Years ago, nurses saw themselves as doers, not thinkers. Nurses were primarily directed what to do, and they carried out the orders. Certainly there were exceptions, such as Florence Nightingale and Mary Seacole, to name two historical pioneers in nursing. By 1996, the National Council of State Boards of Nursing (NCSBN) included four phases of the nursing process (no nursing diagnosis at this time) in the NCLEX-PN® examination. Nursing diagnosis is discussed in Chapter 9. Questions were at the cognitive level of knowledge, comprehension, and application (NCSBN, 1995). In 1999, the four phases were integrated throughout the test plan (NCSBN, 1998). By 2002, the NCSBN integrated all phases of the nursing process, as well as critical thinking, into the NCLEX-PN® examination. The cognitive level of analysis was added to NCLEX-PN® examination questions (NCSBN, 2001). The expectation was that both the nursing process and critical thinking would be taught to the practical/vocational nursing student (SPN/SVN). Critical thinking is an integral part of the nursing process. To do the nursing process, the work of nursing, is to have to think critically. Today nurses who cannot think critically become one of the problems, rather than the solution, in nursing.

Professional Pointer

Critical thinking is a lifelong process (Alfaro-Lefevre, 2003).

Ways of thinking

Definition of applied critical thinking

What exactly is critical thinking, and how does it relate to the nursing decisions you will make at school and during your career? Alfaro-Lefevre (2003) provides a definition of critical thinking and clinical judgment in nursing. Critical thinking in nursing, adapted for practical/vocational nursing, is defined as the following:*

• Entails purposeful, informed, outcome-focused (results-oriented) thinking that requires careful identification of the problems, issues, and risks involved (e.g., deciding whether a patient needs one or more staff to move from bed to chair in a manner that is safe for both patient and staff).

• Is driven by patient, family, and community needs. The practical/vocational nurse must be able to use knowledge to tailor approaches based on circumstances.

• Is based on the principles of the nursing process and on scientific methods—for example, making judgments based on evidence (facts) rather than guesswork. This is a major difference between LPN/LVNs and unlicensed assistive personnel (UAPs).

• Uses both logic and intuition, based on knowledge, skills, and experience of the LPN/LVN.

• Is guided by professional standards, such as those developed for the LPN/LVN by the National Association for Practical Nurse Education and Service (NAPNES) (see Appendix A), the National Federation of Licensed Practical Nurses (NFLPN) (see Appendix B), and the practical/vocational nursing code of ethics.

• Calls for strategies that make the most of human potential (e.g., using individual strengths) and compensates for problems created by human nature (e.g., overcoming the powerful influence of personal beliefs, values, and prejudices).

• Is constantly reevaluating, self-correcting, and striving to improve (e.g., practicing skills, learning new skills, attending classes, and workshops).

Thinking is divided into nonfocused thinking and directed thinking. At one time or another, most of us have used the following examples of thinking:

• Nonfocused thinking: You engaged your brain out of habit without much conscious thought.

• Habitual thinking: We get up to go to the bathroom, shower, dress, and so on. This type of thinking involves any routine we do that is important but does not require us to think hard about how to do it (automatic pilot).

• Random thoughts: Multiple short scenes and thoughts come and go through the mind and have no particular purpose or goal (mental channel surfing).

• Ruminative thinking: The same situation or scene is replayed in the mind over and over, without reaching an outcome (instant replay).

• All-or-none thinking: The mind is made up, and no additional facts will be considered (black-and-white thinking with no grays in between).

• Negative thinking: The mind is stuck on negative thoughts and blocks worthwhile thinking (emotional sabotage).

• Directed (or focused) thinking: Purposeful and outcome-oriented.

• Problem-oriented thinking: Focus on a particular problem to find a solution (e.g., planning your school, work, and home schedule). This could involve collecting information on school and work schedules and schedules of family members who rely on you. It might include delegating tasks, requesting help, making your goals known, and listening for input from those involved in the immediate situation (see Chapter 2). Once the schedule is developed, no further attention is given to the situation until another problem emerges (problem solving).

• Critical thinking: Critical thinking is an advanced way of thinking, a problem-solving method, and more. It is used to resolve problems and to find ways to improve a situation even when no problem exists. It answers the question “How can we do this better?”

Try This

Survey of your Current Level of Critical Thinking

Based on a scale of 0 to 10, with 0 as the lowest and 10 as the highest, rate each statement about thinking as it applies to you. Then list the items you rated as lowest.

___I identify the purpose of my thinking.

___My thinking is goal (or outcome) directed.

___I have an organized method of thinking.

___I question what I do not understand.

___I continually question: What does this mean? Is this useful? Is it fact?

___I question the reliability of sources and information available.

___I keep an open mind.

___My judgments are based on fact (evidence).

Critical Thinking

Make a Personal Plan

1. Prioritize the critical-thinking items you need to work on from the previous learning exercise. Choose the items you think are most important to work on first.

2. Make a schedule and estimate the amount of time it will take to see progress. (We all need to work on critical thinking throughout our lives.)

3. Identify how you will determine what progress is being made.

Critical thinking and practical/vocational nursing

Critical thinking involves questioning with meaning. This type of thinking involves examining personal thinking and the thinking of others. Judgments are made on facts (evidence), not assumptions. The critical thinker avoids criticizing just for the sake of having his or her own way. Decisions are based on the right thing to do rather than emotions or a need to save face. New ideas and alternatives are offered in a constructive way. The thinker is willing to consider other ideas and recognizes that there may be more than one right way to do something. The thinker realizes that a perfect solution may not be possible.

Critical thinking is at its best when you have your brain purposefully engaged—for example, while you listen to a minilecture, view a video, play a CD-ROM, listen to a podcast, participate in a discussion or study group, or are being tutored. A critical thinker is paying attention to what the speaker is saying.

• Do I understand it?

• What does it all mean?

• Where does it all fit in?

You are examining your thinking and the thinking of others. Critical thinking is based on science and scientific principles. The principles include the following:

• Collecting data in an organized way

• Verifying the data in an organized way

• Arranging the data in an organized way

• Looking for gaps in information

• Analyzing the data

• Testing it out (Is the data purposeful and outcome/goal-oriented?)

These scientific principles align with the nursing process, as you will learn in Chapter 9. A major difference for the scientist is that a problem is identified and then data are collected. The nurse using the nursing process collects data first and then determines the nature of the problem (Ignatavicius and Workman, 2010). The critical thinker should routinely ask the following questions about the subject of the thinking task at hand (adapted from Alfaro-Lefevre, 2009):

1. What major outcomes (observable beneficial results) do you expect to achieve (e.g., when working with the RN to develop a care plan for a newly admitted patient)?

2. What problems, issues, or risks must be addressed to achieve the major outcome (e.g., the hospital unit you are working on is short-staffed)?

3. What is the circumstance or context (e.g., the LPN/LVN is working in the patient’s home, where equipment will have to be improvised)?

4. What knowledge is required (e.g., in an area such as mental health, in which you did not have a clinical experience)?

5. How much room is there for error (e.g., the patient is positioned on his back as directed after surgery and begs to be on his side.)?

6. How much time do we have (e.g., the patient who was just admitted is bleeding profusely)?

7. What human and professional resources can help me/us (e.g., the patient is acutely ill and refuses care because of lack of insurance or adequate personal funds)?

8. What perspectives must be considered (e.g., the patient has refused to be examined because of religious beliefs)?

9. What is influencing my thinking (e.g., you are against abortion and do not want to take care of a patient hospitalized because of self-induced abortion)?

10. What must we do to prevent, manage, or eliminate the problems, issues, and risks identified with question 2?

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