Bachelor of Nursing with Honours in General Health Care Programme

Bachelor of Nursing with Honours in Mental Health Care Programme

NURS N412F & NURS N414F Integrated Nursing

Learning Outcomes
Upon completion of the class, students should be able to:
✔ Differentiate thinking and critical thinking

✔ Appreciate the concept of critical thinking

✔ Describe the factors that affect critical thinking

✔ Describe the habits that can promote critical thinking

✔ Appreciate the concept of clinical reasoning

✔ Discuss the importance of clinical reasoning and critical thinking in the nursing
context

Pre-class activity:
⬧ Think about what you would do when a student says that old lady keeps on saying she is in
SOB?

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Critical Thinking
What is Critical Thinking?
It means not accepting information at face value without carefully evaluating it.

In critical thinking…. “Critical” can be replaced by _________________.

Definition of Critical Thinking

⬧ No one single definition because it is a complex process and it will change according to
the context and circumstances being discussed.
⬧ It is operationally defined as the utilization of scientific facts, principles, and laws to
identify, relate, understand, explain, predict, influence, and control nursing phenomena.
(Johnson & Webber, 2015)

Thinking vs. Critical thinking

⬧ Thinking: Merely mental activity, it can be “Mindless” like day dreaming/ reflexes.

⬧ Critical Thinking: controlled and purposeful, use well-reasoned strategies.

What “Critical Thinking” is NOT?

⬧ It is NOT simple being negative or full of criticism.

⬧ It is NOT arguing for the sake of arguing.

⬧ It is NOT accepting information at face value without carefully evaluating it.

When one thinks “critically”, he examines assumptions, evaluates evidence, uncovers

underlying values and reasons before drawing conclusion and making decision.

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 Critical thinking Non-critical thinking

Organized and explained well by using Disorganized and vague

words, examples, pictures or graphics
Criticism for the sake of improvement,
new ideas, and doing things I the best
interest of the key players involved
Criticism for the sake of attacking without
being able to suggest new and constructive
ideas or alternatives; critical for the sake of
having it your way

Curious about intents, facts and reasons Unconcerned about motives, facts, and
behind ideas or actions reasons behind ideas or actions
Thought and knowledge-oriented Task-oriented rather than thought-oriented

Decision making based on facts, and what
is morally and ethically the right thing to
do
Communicative and collaborative with
others when dealing with complex issues
Decision making based on feelings/
emotion-driven
Isolated, competitive, or unable to
communicate with others when dealing
with complex issues.

Critical thinking in Nursing

⬧ It is used extensively in clinical reasoning

⬧ In nursing, critical thinking means using evidence-based strategies in all phases of the
nursing process
⬧ It is evident when nurses:
- Challenge assumptions
- Identify and acknowledge values and beliefs he/ she brings to the situation
- Consider the influence of context
- Generate possible explanations
⬧ It is guided by standards; driven by patient/ family & community needs; based on
principles of nursing process and scientific methods; and focus on quality and safety

Assumption

⬧ When something is taken for granted or presented as fact without supporting

evidence.
(Alfaro-LeFevre, 2020)

⬧ Need to identify assumptions, by:

- Double-check our thinking
- Apply logic
- Make judgements based on best available evidence

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⬧ Critical thinking in nursing 🡺 Not only answering questions,
but also questioning “answers”
⬧ Rewards for critical thinking:
- Gaining confidence
- Be safe and autonomous
- Improve patient outcomes
- Enhance job satisfaction

⬧ Critical thinking is contextual & temporal

⬧ Thinking ahead:
- Anticipate what might happen
- Be proactive
- Can be difficult for novice who are lack of experience
⬧ Thinking-in-action
- It’s a rapid and dynamic reasoning
- Need to consider several things at a time
- Influenced by previous knowledge and experience
- More prone to a “knee-jerk” response and decision
⬧ Thinking back (Reflecting)
- Analyzing decision to look for flaws
- Gain more understanding and make corrections
- A reflective thinking

⬧ Critical thinking Indicators

- Observable behaviors that indicates critical thinking
- Behaviors include: (How many do you have?)

Reflective & self-corrective ___ Flexible, change as needed ___

Self-aware ___ Genuine/ authentic ___
Effective communicator ___ Careful & prudent ___
Curious and inquisitive ___ Open & fair-minded ___
Alert to context ___ Sensitive to diversity ___
Analytical & insightful ___ Creative ___
Logical & intuitive ___ Realistic and practical ___
Proactive & courageous ___ Honest and upright ___
Responsible ___ Patient and persistent ___
Confident and resilient ___

** There is no perfect critical thinker. Critical thinking ability depends on circumstances,

confidence level and previous experience.
“Pattern over time” is more important!!

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Strategies to become a critical thinker

⬧ Gain insight and self-awareness; know your personality, learning styles and
thinking habits
⬧ Building trusting relationship with open communication and code of conduct

⬧ Committed to developing knowledge, attitudes, and skills

⬧ Use evidence-based reference

⬧ Reflect on reasoning process and ask for feedbacks

Factors affecting Critical Thinking Ability

A Personal factors

⬧ Health & Happiness

o One has to be healthy and happy to think critically
⬧ Mindfulness and work-life balance
o Pay attention to own feelings and learn how to take care of oneself
⬧ Fair-mindedness and moral development
o Aware of own values and have a good sense of right and wrong
⬧ Age and maturity
o Moral development comes with maturity (most of the time)
⬧ Personal dislikes, prejudices and biases
o Overcome prejudices and biases in order to think more objectively
and logically
⬧ Self-confidence
o Over-confident vs under-confident
⬧ Past experience
o Bad vs good experience can be enhancing or hindering factor
⬧ Knowledge of problem-solving, decision-making, the nursing process, and the
scientific method
o Familiarity with the process enhances critical thinking
⬧ Early evaluation and reflection
o Make it a habit to evaluate, so as to make correction timely
⬧ Effective writing skills
o Help to apply CT in an organized approach
⬧ Effective reading and learning skills
o Help using resources effectively

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 B Situational factors

⬧ Awareness of risks
o “think before you act”
⬧ Knowledge of related factors
o Awareness of the related factors that can help with solving the
problem
⬧ Awareness of resources
o Awareness to know where to get help
⬧ Positive reinforcement
o For confidence building
⬧ Negative “talks”
o These can impede thinking
⬧ Evaluative (judgmental) style
o Always think someone is judging you
⬧ Presence of motivating factors
o Rewarding outcome
⬧ Time limitations
o Can be enhancing or impeding
⬧ Distraction and interruptions
o Cause one to sway from focus

Habits that promote Critical Thinking & be an effective person

1 Be proactive
⬧ Be a responsible person and take initiative. Choose own actions, attitude and
moods
⬧ Do not blame others for wrong actions

⬧ Always do the right thing, without being asked, and even when no one is
looking
2 Begin with the End in mind
⬧ Plan ahead and set goals

⬧ Be an important part of the group, and contribute to common mission and

vision
3 Put first things first
⬧ Spend time on things that are most important

⬧ Set priority, make schedule, and follow the plan

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 ⬧ Disciplined and organized
4 Think Win-Win
⬧ Balance courage for getting what one wants with considerations for what
others want
⬧ Look for alternatives when conflicts arise
5 Seek first to understand, then to be understood
⬧ Listen before talk

⬧ Listen to others’ ideas and feelings

⬧ See things from others’ viewpoint

6 Synergize
⬧ Value others’ strength and learn from them

⬧ Work well in groups because teaming with others can create better solutions
than working alone
⬧ Be humble
7 Sharpen the saw
⬧ Take care of self

⬧ Spend time with family and friends

Other strategies that promote critical thinking

⬧ Apply knowledge: compare and contrast

⬧ Communication: always ask “why”; replace “I don’t know” with “I need to

find out”
⬧ Use maps, diagrams, decision trees…etc to organize information

Clinical Reasoning
• It is a complex process that use
– cognition,
– meta-cognition, and
– discipline-specific knowledge
• To gather and analyze patient information,
• To evaluate its significance, and
• To weigh alternative actions
• It is used to identify and diagnose actual and potential patient problems; to make clinical
decisions for problem resolution so as to achieve positive patient outcomes.
(Simmons, 2010)

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 ⬧ Clinical reasoning is important because it allows nurses to make timely and effective
patient-centered decisions
⬧ Fundamental difference between a novice and an expert
⬧ Having mere good knowledge and skills is not equal to having good clinical reasoning
skills

Clinical reasoning vs. Critical thinking

⬧ Clinical reasoning: a thinking process to direct a person to take “wise” action or
to take the best judged action in a specific context
⬧ Critical thinking: the rational examination of ideas, inferences, assumptions,
principlism, arguments, conclusions, issues, statements, beliefs and actions.

Terms

⬧ In literature, clinical reasoning, clinical judgment, problem solving, decision making, and
critical thinking are often used interchangeably.
⬧ It guides nurses in assessing, assimilating, retrieving, and/ or discarding components of
information that affect patient care.

Clinical judgment: outcome of clinical reasoning

⬧ An interpretation/ conclusion on the patient’s concerns or health problems
⬧ It is the decision:
- To/ not to take action
- To use/ modify standard approach
- To improvise new approach as deemed appropriate by the patient’s
response

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Clinical Reasoning in Nursing
⬧ A process, which include:
- Collect cues
- Process the information
- Analysis the data
- Come to an understanding of a patient problem or situation
- Plan and implement interventions
- Evaluate outcomes
- Reflect on and learn from the process

Assessment Diagnosis Planning Implementation Evaluation

4 steps in Clinical Reasoning Process

8 steps in Clinical Reasoning Process

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 Clinical Reasoning Cycle

Reflection
Reflection-in-action: ability to interpret the patient’s response to an intervention
Reflection-on-action: subsequent thinking about the situation and what he/ she has
learned from it

Clinical Reasoning skills

1 Clustering related cues
⬧ Allows you to see patterns and relationship among data
2 Checking accuracy and reliability
⬧ Review both subjective and objective data

⬧ To avoid making assumptions

3 Distinguish normal from abnormal
⬧ Apply knowledge
4 Distinguish relevant from irrelevant
⬧ Focus on pertinent facts
5 Assessing systematically & comprehensively
⬧ Avoid making mistakes due to incomplete information
6 Identify patterns
⬧ Identify gaps in data collection
7 Identify missing information
⬧ To fill the gaps

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 8 Diagnosing actual & potential health problems
⬧ Identify risk factors
9 Setting priority
10 Determine patient-centered and individualized interventions
⬧ With SMART criteria
11 Identify assumptions
12 Making inferences
Inference: forming opinions and judgments that follow logically, based on patient’s sign
and symptoms
⬧ Avoid jumping to conclusion too quickly

⬧ Think of alternative conclusions

⬧ Use statements “ I suspect this…….”

Goals of Nursing
⬧ The most important starting point in becoming a nurse
– What do we, nurses, aim to do?
• Prevent illness
• Promote, maintain and restore health
• Maximize sense of well-being, independence & functional ability
• Provide cost-effective and efficient care
• Continually work to improve patient outcomes

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Reference List

Alfaro-LeFevre, R. (2014). Applying nursing process. The foundation for clinical reasoning. (8th
ed.). Lippincott Williams & Wilkins.

Alfaro-LeFevre, R. (2020). Critical thinking, clinical reasoning and clinical judgment. A practical
approach. (7th ed.). Elsevier Saunders.

Forsgren, S.; Christensen, T. & Hedemalm, A. (2014). Evaluation of the case method in nursing
education. Nurse Education in Practice, 14, pp. 164 – 169.

Johnson, B.M. & Webber, P.B. (2015). An introduction to theory and reasoning in nursing. (4th
ed.). Wolters Kluwer.

Kassirer, J., Wong, J. & Kopelman, R. (2010). Learning clinical reasoning. (2nd ed.). Lippincott
Williams & Wilkins.

Koharchik, L., Caputi, L., Robb, M. & Culleiton, A.L. (2015). Fostering clinical reasoning in nursing
students. AJN, January, 115 (1), p.58 – 61.

LeMone, P., Burke, K.M., Bauldoff, G., & Gubrud, P. (2015). Medical-Surgical Nursing. Clinical
reasoning in patient care. (6th ed.). Pearson.

Marwat, M.F. (2013). Nursing Process. Patel Institute of nursing & allied health sciences.
Downloaded from http://www.slideshare.net/farooqmarwat/nursing-process-26614365

Simmon, B. (2010). Clinical reasoning: concept analysis. Journal of Advanced Nursing, 66(5), pp.
1151 – 158.

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