Psychiatric-mental health nursing care is practiced in multiple settings across the health care continuum. Patients of all ages in need of psychiatric-mental health nursing care can be found in hospitals, community agencies, and residential settings. Across all these settings and age groups, psychiatric-mental health nurses integrate critical thinking skills for clinical decision making throughout the interpersonal relationship. Critical thinking and clinical decision making are crucial elements to ensure that the patient’s needs are assessed, relevant problems are identified, and therapeutic nursing interventions are planned, implemented, and evaluated (Wilkinson,2011).

Clinical decision making based on critical thinking is similar across all clinical settings. One unique dimension of critical thinking in psychiatric-mental health nursing is the importance of the interpersonal relationship as a major healing factor in delivering psychiatric nursing care. This chapter focuses on how psychiatric nurses integrate the concepts of critical thinking, clinical decision making, and the nursing process within the interpersonal relationship to address patient needs and delivery of nursing care. Throughout this textbook, a recurring special feature, “How Would You Respond?” is used to promote the development of critical thinking and clinical decision-making skills.

CRITICAL THINKING AND CLINICAL DECISION MAKING

CRITICAL THINKING refers to a purposeful method of reasoning that is systematic, reflective, rational, and outcome oriented. It is an important part of psychiatric-mental health nursing and the interpersonal relationship. Through the use of critical thinking, psychiatric-mental health nurses make clinical decisions that translate into an appropriate plan of care for the patient (Harding & Snyder, 2015).

Critical thinking correlated with clinical decision making does not refer to thinking that is judgmental, negative, or dismissive about a given strategy, plan, or subject under consideration. Rather, it is a conscious, organized activity that requires development over time through consistent effort, practice, and experience. Critical thinking is dynamic, not static, and ever-evolving based on the circumstances of the individualized situation.

Numerous definitions have been developed about critical thinking and how it applies to nursing practice. Scheffer and Rubenfeld (2000), in a consensus statement, described critical thinking in nursing as

This consensus statement indicates that critical thinking is a positive skill set used by nurses to plan patient care.

Domains of Critical Thinking

Four specific domains have been identified as essential to critical thinking (Paul, 1993). These domains include the following:

Elements Necessary for Critical Thinking

Critical thinking requires practice, effort, and experience. It involves the use of cognitive skills and working through DISPOSITIONS, the way a person approaches life and living (Facione, 2010). Boxes 5-1 and 5-2 highlight the cognitive skills and dispositions important for critical thinking.

In addition to these cognitive skills and dispositions, evidence-based research has identified specific behaviors that demonstrate the knowledge, characteristics, and skills needed to promote critical thinking for clinical decision making. These behaviors are termed CRITICAL THINKING INDICATORS™ (CTIs^™; Alfaro-LeFevre, 2010). The two major categories of CTIs address knowledge and intellectual skills and competencies. Knowledge indicators involve:

Intellectual skills and competencies involve:

Nurses also need to possess personal CTIs that support the critical thinking characteristics. These personal CTIs reflect the nurse’s behaviors, attitudes, and qualities that are associated with critical thinking.

Framework for Critical Thinking and Clinical Decision Making

The question is, “How is critical thinking related to clinical decision making in psychiatric-mental health nursing?” First, critical thinking is a skill set involving cognitive skills and dispositions. It is a framework that structures psychiatric-mental health nurse’s clinical decision making for psychiatric-mental health patients and their needs throughout the interpersonal relationship. One way that psychiatric-mental health nurses use critical thinking as a framework for clinical decision making is to answer a structured series of questions either through individual reflection or in consultation with other nurses. Facione (2010) developed the “IDEALS” approach to assist psychiatric-mental health nurses in making therapeutic clinical decisions. This framework includes “Six Questions for Effective Thinking and Problem Solving” (Box 5-3).

Reflecting on and answering these questions can promote critical thinking involving cognitive skills and dispositions when a psychiatric-mental health nurse is engaged in the interpersonal relationship and faces a clinical problem in delivering care. One example of psychiatric-mental health nurses using critical thinking skills to solve patient care problems may include situations that involve the need to alter a noneffective plan of care after a nurse–patient interaction. Another example may occur when the nurse requests clinical supervision to better understand how personal feelings may be influencing the nurse–patient relationship. A third example may be when a nurse participates in a case conference related to developing a more consistent approach to a patient’s needs. Thus, when issues arise for a patient or within the interpersonal relationship, the psychiatric-mental health nurse’s critical thinking skills can help find the answer to the question, “What should I say or do now to meet this patient’s needs?”

THE NURSING PROCESS

The NURSING PROCESS is a systematic method of problem solving that provides the nurse with a logical, organized framework from which to deliver nursing care. It is an ongoing, complex, cyclical process that requires the nurse to continually collect data, critically analyze it, and incorporate it into the patient’s treatment plan (Fortinash & Holoday Worret, 2008). Thus, the nursing process integrates critical thinking skills and clinical decision making. According to the American Nurses Association and The International Society of Psychiatric Mental Health Nurses (2014):

The nursing process used in this text includes four key stages: assessment, planning/diagnosing, implementation, and evaluation (APIE). Nurses use the nursing process to deliver safe, effective therapeutic nursing care regardless of the setting. The challenge for psychiatric-mental health nurses is to integrate the specialized focus of their work with patients—the therapeutic use of self within the interpersonal relationship—with their nursing process skills. The integration of Peplau’s four-phase interpersonal model with the four-step nursing process model challenges the nurse to use critical thinking skills to provide care for psychiatric-mental health patients. Both the nursing process and the interpersonal relationship reflect a problem-solving approach to providing care. Their integration is important because it is the foundation for sound clinical decision making in psychiatric-mental health nursing.

The Nursing Process and the Interpersonal Relationship

Recall from Chapter 2 that Peplau identified four phases of the interpersonal relationship: orientation, identification, exploitation, and resolution. These phases closely parallel the stages of the nursing process. Figure 5-1 depicts the correlations among critical thinking, clinical decision making, the interpersonal relationship, and the nursing process.

Assessment

The first stage of the nursing process is assessment, which involves the collection of patient data through a patient history and physical assessment. For the psychiatric-mental health patient, a mental status examination and psychosocial assessment are essential components. The nurse obtains additional information from the patient’s medical record as well as from his or her own knowledge of relevant and current literature. This data collection process is ongoing, with the nurse continuously updating and validating the information.

Peplau’s orientation and identification phases correspond to the assessment phase of the nursing process. In some clinical situations, a psychiatric-mental health nurse will have information about the patient before meeting him or her. This information may come from a variety of sources. The nurse may have information from a nursing report, another professional, records from other agencies, the patient’s significant others, or a patient having filled out an assessment questionnaire before the meeting. At other times, a psychiatric-mental health nurse may need to respond to a patient’s needs without any previous clinical history, such as in a crisis situation. The nurse uses observation skills to gather clinical information that can guide nursing interventions in the orientation and identification phases of such a relationship. A nurse might encounter a psychiatric patient in a hospital unit day room after an angry outburst in which the patient threatens to harm himself or herself. Although the nurse may have only minimal background information on the patient, the nurse can gather data based on the patient’s current emotional and behavioral status, which will guide the assessment and planning of care. Peplau also felt that the nurse should not explicitly focus on his or her own individual behavior or the client’s individual behavior; rather, the combined experience of the interaction should be interpreted (D’Antonio, Beeber, Sills, & Naegle, 2014).

Figure 5-1 Interrelationship among critical thinking, clinical decision making, the interpersonal relationship, and the nursing process.

Information about a patient’s prior clinical history is important because it can influence the orientation and identification phases when the nurse and the patient interact. When reviewing a patient’s clinical history, a psychiatric-mental health nurse needs to mobilize therapeutic use of self-skills to analyze and monitor his or her own reactions to the information and how it might help or hinder the establishment of a therapeutic relationship. Information that a psychiatric-mental health nurse has before meeting the patient, whether it is historical in nature or immediately in the here and now, can trigger a range of reactions for the nurse. The psychiatric nurse needs to develop self-awareness about how either a stereotypically biased reaction (e.g., questioning how any mother could attempt to harm her newborn) or a personal reaction (such as a nurse who works in substance abuse recovery reacting negatively to a patient’s suicide attempt during a relapse) can impede the development of a therapeutic relationship before it even begins. How Would You Respond? 5-1 provides a practical example for the therapeutic use of self during the assessment stage and orientation phase.

The assessment stage begins when the patient and nurse meet, often for the first time. According to Peplau (1952), the orientation and identification phases begin when the nurse and the patient meet together and begin to structure a relationship that can therapeutically address the patient’s needs. Whether this is an encounter where the nurse meets the patient for the first time or the patient is known to the nurse from a previous therapeutic relationship and has now returned for further help, the assessment stage and the orientation and identification phases set the stage for how the nursing process and interpersonal relationship will unfold. Anxiety for both the nurse and the patient is common during this time because each has preconceptions about the other as well as uncertainty about how and if help can be provided.

The nurse collects biopsychosocial clinical assessment data using the formats specific to the setting, for example, the hospital unit, emergency department, community agency, residential setting, or home health care setting. This clinical assessment occurs within the nurse–patient relationship. The psychiatric-mental health nurse works to build a trusting alliance with the patient so that the patient will share his or her perceptions about why this meeting is occurring and what his or her needs are. Using critical thinking skills, the nurse and the patient identify the problem and define the context, thereby providing the basis for determining future strategies to address the problems.

 

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