Critical Thinking, Clinical Decision Making, and the Interpersonal Relationship


CHAPTER 5






CRITICAL THINKING, CLINICAL DECISION MAKING, AND THE INTERPERSONAL RELATIONSHIP


Angie S. Chesser


CHAPTER CONTENTS


Critical Thinking and Clinical Decision Making


The Nursing Process


Implications for Psychiatric-Mental Health Nursing


EXPECTED LEARNING OUTCOMES


After completing this chapter, the student will be able to:


  1.  Identify the basic concepts involved in critical thinking


  2.  Correlate critical thinking with clinical decision making


  3.  Describe the framework for critical thinking


  4.  Describe how the nursing process is related to critical thinking and clinical decision making


  5.  Correlate the stages of the nursing process with Peplau’s phases of the interpersonal relationship


KEY TERMS


Critical thinking


Critical Thinking Indicators™ (CTIs™)


Dispositions


Nursing process


Psychoeducational intervention



 


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



         an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open mindedness, perseverance and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discrimination, information seeking, logical reasoning, predicting, and transforming knowledge. (p. 357)


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



 





Critical thinking is a purposeful method of reasoning that is systematic, reflective, rational, organized, and outcome oriented. Effort, practice, and experience are necessary to develop critical thinking.






Domains of Critical Thinking


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



image    Elements of Thought—The basic building blocks of thinking, such as purpose (what one hopes to accomplish), question or problem at issue, points of view or frame of reference, empirical dimension (evidence, data, or information), concepts and ideas, assumptions, and implications and consequences.


image    Abilities—The skills essential to higher order thinking, such as evaluating the credibility, analyzing arguments, clarifying meanings, generating possible solutions, and developing criteria for evaluation.


image    Affective Dimensions—The attitudes, dispositions, passions, and traits of mind essential to higher order thinking in real settings, such as thinking independently, being fair minded, developing insight, intellectual humility, intellectual courage, perseverance, and developing confidence in reasoning and intellectual curiosity.


image    Intellectual Standards—The standards used to critique higher-order thinking, such as clarity, specificity, consistency, preciseness, significance, accuracy, and fairness (Paul, 1993).


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:



image    Clarifying nursing versus medical information, normal and abnormal function including factors that affect normal function, rationales for interventions, policies and procedures, standards, laws and practice acts that are applicable to the situation, ethical and legal principles, and available information resources


image    Demonstrating focused nursing assessment skills and related technical skills, and clarifying personal values, beliefs, and needs, including how one’s self may differ from others’ preferences and organizational mission and values.


Intellectual skills and competencies involve:



image    Application of standards, principles, laws, and ethics


image    Systematic and comprehensive assessment


image    Detection of bias and determination of information credibility



 





image


BOX 5-1: COGNITIVE SKILLS ASSOCIATED WITH CRITICAL THINKING







INTERPRETATION



  Comprehension and expression of the meaning or significance of wide-ranging experiences, situations, data, events, and beliefs


  Ability to categorize, decode, and clarify the meaning and significance of the information


ANALYSIS



  Identification of intended and inferred relationships


  Examination of ideas


  Detection and analysis of arguments


EVALUATION



  Assessment of credibility


  Assessment of logical strength of actual or intended inferential relationships


INFERENCE



  Ability to draw reasonable conclusions, conjectures, and hypotheses


  Ability to arrive at consequences based on data evidence, beliefs, opinions, and descriptions


  Evidence queries, alternative conjectures, and conclusion drawing


EXPLANATION



  Presentation of coherent, logical, and rational reasoning


  Description of methods and results, justification of procedures, proposal and defense of one’s explanations or points of view, and presentation of full, well-reasoned arguments for seeking the best understanding


SELF-REGULATION



  Ability to self-consciously monitor one’s cognitive activities, elements used in activities, and results obtained


  Self-examination and self-correction


Adapted from Facione (2010).







 





image


BOX 5-2: DISPOSITIONS ASSOCIATED WITH CRITICAL THINKING








  Independent thinking


  Inquisitiveness toward a wide range of issues


  Concern to be and remain well informed


  Self-confidence in own abilities


  Open mindedness, fair mindedness


  Flexibility for alternatives and other options


  Honesty related to one’s own biases, prejudices, and stereotypes


  Intellectual courage: willingness to reconsider and revise views when change is necessary


  Creativity or “thinking outside the box”


Adapted from Facione (2010).






 

image    Identification of assumptions and inconsistencies


image    Development of reasonable conclusions based on evidence


image    Determination of individual outcomes with a focus on results


image    Risk management; priority setting


image    Effective communication


image    Individualization of interventions


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.



 





The four domains of critical thinking are elements of thought, abilities, affective dimensions, and intellectual standards. Critical thinking involves the use of cognitive skills and working through dispositions or the way a person approaches life and living.






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 psychiatric-mental health nurse uses critical thinking skills to find the answer to the question about what to do or say to meet the patient’s needs.







 





image


BOX 5-3: SIX QUESTIONS FOR EFFECTIVE THINKING AND PROBLEM SOLVING: “IDEALS”































Identify the problem:


“What’s the real question we’re facing here?”


Define the context:


“What are the facts and circumstances that frame this problem?”


Enumerate choices:


“What are our most plausible three or four options?”


Analyze options:


“What is our best course of action, all things considered?”


List reasons explicitly:


“Exactly why are we making this choice rather than another?”


Self-correct:


“Okay, let’s look at it again. What did we miss?”


Adapted from Facione (2010).






 





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 six Standards of Practice describe a competent level of psychiatric-mental health nursing care as demonstrated by the critical thinking model known as the nursing process …. The nursing process encompasses all significant actions taken by registered nurses, and forms the foundation of the nurse’s decision making.


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.



 





Both the nursing process and the interpersonal relationship reflect a problem-solving approach to providing care. Psychiatricmental health nurses integrate the nursing process and the interpersonal relationship for sound clinical decision making in psychiatricmental health nursing.






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).


image


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.


Sep 16, 2017 | Posted by in NURSING | Comments Off on Critical Thinking, Clinical Decision Making, and the Interpersonal Relationship

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