thinking skills include the ability to do critical analysis, perform inductive and deductive reasoning, make valid inferences, differentiate facts from opinions, evaluate the credibility of information sources, clarify concepts, and recognize assumptions. • Critical thinkers have certain attitudes: independence, fair-mindedness, insight, intellectual humility, intellectual courage to challenge the status quo and rituals, integrity, perseverance, confidence, and curiosity. • Critical thinking consists of high-level cognitive processes that include problem solving and decision making. There are several problem-solving methods: trial and error, intuition, the nursing process, the scientific method, and the modified scientific method. Nurses use the scientific method or research process when they participate in nursing and health research. • The nursing process and critical thinking are interrelated and interdependent, but they are not identical. Both involve problem solving, decision making, and creativity. • Nurses must make decisions in both their personal and professional lives. The steps of the decisionmaking process include identifying the purpose of the decision, setting the criteria, weighting the criteria, seeking alternatives, examining alternatives, projecting, implementing, and evaluating the action. • Everyone has at least some level of critical-thinking skill, and that skill can be developed with practice. Some guidelines to enhance critical-thinking skills and attitudes include performing a selfassessment, tolerating dissonance and ambiguity, seeking situations where good thinking is productive, and creating environments that support critical thinking. TEST YOUR KNOWLEDGE 1. A client with diarrhea also has a physician's order for a bulk laxative daily. The nurse, not realizing that bulk laxatives can help solidify certain types of diarrhea, concludes "The physician does not know the client has diarrhea." This statement is an example of: 1. A fact. 2. An inference. 3. A judgment. 4. An opinion. 2. A client reports feeling hungry, but does not eat when food is served. Using critical-thinking skills, the nurse should perform which of the following? 1. Assess why the client is not ingesting the food provided. 2. Continue to leave the food at the beside until the client is hungry enough to eat. 3. Notify the primary care provider that tube feeding may be indicated soon. 4. Believe the client is not really hungry. 3. Although one nurse feels the manager prepared the holiday work schedule unfairly, the manager states that it is the same type of schedule used in the past and other nurses have no problems with it. The nurse continues to feel uncomfortable about how the schedule was created. Which response indicates the nurse is displaying an attitude of critical thinking? 1. Accepting the preferences of the other nurses since there are several of them

2. Recognizing that the nurse must have reached a false conclusion 3. Considering going to a higher authority than the manager for an explanation 4. Continuing to query the manager until the nurse understands the explanation 4. The client who is short of breath benefits from the head of the bed being elevated. Because this position can result in skin breakdown in the sacral area, the nurse decides to study the amount of sacral pressure occurring in other positions. This decision is an example of which of the following? 1. The scientific method 2. The trial-and-error method 3. Intuition 4. The nursing process 5. In the decision-making process, the nurse sets and weights the criteria, examines alternatives, and performs which of the following before implementing the plan? 1. Reexamines the purpose for making the decision 2. Consults the client and family members to determine their view of the criteria 3. Identifies and considers various means for reaching the outcomes 4. Determines the logical course of action should intervening problems arise See Answers to Test Your Knowledge in Appendix A. EXPLORE MEDIALINK WWW.PRENHALL.COM/BERMAN COMPANION WEBSITE • Additional NCLEX Review • Case Study: Examining an Increase in Pressure Ulcers • Application Activity: Practicing Critical Thinking • Links to Resources READINGS AND REFERENCES SUGGESTED READINGS Edwards, S. (2003). Professional issues. Critical thinking at the bedside: A practical perspective. British Journal of Nursing, 12, 1142-1149. This article provides a comprehensive review of critical thinking from theoretical and practical perspectives. The many models from the literature are often complex and difficult to interpret in relation to clinical practice situations. If theory cannot be integrated into practice, then its value to nursing should be questioned. The task now is to formalize and cement the connections between the two concepts at the bedside. Oermann, M. H. (2004). Using active learning in lecture: Best of "both worlds." International Journal of Nursing Education Scholarship, 1(1), Article 1. The lecture mode of content delivery has sometimes been viewed negatively. This well-known author in teaching and critical thinking explores another approach: integrating active learning within lecture, gaining the benefits of both methods. This article examines benefits of an integrated approach to teaching and presents strategies for active learning intended for use with lecture.

RELATED RESEARCH Gurney, D. (2004). Triage decisions. Exercises in critical thinking at triage: Prioritizing patients with similar acuities. Journal of Emergency Nursing, 30, 514-516. Hoffman, K., & Elwin, C. (2004). The relationship between critical thinking and confidence in decision-making. Australian Journal of Advanced Nursing, 22(1), 8-12. REFERENCES Alfaro-LeFevre, R. (2004). Critical thinking in nursing: A practical approach (3rd ed.). Philadelphia: W. B. Saunders. Catalano, J. T. (2003). Nursing now! Today' s issues, tomorrow' s trends (3rd ed.). Philadelphia: F. A. Davis. Forneris, S. G. (2004). Exploring the attributes of critical thinking: A conceptual basis. International Journal of Nursing Education Scholarship, 1 (1), Article 9, 1-19. Retrieved June 18, 2006, from http://www.bepress.comlijnes/vol1/iss1/art9 Hicks, F. D., Merritt, S. L., & Elstein, A. S. (2003). Critical thinking and clinical decision making in critical care nursing: A pilot study. Heart & Lung, 32, 169-180. National League for Nursing. (2000). Think tank on critical thinking. New York: Author. Paul, R., & Elder, L. (2005). A guide for educators to critical thinking competency standards. Dillon Beach, CA: Foundation for Critical Thinking. SELECTED BIBLIOGRAPHY Allen, G. D., Rubenfield, M. G., & Scheffer, B. K. (2004). Reliability assessment of critical thinking. Journal of Professional Nursing, 20(1), 15-22. Benner, P. E., Hooper-Kyriakidis, P. L., & Stannard, D. (1999). Clinical wisdom and interventions in critical care: A thinking-in-action approach. Philadelphia: W. B. Saunders. Elder, L., & Paul, R. (2003). A miniature guide for students and faculty to the foundations of analytic thinking: How to take thinking apart and what to look for when you do. Dillon Beach, CA: Foundation for Critical Thinking. Hood, L. J., & Leddy, S. K. (2003). Leddy & Pepper's conceptual bases of nursing practice (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Jackson, M., Ignatavicius, D. D., & Case, B. (2006). Conversations in critical thinking and clinical judgment. Boston: Jones & Bartlett. Moore, B. N., & Parker, R. (2007). Critical thinking (8th ed.). Boston: McGraw-Hill. Rubenfeld, M. G., & Scheffer, B. (2006). Critical thinking TACTICS for nurses. Boston: Jones & Bartlett. Staib, S. (2003). Teaching and measuring critical thinking. Journal of Nursing Education, 42, 498507.Wilkinson, J. M. (2007). Nursing process and critical thinking (4th ed.). Upper Saddle River, NJ: Prentice Hall Health.

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