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Critical Thinking in Nursing

Janie Rigsby

Mt. San Jacinto College

Advanced Medical Surgical Nursing

NURS 244

Wade Hagan, PhD, RN, PHN, CCRN

August 26, 2010

Critical Thinking in Nursing

The purpose of this paper is to discuss the importance of critical thinking (CT) within the

nursing profession. Critical thinking is responsible for positive patient outcomes. The concept of

critical thinking is critical to the nursing profession (Scheffer & Rubenfeld, 2000). In order for

the nursing process to be successful, nurses must be able to problem-solve and make decisions

quickly (Scheffer & Rubenfeld, 2000).

Critical Thinking Defined

There are many different definitions of critical thinking within the nursing world. I feel

that critical thinking is far more than pure intelligence. Critical thinking must incorporate

analysis, application of knowledge, decision-making, open-mindedness, and reflection. Critical

thinking skills are a blend of knowledge and experience. During first semester, our clinical

rotation was at Hemet Valley Medical Center. The nurses on the floor were short of Certified

Nursing Assistants (CNAs). These nurses were more than happy to utilize the nursing students

for CNA duties at the expense of performing skills that were needed to complete our clinical


I was caring for a female, 43 years old, 87 pounds, diagnosed with chronic renal failure.

Her skin was so thin that it was being pulled off by the top sheet. She had several wounds that

had formed blisters and others in various stages of healing. Although I was a first semester nurse

with only 3 weeks of clinical experience, I knew that with renal failure, something must be

wrong with her kidneys. I went to the chart to check about the intake and output measurements. I

could not find them in the chart. My nurse was very unapproachable so I made a note in my little

note-pad to check about those measurements with my clinical advisor when she returned.
I went back to the patient’s room and asked about her intake and output. She reported that

she was not allowed to eat or drink and that she had not gone to the bathroom in the last 24 hour

period. Was she on dialysis? No, she was not. Back to the chart I went to check electrolytes and

for any procedures that were upcoming. There weren’t any procedures that I could see in the

chart but maybe I didn’t know where in the chart to look. As far as the electrolytes, her

potassium, sodium and phosphorus were trending upwards and were now higher than the normal

limits. I wrote the lab values down in my notebook and intended to ask my clinical advisor about

any action that should be taken. I knew high potassium could aggravate the heart so I went back

in the room to check if she was on telemetry. Her telemetry box was in her bed, not even

attached to the leads. The box had rubbed several layers of her skin off and blood had dried on

the sheet.

At that point, I went to the nurses’ station, politely asked my nurse if she could help me

with my patient. I was very diplomatic in expressing my concerns about the patient to my nurse

and she dismissed every one of them. At that point, a new air bed had arrived for our patient. My

nurse wanted the patient to move to a chair while the beds were exchanged. I knew there was no

way that this patient could bear weight. She was weak, dizzy, and had not ambulated in 4 days. I

asked the patient, “Are you able to stand up?” She replied that she did not think she could. I

noticed the look of determination on my nurses’ face that this patient was going to go in that

chair NOW! The nurse tells me to grab up the patient under the armpits and that she would lift

her feet in order to do this transfer. I asked the nurse if we could call for help or transfer the

patient directly from her present bed to the new bed using a lift sheet. The nurse stated that she

would never call for help with a tiny 87 pound patient. I knew this situation was not right. I told

the nurse that it was the policy of the school that if a patient cannot bear weight, students are
supposed to use a Hoyer lift or call the lift team. She said, “Fine. I will do it myself.” I told her

that I would go to get help.

I left the room and came back with the charge nurse. In the nurses’ attempt to move the

patient, the patient’s skin had sloughed off causing my nurse to lose her grip on the client. The

patient was on the floor. The patient’s skin had rubbed off along the left lateral side of her torso

and on part of her leg. The nurse that had tried to move her had hurt her back in the ordeal.

I look back on that day and know that there were many things I could have done

differently. I should have trusted my instincts and called my clinical instructor when I realized

that this patient’s needs were not being addressed by this nurse. I should have advocated on my

patient’s behalf in such a way that she would not have been hurt. I could have suggested to that

nurse that she could go back about her work and that my instructor and I would facilitate the

move. In hindsight, I realize that the nurse was somewhat vindictive about caring for that patient.

The nurse was upset that she had to “deal with” the patient at that given moment. I vowed to

myself that when I earned my nursing license, I would never be that type of nurse.

During second semester, a client came up from the emergency room after having a stroke

the day prior. The person who performed his swallow evaluation stated that he failed to swallow

properly. She said that he probably could tolerate a liquid diet. She failed him because she did

not want a Certified Nursing Assistant to feed him too fast and cause him to aspirate. The

question was whether or not nutrition could be started through a means other than oral intake. He

did not have an Advanced Directive on file at the hospital but his wife said it was at home. The

wife reported that he did not want any type of tube feeding. The intravenous line was

discontinued, the patient was referred to hospice and passed away 5 days later.
I have run the scenario through my head a thousand times. What if a different person had

done his swallow evaluation? He could have been able to swallow the following day. Why was

the wife not asked to produce the advanced directive? What was my role as patient advocate in

this situation? As a student, I was told that I am a guest in the hospital and I am only to observe.

As a result of this situation, I am a proponent for advanced directives and have insisted that my

family fill one out and keep it safe and available.

Lunney (2010) states that critical thinking is as simple as thinking about thinking. The

definition seemed too simplistic but the article continues to state that there are 17 different

aspects of critical thinking. The seventeen aspects include: “confidence, contextual perspective,

creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness,

perseverance, reflection, analysis, applying standards, discriminating, information seeking,

logical reasoning, predicting and transforming knowledge” (Scheffer & Rubenfeld, 2000, p. 88).

While the aforementioned qualities are desirable, they may not all be necessary.

Turner (2005) compiled and analyzed information about CT skills during the period 1981

to 2002. They found the definition of critical thinking has “matured since its first appearance”

(Turner, 2005, p. 88). Facione (1990) wrote that critical thinking is defined as “purposeful, self-

regulatory judgment which results in interpretation, analysis, evaluation, inference, as well as the

explanation of the evidential, conceptual, methodological, criteriological, or contextual

considerations upon which that judgment was based” (as cited in Turner, 2005, p. 274). This

definition encompasses many of the necessary qualities that may be needed to be a critical


According to Watson & Glaser (1980), critical thinking is a “composite of attitudes,

knowledge, and skills which includes: (1) attitudes of inquiry that involve an ability to recognize
the existence of problems and an acceptance of the general need for evidence in support of what

is asserted to be true: (2) knowledge of the nature of valid inferences, abstractions, and

generalizations in which the weight or accuracy of different kinds of evidence are logically

determined; and (3) skills in applying and applying the above attitudes and knowledge” (as cited

in Setareh, 2005, p. 20). This definition appears to be written just for nurses as they must master

knowledge as well as skills and the wisdom to apply them. There are many definitions of critical

thinking but multiple definitions give rise to lack of clarity (Turner, 2005). The “result is poor

communication and misunderstanding for those attempting to conduct research as well as those

trying to put research into practice.” (Turner, 2005, p. 272).

Critical Thinking and the Nursing Process

Critical thinking and the nursing process have many similarities. The National League for

Nursing Accrediting Commission has mandated that both subjects be incorporated into nursing

curricula (Huckabay, 2009). The nursing process consists of assessment, diagnosis, planning,

implementation, and evaluation (Berman, Snyder, Kozier, & Erb, 2008). This process takes

nurses from intake of the client to discharge. The care plan is updated as needed and the client is

constantly being reassessed. The nursing process creates parameters for nurses so that everyone

on the health care team shares the same knowledge regarding the plan of care (Berman et al.,

2008). Critical thinking is involved in the nursing process as CT skills are necessary for proper

assessment, planning, implementation and evaluation (Berman et al., 2008). Without critical

thinking, nurses would not know when to augment the care plan.

In contrast, Koch (1997) believes the nursing process is static and closely resembles the

scientific method. Koch (1997) believes that “strict adherence to the nursing process stifles our

creativity” and that nurses “must learn to think critically and to base actions on data-driven
conclusions” (Koch, 1997, para. 3). Berman (2008) states that the nursing process is the

problem-solving aspect of client care with critical thinking as the decision-making aspect. The

nursing process provides a standardized framework for client treatment (Berman et al., 2008).

Critical thinking personalizes the framework to make the plan of care client specific. CT skills

are necessary to think in specifics, to accurately reason through problems and incorporate

decisions into client care (Koch, 1997).

Critical Thinking for Nurses

Presently, Registered Nursing demands its own definition of critical thinking. While

other professions require critical thinking skills, nurses are in a category all by themselves. First

year students often struggle with CT skills. These nursing students need to be taught to think in

many dimensions. Critical thinking classes are incorporated into nursing programs with varied

amounts of success (Facione, 1990). There are programs that focus on reflection while others use

human patient simulator to engrain CT skills (Horan, 2009). The use of a trained preceptor is

another way to help the novice nurse gain the CT skills necessary for success (Zhang, 2008).

Incorporation of CT skills into the nursing curriculum is a wonderful way to distinguish if

candidates have a disposition toward critical thinking. This disposition would include

“inquisitiveness, a keenness of mind, a zealous dedication to reason, and a hunger or eagerness

for reliable information” (Zhang, 2008, p. 176). While a nurse may graduate from nursing school

with many skills at hand, CT skills are assimilated over time. There are no two clients alike not

will there be two solutions alike. Skills and accurate judgment calls are imperative to excellent

job performance (Berman et al., 2008).

The job of the nurse is so multi-facetted and because of this, nurses must think at a very

high level as well as be able to incorporate vast amounts of knowledge (Zhang, 2008). The
nursing profession must adopt a universal definition such as the aforementioned definitions from

Watson & Glaser (1980), Facione (1990), and Scheffer (2000). The nursing profession should

also seek to research and apply evidenced-based practice in regards to fostering CT skills within

the hospital setting (Lunney, 2010). Fine-tuning this definition will clarify goals and provide a

basis for development of ways to improve critical thinking development and testing (Setareh,


Berman, A., Snyder, S. J., Kozier, B., & Erb, G. (2008). Fundamentals of Nursing: Concepts,

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Koch, F. (1997). It is time to move from the nursing process to critical thinking. Association of

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Scheffer, B., & Rubenfeld, M. (2000). A consensus statement on critical thinking. Journal of

Nursing Educaton, 352-359. Retrieved from viewer?vid=5&hid

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students from China. Nursing and Health Sciences, 10, 175-181. doi: 10.1111/j.1442-