CASE STUDY REPORT: CRITICAL THINKING IN NURSING

Arranged in order to completing the assignment of Basic Concept in Nursing

By:

Group B / Class International / Semester II / Batch 2020

Fuzna Dahlia Mudzakiroh (I1J020010)
Harsanti Ratna Hanifah (I1B020053)
Mutiara Romadhon (I1B020040)
Nur Aljananti (I1J020004)

DEPARTMENT OF NURSING
FACULTY OF HEALTH SCIENCES
JENDERAL SOEDIRMAN UNIVERSITY
MARCH 2021
 CHAPTER I

INTRODUCTION

Critical thinking is more than just an ordinary thinking. It is a quite complex process
which needs an organized thought process. Critical thinking allows to you to be active,
cognitive, and be logical in processing thoughts before finally delivering them. This includes
identifying the problem, analyzing all information related to the problem, evaluating
information, and making conclusions.

In nursing, critical thinking is very much needed. Thinking, feeling, doing is the
principles of critical thinking in nursing according to Wilkinson (1992). Critical thinking is a
process that runs continuously covering the interaction of a series of thoughts and
perceptions, while critical thinking is a basic concept consisting of concepts related to the
learning process and critical itself from various perspectives, as a nurse who is part of the
service provider. Health, namely providing nursing care services by using the nursing process
will always be required to think critically in various situations.

Nurses will face a wide variety of clinical situations relating to patients, family
members, and other health care staff, so it is important to think intelligently in each situation.
To think smart, the nurse must develop critical thinking in dealing with any new problems
and experiences that concern the patient in an open minded, creative, confident and
thoughtful way. The nurse has a responsibility to make informed and accurate clinical
decisions. Clinical decision-making is what differentiates nurses and technical staff.
Professional nurses will take prompt action when the client's condition worsens, detect if the
patient has complications and have the initiative to overcome them (Potter & Perry, 2009).
 CHAPTER II

REPORT CASE

I. Case
Mr. Spicer is a client with a terminal illness. His wife and son asked for pain control. Mrs
Spicer asked the doctor to increase the dose of the drug even though the effect did not really
matter. She didn't want to see her husband suffer. His son refuses to give me too many
narcotic drugs and thinks his father can still decide what is best for himself. Mr. Spicer is still
conscious and can talk about his feelings about dying. He seemed to respect the nurse's
willingness to speak to him.
1. How does the nurse apply critical thinking behavior in the form of justice in this case?
2. How does the nurse apply critical thinking behavior in the form of responsibility in
this case?
3. How does the nurse apply critical thinking behavior in the form of creatives in this
case?
II. Answer
1. As nurses, we must not allow personal opinions to influence the way of a client is treated
with the disease. The nurse must look at the situation objectively and analyze all aspects to
fully understand the situation before making a decision. As in this case we can identify the
problem that are:
 From the wife's side: because she didn't want to see her husband suffer, finally she
asked the doctor to increase the dosage of medicine. However, it needs to be studied
and identified the pain experienced by this patient, including mild or severe pain
 From the child's side: refusing to give too many narcotic drugs and considers the
father can still decide (it is certain whether the patient can really decide)
 Meanwhile, from Mr. Spicer's side it was written if he was still conscious and able to
speak. He seemed to respect the nurse's willingness to speak to him. Then the nurse
can chat with him and assess whether this mister spicer is capable.
 The nurse first talks to the patient and the patient's family first to decide what steps to
take next. In the act of making decisions in drug administration, the nurse must be
able to discuss it with the doctor, only then will the nurse be able to explain to the
family the reasons why the action is taken, the most important thing in this case is that
 a patient can feel calm and comfortable in dealing with his case, and the family is also
not worried towards Mr. Spicer.
2. When a nurse is caring for a client, they must be responsible for carrying out the correct
care activities according to the standard of practice that is the minimum level that must be
met to ensure high quality care. In the case of Mr. Spicer a nurse must think carefully even
if neccessary discuss it with a person in authority such as a doctor, never take shortcuts
when administering drugs. having done and made a mindful decision. a nurse must be able
to account for all the results for his actions and admit if the treatment provided is
ineffective. In this case the nurse needs to consider:
 If the conventional analgesic that is given cannot relieve pain anymore, it is
necessary to give morphine in increasing and more frequent doses. The medical
team is faced with increasing doses of morphine which can be fatal to patients; on
the one hand, administration of morphine is the only effective means of this
terminal case. Even if the patient actually asks for an end to his life, the medical
team must realize that euthanasia cannot be done by increasing the dose of
morphine again. Administration of morphine is intended for good pain relief (good
effect) but if the patient dies from it, it is not the intended effect.
3. In creative cases, a nurse can find solutions beyond existing standards but still conform to
nursing standards. In the case of Mr. Spincer, because the patient is still in a conscious
state, a nurse can ask in advance whether the medicine he has been taking has a
sufficiently effective effect on the pain or not. If not, the nurse can find other ways to help
the client to increase his sense of comfort and mobility while in the hospital. There are
several actions that can be taken, namely:
 Palliative care is the treatment of a patient and his family who has an incurable
disease by maximizing the patient's quality of life and reducing annoying
symptoms, reducing pain by paying attention to psychological and spiritual
aspects. WHO emphasizes that in providing palliative services must be based on
the following pattern:
1) improve the quality of life and regard death as a normal process,
2) do not hasten or delay death
3) relieve pain and other disturbing complaints,
4) maintain psychological and spiritual balance,
 5) The University of North Sumatra 4 makes efforts to keep the patient active until
the end of his life,
6) make an effort and help overcome the atmosphere of grief in the family (Dzauzi
et al., 2011).
 The Theory of Peaceful End of Life, this theory uses five main conceptual
approaches, namely, freedom from pain, feelings of comfort, feelings of dignity
and respect, feelings of peace, feeling close to the people closest to them. So,
because patients with terminal disease have no medicine, what is needed and can
be given is mainly from giving a feeling of comfort and peace. Moreover, in this
case, it was stated that the patient was still conscious and able to speak. The patient
really needs a nurse to listen to his complaints, and the terminal patient really
appreciates the relationship with the clinician or in other words the nurse, the
relationship with the family, or the person closest to him, so that pain is resolved
by the presence of people around him, feels comfortable being close to his closest
people, feels valued even though with the conditions experienced, a feeling of
peace so that the patient is calm (Campbell & L, 2013, pp. 7–39). In addition, other
examples to provide comfort are such as giving massage, compressing the part
where the pain is felt.
 CHAPTER III

DISCUSSION

A. Definition of Critical Thinking

Thinking and learning is a process that is related over time, clinical knowledge and
experience will improve a nurse's ability to make observations, assessments and make
choices. In general, the definition of critical thinking focuses on logical thinking and the
underlying reasons (Di Vito-Thomas, 2005). Critical thinking is an active and organized
cognitive process that is used to determine one's thoughts and thoughts about others (Chaffe,
2002). This includes identifying the problem (eg, client's problem), analyzing all information
related to the problem (eg, client clinical data), evaluating information (reviewing
assumptions and evidence), and making conclusions (Settertsen and Laure, 2004).
According to Wilkinson (1992), the characteristics of critical thinking in nursing in
principle are a unity of thinking, feeling, and doing. Given that the nursing profession is a
profession that directly faces human life, in carrying out its activities, nurses use a
combination of thinking, feeling, and doing comprehensively and in synergy. Nurses apply
thinking skills by using knowledge from various subjects and their environment to make or
make decisions in action.
Critical thinking is a process that runs continuously covering the interaction of a series of
thoughts and perceptions, while critical thinking is a basic concept consisting of concepts
related to the learning process and critical itself from various perspectives, as a nurse who is
part of the service provider. Health, namely providing nursing care services by using the
nursing process will always be required to think critically in various situations.
The use of evidence-based knowledge, knowledge-based knowledge, or clinical
experience will help a person become a critical thinker. Thinking critically and learning about
comfortable concepts beforehand can make a person better prepared to anticipate client
needs. We can also identify comfort problems more quickly and solve them well. Critical
thinking is a commitment to think clearly, precisely and accurately, and to act according to
circumstances.
Critical thinking does not only require cognitive abilities, but also a person's habit of
asking questions, having good relationships, being honest and always willing to think clearly
about a problem (Facione, 1990). When applied to nursing, the essence of critical thinking
indicates a complex clinical decision-making process.

Nurses will face a wide variety of clinical situations relating to patients, family members,
and other health care staff, so it is important to think intelligently in each situation. To think
smart, the nurse must develop critical thinking in dealing with any new problems and
experiences that concern the patient in an open minded, creative, confident and thoughtful
way. The nurse has a responsibility to make informed and accurate clinical decisions. Clinical
decision-making is what differentiates nurses and technical staff. Professional nurses will
take prompt action when the client's condition worsens, detect if the patient has
complications and have the initiative to overcome them (Potter & Perry, 2009).

Nurses who apply critical thinking to work will focus on solving problems and making
decisions, and will not make hasty or careless decisions. The application of critical thinking
in the nursing process with real cases will give nurses an overview of providing
comprehensive and quality nursing care (Budiono and Sumirah, 2015, p.90).

B. Characteristics of Critical Thinking

The following are characteristics of the critical thinking process and its description
(Deswani 2009, p. 120):
1. Conceptualization means the intellectual process to form a concept.
2. Rational and reasoned means that the arguments given are always based on analysis and
have a strong basis for real facts or phenomena.
3. Reflective means that a critical thinker does not use assumptions or perceptions in
thinking or making decisions.
4. Part of an attitude, namely the understanding of an attitude that must be taken,
5. Independent thinking means that a critical thinker always thinks about himself,
6. Critical thinking is creative thinking,
7. Thinking fairly and openly, namely trying to change, from wrong and less profitable
thinking to right and better, and
8. Making decisions based on confidence.

C. Quality of Critical Thinking

1. Systematic and always use high criteria (best) from an intellectual point of view for the
thinking results to be achieved.
2. Individuals are fully responsible for the process of thinking activities.
3. Always use criteria based on predetermined standards in monitoring thought processes.
4. Evaluating the effectiveness of thinking activities in terms of achieving predetermined
goals.

D. Behavioral Aspects of Critical Thinking

1. Relevance, the questions asked must be related to each other.
2. Importance, the issue or point of view that is conveyed must be important.
3. Novelty, providing new information or ideas and a good attitude of accepting new ideas.
4. Outside material, Using his own experience or material received from lectures.
5. Ambiguity clarified, looking for explanations or more information if you feel unclear
6. Circle ideas, connect ideas, facts or views and seek new data from the information that
has been collected.
7. Justification, provides evidence of evidence, examples or justification for a solution or a
conclusion it draws.
8. Critical assessment, evaluating every contribution or input that comes from within
himself or from others.
9. Practical utility, new ideas submitted must be usable or usable.
10. Width of understanding, the discussion that is delivered is to expand the content or
material of the discussion.

E. Cognitive Activities in Critical Thinking

1. Asking questions to determine the reasons and causes for something to happen and
determine whether other information is needed.
2. Gather as much relevant information as possible to consider all relevant factors.
3. Validating the information available to ensure that it is accurate according to fact or
evidence.
4. Analyze this information to determine meaning and whether the information forms a
series as material for making conclusions.
5. Use past experience and knowledge to explain what is happening and to anticipate what
will happen next.
6. Maintaining a flexible attitude to facts or data that guides thinking and considering all
possibilities.
7. Consider the options available and assess the advantages and disadvantages of each
option.
8. Formulate a decision that reflects creative and independent decision making.

F. Concepts for Critical Thinkers

1. Seeing clearly: looking for the true meaning of a situation, and having the courage to ask
questions such as being honest and objective in asking questions.
2. Open-minded: that is, tolerance of other opinions such as being sensitive to your own
predictions and respecting the opinions of others.
3. Analytical thinking: by analyzing potentially problematic situations such as anticipating
possible outcomes or consequences, valuable explanations, and using evidence-based
knowledge.
4. Systematic: always organized, focused, working hard in every job.
5. Confidence : believe in the self-explanatory process
6. Curiosity: willing to gain knowledge and learn to explain even though the application of
our knowledge is not always good.
7. Adults: multiple solutions are acceptable, look back at our judgment and have a mature
mind.

G. Levels of Critical Thinking in Nursing

The ability to think critically grows when acquiring new knowledge in nursing practice.
Kataoka-Yahiro and Saylor (1994) developed a critical thinking model which includes three
levels of critical thinking, namely: basic, complex and commitment.
1. Basic critical thinking
At the basic critical thinking stage, students believe that experts have the right answer to
every problem. Thinking is real-based on a certain rule. At this stage, the answer to a
complex problem is either true or false and one correct answer is usually available for
each problem. At this stage a person still has no experience, weak competence and an
inflexible attitude.
2. Complex critical thinking
At this stage a person begins to be able to separate himself from a rule. They analyze and
examine options more independently. The ability to think and the desire to see the
 opinions of experts more broadly began to form. In complex critical thinking, each
solution has its own advantages and risks that must be carefully considered before
making the final decision.
3. Commitment
At this stage a person can anticipate the situation to make a choice without the help of
others. Whatever decision is made, someone is able to take responsibility for it. At the
level of commitment, we choose appropriate, complex alternatives to a problem.

H. Critical Thinking Skills

Nurses who think critically will find ways to solve problems from nursing care by
applying the knowledge and information they have to make decisions. Thus, a typical nurse
with critical thinking will find it easier to solve problems and solve problems. (In a journal
according to Facione PA and Giancarlo Vol. 50 No.1) (2001, p. 3) The Journal of General
Education:
1. Interpretation is understanding and expressing the meaning or significance of various
experiences, situations, data, events, judgments, habits or customs, beliefs, rules,
procedures or criteria,
2. Analysis is identifying the intended and actual inferensional relationship between
statements, questions, concepts, descriptions,
3. Evaluation is assessing the credibility of statements or representations which are reports
or descriptions of perceptions, experiences, judgments, opinions and assessing the logical
strength of inferential or intended relationships among statements, descriptions,
questions or forms. other forms of representation,
4. Inference (explanation), being able to state the results of someone's explanation,
presenting someone's reasoning in the form of strong arguments,
5. Self-regulation, means to consciously monitor one's cognitive activities, the elements
used in these activities and the results obtained, especially by applying skills in analysis
and evaluation for self-infertional research by looking at the question, confirm, validate
or correct either the reasoning or the results.

The nurse makes decisions in every action, while the nurse also plans and provides care. The
effectiveness and accuracy of decision making requires proficiency in collecting data and
critical thinking skills. Critical thinking in nursing is a very important component of
professional accountability and one of the determinants of the quality of nursing care.
I. Critical Thinking Components in Nursing
 Specific Basic Knowledge in Nursing
This knowledge varies, for example, such as information and theory from the basic
sciences, humanities, behavioral science, and nursing. Nurses use their basic knowledge
in a different way from other medical disciplines because they think about client
problems in a holistic way.
 Experience
Clinical learning experience is required to fulfill clinical decision-making skills (Roche,
2002). In a clinical situation, we will begin to learn from observing feelings, talking to
clients and families, and reflecting actively on the experiences that have been obtained.
With experience, we will begin to understand the clinical situation, identify patterns of
client health, and assess whether these patterns are related or not to the client's health.
 Critical Thinking Competencies
a. General critical thinking competence
b. Specific critical thinking competencies in clinical situations
c. Specific critical thinking competencies in the nursing process of nursing
 Behavior to behave critically
a. Self-confidence, grows with experience in recognizing strengths and limitations and
has the assurance of completing tasks or goals such as carrying out the nursing
process or making diagnostic decisions. When we show confidence, clients will see
from the way we communicate and provide care so that trust builds between nurses
and clients.
b. Think independently, challenge the way of thinking of others and seek logical and
rational answers to a problem and consider various concepts and ideas before forming
opinions and making judgments. Independent thinking is an important step in
evidence-based practice when nurses ask questions and look for evidence behind the
clinical problems they find.
c. Justice, a critical thinker must be able to handle all situations fairly. This means that
bias and accusations will not influence the decision. Look at the situation objectively
and analyze thoroughly before making a decision. Imagining what it would be like if
we were in a client position can help us to see the client's situation in a new light and
appreciate the difficulties they were having.
 d. Responsibility and accountability. Nurses are responsible for carrying out proper care
activities according to practice standards. As nurses, we must be able to account for
all the results for the actions given to clients and must be willing to admit that the
treatment provided is ineffective.
e. Taking risks, a critical thinker is always willing to take risks in trying different ways
to solve problems. The willingness to take risks comes from experience in dealing
with the same problem. When taking risks, always subvert all options, analyze all
potential harm to the client, then take reasonable, logical and sound action.
f. Discipline, being disciplined will help us identify problems more accurately and be
able to take appropriate action.
g. Persistently, a critical thinker is required to find effective solutions to client problems.
This is necessary if an existing problem cannot be resolved or if the same problem
occurs again. Learn as much as you can about the problem and try different
approaches to solving it. Persistent means constantly looking for multiple sources
until we can find the best solution for a client's problem. A persistent critical thinker is
never satisfied with minimal effort, but always works hard to achieve maximum
results in client care.
h. Creative, includes original thinking. This means we find solutions outside the existing
routine standards but still run them according to nursing standards.
i. Curiosity, observing all the information about the client so that when analyzing the
data, sometimes the pattern that is obtained is not very clear and motivates us to look
further and investigate clinical situations so as to get information that can help us
make decisions.
j. Integrity, critical thinkers always ask questions and test their own knowledge and
beliefs. A person with integrity will be honest and willing to admit mistakes in
behavior, ideas, and thoughts and follow the best nursing standards.
k. Humble, acknowledging the limitations of our knowledge and skills. Critical thinkers
try to find the knowledge they need to make the right decisions.

J. Standards for critical thinking

a. Intellectual standard
1.) Rational and have good reasons. Critical thinking is done by someone because
there are reasons and rationale right from a situation, not based on conjecture or
personal reasons such as the fear of a subordinate having a boss,
 2.) Reflective reflection. Critical thinking is done by focusing on the problem and
collecting data and facts according to the complete problem.
3.) Investigate. Someone who thinks critically always examines the problem deeper,
4.) Autonomy. Critical thinking is done by someone without any influence from
others, only based on analysis and decision making.
5.) Creative. Someone who thinks critically must have the ability to use a concept or
theory in a different situation.
6.) Open. Critical thinking is done by reviewing the reasons that a person has used in
making decisions openly.
7.) Evaluate. Critical thinking is done to re-evaluate opinions and decisions on
actions, attitudes, techniques, and skills that a person has taken on a problem.
Professional standards or characteristics are benchmarks used in a profession that
requires special skills to live it. In this case, nursing has a nursing code of ethics
and standards of nursing care practice. (Rubenfeld & Scheffer, 2006).
8.) Clear, precise, specific, accurate, relevant, reasoned, consistent, logical, deep,
broad, complete, significant, sufficient and fair.
b. Professional standards
1.) Ethical criteria for nursing assessment
2.) Criteria for evaluation
3.) Professional responsibility

K. The Five-Stage Model of the Nursing Process

Components in the nursing process include analysis, assessment, nursing diagnosis,
intervention / planning, implementation and evaluation. The synthesis of critical thinking
with nursing competence also includes: knowledge, experience, standards and behavior.

L. Developing Critical Thinking Skills

a. Keep a reflective journal
b. Concept mapping, and
c. Meeting with collegues
 CHAPTER IV

CONCLUSION

Critical thinking is an active and organized cognitive process that is used to determine
one's thoughts and thoughts about others (Chaffe, 2002). This includes identifying the
problem (eg, client's problem), analyzing all information related to the problem (eg, client
clinical data), evaluating information (reviewing assumptions and evidence), and making
conclusions (Settertsen and Laure, 2004). Critical thinking is a process that runs continuously
covering the interaction of a series of thoughts and perceptions, while also is a basic concept
consisting of concepts related to the learning process and critical itself from various
perspectives.

Given that the nursing profession is a profession that directly faces human life, in
carrying out its activities, nurses use a combination of thinking, feeling, and doing
comprehensively and in synergy. Nurses apply thinking skills by using knowledge from
various subjects and their environment to make or make decisions in action. When applied to
nursing, the essence of critical thinking indicates a complex clinical decision-making process.

To think smart, the nurse must develop critical thinking in dealing with any new
problems and experiences that concern the patient in an open minded, creative, confident and
thoughtful way. The nurse has a responsibility to make informed and accurate clinical
decisions. Clinical decision-making is what differentiates nurses and technical staff.
Professional nurses will take prompt action when the client's condition worsens, detect if the
patient has complications and have the initiative to overcome them (Potter & Perry, 2009).

Critical Thinking Components in Nursing:

 Specific Basic Knowledge in Nursing

 Experience
 Critical Thinking Competencies
a. General critical thinking competence
b. Specific critical thinking competencies in clinical situations
c. Specific critical thinking competencies in the nursing process of nursing
 Behavior to behave critically
 In the case study, Mr. Spicer’s case with a terminal illness, there are things that need
to be paid attention to as in the form of critical thinking in nursing. As nurses, we must not
allow personal opinions to influence the way of a client is treated with the disease. The nurse
must look at the situation objectively and analyze all aspects to fully understand the situation
before making a decision.

When a nurse is caring for a client, they must be responsible for carrying out the
correct care activities according to the standard of practice that is the minimum level that
must be met to ensure high quality care. In the case of Mr. Spicer a nurse must think carefully
even if neccessary discuss it with a person in authority such as a doctor, never take shortcuts
when administering drugs. having done and made a mindful decision. a nurse must be able to
account for all the results for his actions and admit if the treatment provided is ineffective.

In creative cases, a nurse can find solutions beyond existing standards but still
conform to nursing standards. In the case of Mr. Spincer, because the patient is still in a
conscious state, a nurse can ask in advance whether the medicine he has been taking has a
sufficiently effective effect on the pain or not. If not, the nurse can find other ways to help the
client to increase his sense of comfort and mobility while in the hospital.
 REFERENCES

Potter & Perry. (2009). Fundamentals of Nursing 7th Ed. St. Louis, Missouri: Mosby
Elsevier.

Potter & Perry. (2009). Fundamental Keperawatan Buku 1 Edisi 7. Singapore: Elseiver.

Djauzi, S., (2011). Perawatan Paliatif dan Bebas NyeriPada Penyakit Kanker. Jakarta: YPI.
Pers

Felenditi, D., (2013). TERAPI PALIATIF DALAM PROFESI KEDOKTERAN. Jurnal

Biomedik (JBM), 5(1), 21 – 25.

Yasinta, M. 2019. Penyakit Terminal. Eprints : http://eprints.ukmc.ac.id/3365/4/IK-2019-

1733067P-chapter1.pdf