Critical thinking, the nursing process, and clinical judgment

Learning outcomes

After studying this chapter, students will be able to:

• Define critical thinking.

• Describe the importance of critical thinking in nursing.

• Contrast the characteristics of “novice thinking” with those of “expert thinking.”

• Explain the purpose and phases of the nursing process.

• Differentiate between nursing orders and medical orders.

• Explain the differences between independent, interdependent, and dependent nursing actions.

• Describe evaluation and its importance in the nursing process.

• Define clinical judgment in nursing practice and explain how it is developed.

• Devise a personal plan to use in developing sound clinical judgment.

To enhance your understanding of this chapter, try the Student Exercises on the Evolve site at http://evolve.elsevier.com/Black/professional.

Almost every encounter a nurse has with a patient is an opportunity for the nurse to assist the patient to a higher level of wellness or comfort. A nurse’s ability to think critically about a patient’s particular needs and how best to meet them will determine the extent to which a patient benefits from the nurse’s care. A nurse’s ability to use a reliable cognitive approach is crucial in determining a patient’s priorities for care and in making sound clinical decisions in addressing those priorities. This chapter explores several important and interdependent aspects of thinking and decision making in nursing: critical thinking, the nursing process, and clinical judgment.

Chapter opening photo from istockphoto.com.

Defining critical thinking

Defining “critical thinking” is a complex task that requires an understanding of how people think through problems. Educators and philosophers struggled with definitions of critical thinking for several decades. Two decades ago, the American Philosophical Association published an expert consensus statement (Box 8-1) describing critical thinking and attributes of the ideal critical thinker. This expert statement, still widely used, was the culmination of 3 years of work by Facione and others who synthesized the work of numerous persons who had defined critical thinking. More recently, Facione (2006) noted that giving a definition of critical thinking that can be memorized by the learner is actually antithetical to critical thinking! This means that the very definition of critical thinking does not lend itself to simplistic thinking and memorization.

BOX 8-1 EXPERT CONSENSUS STATEMENT REGARDING CRITICAL THINKING AND THE IDEAL CRITICAL THINKER

We understand critical thinking (CT) to be purposeful, self-regulatory judgment that results in interpretation, analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment is based. CT is essential as a tool of inquiry. As such, CT is a liberating force in education and a powerful resource in one’s personal and civic life. While not synonymous with good thinking, CT is a pervasive and self-rectifying human phenomenon. The ideal critical thinker is habitually inquisitive, well-informed, trustful of reason, open-minded, flexible, fair-minded in evaluation, honest in facing personal biases, prudent in making judgments, willing to reconsider, clear about issues, orderly in complex matters, diligent in seeking relevant information, reasonable in the selection of criteria, focused in inquiry, and persistent in seeking results that are as precise as the subject and the circumstances of inquiry permit. Thus educating good critical thinkers means working toward this ideal. It combines developing CT skills with nurturing those dispositions that consistently yield useful insights and that are the basis of a rational and democratic society.

From American Philosophical Association: Critical Thinking: A Statement of Expert Consensus for Purposes of Educational Assessment and Instruction, The Delphi report: Research findings and recommendations prepared for the committee on pre-college philosophy, 1990, ERIC Document Reproduction Services, pp. 315–423.

The Paul-Elder Critical Thinking Framework is grounded in this definition of critical thinking:

“Critical thinking is that mode of thinking—about any subject, content, or problem—in which the thinker improves the quality of his or her thinking by skillfully taking charge of the structures inherent in thinking and imposing intellectual standards upon them.”

Paul and Elder, 2012

Paul and Elder (2012) go on to describe a “well-cultivated critical thinker” as one who does the following:

• Raises questions and problems and formulates them clearly and precisely

• Gathers and assesses relevant information, using abstract ideas for interpretation

• Arrives at conclusions and solutions that are well-reasoned and tests them against relevant standards

• Is open-minded and recognizes alternative ways of seeing problems, and has the ability to assess the assumptions, implications, and consequences of alternative views of problems

• Communicates effectively with others as solutions to complex problems are formulated

We live in a “new knowledge economy” driven by information and technology that changes quickly. Analyzing and integrating information across an increasing number of sources of knowledge requires that you have flexible intellectual skills. Being a good critical thinker makes you more adaptable in this new economy of knowledge (Lau and Chan, 2012). An excellent website on critical thinking can be found at http://philosophy.hku.hk/think/ (OpenCourseWare on critical thinking, logic, and creativity).

So what does this have to do with nursing? The answer is very simple: excellent critical thinking skills are required for you to make good clinical judgments. You will be responsible and accountable for your own decisions as a professional nurse. The development of critical thinking skills is crucial as you provide nursing care for patients with increasingly complex conditions. Critical thinking skills provide you with a powerful means of determining patient needs, interpreting physician orders, and intervening appropriately. Box 8-2 presents an example of the importance of critical thinking in the provision of safe care.

BOX 8-2 USING CRITICAL THINKING SKILLS TO IMPROVE A PATIENT’S CARE

Ms. George has recently undergone bariatric surgery after many attempts to lose weight over the years have failed. She is to be discharged home on postoperative day 2, as per the usual protocol. Although she describes herself as “not feeling well at all,” the physician writes the order for discharge and you, as the nurse who does postoperative discharge planning for the surgery practice, prepare Ms. George to go home with her new dietary guidelines and encouragement for her successful weight loss. You note that Ms. George does not seem as comfortable or pleased with her surgery as most patients with whom you have worked in the past.

Ms. George has to wait 3 hours for her husband to drive her home, and you note that she continues to lie on the bed passively, and her lethargy is increasing. You take her vital signs and note that her temperature is 37.8° C and her pulse is 115. You listen to her chest and note that it is difficult to appreciate breath sounds due to the patient’s body habitus. Ms. George points to an area just below her left breast where she notes pain with inspiration. You call her physician to report your findings; she responds that Ms. George’s pain is “not unusual” with her type of bariatric surgery and that her slightly increased temperature is “most likely” related to her being somewhat dehydrated. She instructs you to have Ms. George force fluids to the extent that she can tolerate it, and to take mild pain medication for postoperative pain. You ask her to consider delaying her discharge home, but she refuses.

You give Ms. George acetaminophen as ordered, but her pain on inspiration continues. Her temperature remains at 37.8° C, and her pulse is 120. You measure her O₂ saturation with a pulse oximeter, and it is 91%. Her respirations are 26 and somewhat shallow. Her surgeon does not respond to your page, so you call the nursing supervisor, explaining to him that you are concerned with Ms. George’s impending discharge. Although you are wary of the surgeon’s reaction, you call the hospitalist (a physician who sees inpatients in the absence of their attending physician), who orders a chest x-ray study. Ms. George has evidence of a consolidation in her left lower lobe, which turns out to be a pulmonary abscess. She is treated on intravenous antibiotics for 5 days, and the abscess eventually has to be aspirated and drained.

Your critical thinking skills and willingness to advocate for your patient prevented an even worse postoperative course. You recognized that Ms. George’s lethargy was unusual, and the location and timing of her pain was of concern. You also realized that although her temperature appeared to be stable, she had been given a pain medicine (acetaminophen) that also reduces fever, so in fact, a temperature increase may have been masked by the antipyretic properties of the acetaminophen. You demonstrated excellent clinical judgment in measuring her O₂ saturation. Furthermore, you sought support through the nursing “chain of command” when you engaged the nursing supervisor, who supported you in contacting the hospitalist. The specific, detailed information that you were able to provide the hospitalist allowed him to follow a logical diagnostic path, determining that Ms. George did indeed have a significant postoperative complication. Two days later, Ms. George reports that she is “feeling much better” and is walking in the hallways several times a day.

Critical thinking in nursing

You may be wondering at this point, “How am I ever going to learn how to make connections among all of the data I have about a patient?” This is a common response for a nursing student who is just learning some of the most basic psychomotor skills in preparation for practice. You need to understand that, just like learning to give injections safely and maintaining a sterile field properly, you can learn to think critically. This involves paying attention to how you think and making thinking itself a focus of concern. A nurse who is exercising critical thinking asks the following questions: “What assumptions have I made about this patient?” “How do I know my assumptions are accurate?” “Do I need any additional information?” and “How might I look at this situation differently?”

Nurses just beginning to pay attention to their thinking processes may ask these questions after nurse–patient interactions have ended. This is known as reflective thinking. Reflective thinking is an active process valuable in learning and changing behaviors, perspectives, or practices. Nurses can also learn to examine their thinking processes during an interaction as they learn to “think on their feet.” This is a characteristic of expert nurses. As you move from novice to expert, your ability to think critically will improve with practice. In Chapter 6 you read about Dr. Patricia Benner (1984, 1996), who studied the differences in expertise of nurses at different stages in their careers, from novice to expert. So it is with critical thinking: novices think differently from experts. Box 8-3 summarizes the differences in novice and expert thinking.

BOX 8-3 NOVICE THINKING COMPARED WITH EXPERT THINKING

Novice nurses

• Tend to organize knowledge as separate facts. Must rely heavily on resources (e.g., texts, notes, preceptors). Lack knowledge gained from actually doing (e.g., listening to breath sounds).

• Focus so much on actions that they may not fully assess before acting

• Need and follow clear-cut rules

• Are often hampered by unawareness of resources

• May be hindered by anxiety and lack of self-confidence

• Tend to rely on step-by-step procedures and follow standards and policies rigidly

• Tend to focus more on performing procedures correctly than on the patient’s response to the procedure

• Have limited knowledge of suspected problems; therefore they question and collect data more superficially or in a less focused way than more experienced nurses

• Learn more readily when matched with a supportive, knowledgeable preceptor or mentor

Expert nurses

• Tend to store knowledge in a highly organized and structured manner, making recall of information easier. Have a large storehouse of experiential knowledge (e.g., what abnormal breath sounds sound like, what subtle changes look like).

• Assess and consider different options for intervening before acting

• Know which rules are flexible and when it is appropriate to bend the rules

• Are aware of resources and how to use them

• Are usually more self-confident, less anxious, and therefore more focused than less experienced nurses

• Know when it is safe to skip steps or do two steps together. Are able to focus on both the parts (the procedures) and the whole (the patient response).

• Are comfortable with rethinking a procedure if patient needs require modification of the procedure

• Have a better idea of suspected problems, allowing them to question more deeply and collect more relevant and in-depth data

• Analyze standards and policies, looking for ways to improve them

• Are challenged by novices’ questions, clarifying their own thinking when teaching novices

From Alfaro-LeFevre R: Critical Thinking in Nursing: A Practical Approach, ed. 2, Philadelphia, 1999, Saunders. Reprinted with permission.

Critical thinking is a complex, purposeful, disciplined process that has specific characteristics that make it different from run-of-the-mill problem solving. Critical thinking in nursing is undergirded by the standards and ethics of the profession. Consciously developed to improve patient outcomes, critical thinking by the nurse is driven by the needs of the patient and family. Nurses who think critically are engaged in a process of constant evaluation, redirection, improvement, and increased efficiency. Be aware that critical thinking involves far more than stating your opinion. You must be able to describe how you came to a conclusion and support your conclusions with explicit data and rationales. Becoming an excellent critical thinker is significantly related to increased years of work experience and to higher education level; moreover, nurses with critical thinking abilities tend to be more competent in their practice than nurses with less well-developed critical thinking skills (Chang, Chang, Kuo et al., 2011). Box 8-4 summarizes these characteristics and offers an opportunity for you to evaluate your progress as a critical thinker.

BOX 8-4 SELF-ASSESSMENT: CRITICAL THINKING

Directions: Listed below are 15 characteristics of critical thinkers. Mark a plus sign (+) next to those you now possess, mark IP (in progress) next to those you have partially mastered, and mark a zero (0) next to those you have not yet mastered. When you are finished, make a plan for developing the areas that need improvement. Share it with at least one person, and report on progress weekly.

Characteristics of critical thinkers: How do you measure up?

______ Inquisitive/curious/seeks truth

______ Self-informed/finds own answers

______ Analytic/confident in own reasoning skills

______ Open-minded

______ Flexible

______ Fair-minded

______ Honest about personal biases/self-aware

______ Prudent/exercises sound judgment

______ Willing to revise judgment when new evidence warrants

______ Clear about issues

______ Orderly in complex matters/organized approach to problems

______ Diligent in seeking information

______ Persistent

______ Reasonable

______ Focused on inquiry

An excellent continuing education (CE) self-study module designed to improve your ability to think critically can be found online (www.nurse.com/ce/CE168-60/Improving-Your-Ability-to-Think-Critically). Continuing one’s education through lifelong learning is an excellent way to maintain and enhance your critical thinking skills. The website www.nurse.com has more than 500 CE opportunities available online and may be helpful to you as you seek to increase your knowledge base and improve your clinical judgment. Being intentional about improving your critical thinking skills ensures that you bring your best effort to the bedside in providing care for your patients.

The nursing process: An intellectual standard

Critical thinking requires systematic and disciplined use of universal intellectual standards (Paul and Elder, 2012). In the practice of nursing, the nursing process represents a universal intellectual standard by which problems are addressed and solved. The nursing process is a method of critical thinking focused on solving patient problems in professional practice. The nursing process is “a conceptual framework that enables the student or the practicing nurse to think systematically and process pertinent information about the patient” (Huckabay, 2009, p. 72).

Humans are involved in problem solving on a daily basis. Suppose your favorite band is performing in a nearby city the night before your big exam in pathophysiology. Your exam counts 35% of your final grade. But you have wanted to see this band since you were 15, and you do not know when you will have another chance. You are faced with weighing a number of factors that will influence your decision about whether to go see the band: your grade going into the exam; how late you will be out the night before the exam; how far you will have to drive to see the band; and how much study time you will have to prepare for the exam in advance. You are really conflicted about this, so you decide to let another factor determine what you will do: the cost of the ticket. When you learn that the only seats available are near the back of the venue and cost $105.00 each, you decide to stay home, get a good night’s sleep before the big exam, and make a 98%. You then realize that with such a good grade on this exam, you will have much less pressure when studying for the final exam at the end of the semester. You have identified a problem (not a particularly serious one, but one with personal significance!), considered various factors related to the problem, identified possible actions, selected the best alternative, evaluated the success of the alternative selected, and made adjustments to the solution based on the evaluation. This is the same general process nurses use in solving patient problems through the nursing process.

For individuals outside the profession, nursing is commonly and simplistically defined in terms of tasks nurses perform. Many students get frustrated with activities and courses in nursing school that are not focused on these tasks, believing themselves that the tasks of nursing are nursing. Even within the profession, the intellectual basis of nursing practice was not articulated until the 1960s, when nursing educators and leaders began to identify and name the components of nursing’s intellectual processes. This marked the beginning of the nursing process.

In the 1970s and 1980s, debate about the use of the term “diagnosis” began. Until then, diagnosis was considered to be within the scope of practice of physicians only. Although nurses were not educated or licensed to diagnose medical conditions in patients, nurses recognized that there were human responses amenable to independent nursing intervention. A nursing diagnosis, then, is “a clinical judgment about individual, family or community responses to actual or potential health problems or life processes which provide the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability” (NANDA-I, 2012). These responses could be identified (diagnosed) through the careful application of specific defining characteristics.

In 1973, the National Group for the Classification of Nursing Diagnosis published its first list of nursing diagnoses. This organization, which recently celebrated its 40th year, is now known as NANDA International (NANDA-I; NANDA is the acronym for North American Nursing Diagnosis Association). Its mission is to “facilitate the development, refinement, dissemination and use of standardized nursing diagnostic terminology” with the goal to “improve the health care of all people” (NANDA-I, 2012). In 2011, NANDA-I published its 2012–2014 edition of Nursing Diagnoses: Definitions and Classifications. Currently, NANDA-I has more than 200 diagnoses approved for clinical testing and has recently added 16 new diagnoses and 8 revised diagnoses. Diagnoses are also retired if it becomes evident that their usefulness is limited or outdated, such as the former diagnosis “disturbed thought processes.”

Here is a simple example of how an approved nursing diagnosis may be used:

Two days after a surgery for a large but benign abdominal mass, Mr. Stevens has not yet been able to tolerate solid food and has diminished bowel sounds. His abdomen is somewhat distended. Your diagnosis is that Mr. Stevens has dysfunctional gastrointestinal motility. This diagnosis is based on NANDA-I’s taxonomy because you have determined that the risk factors and physical signs and symptoms associated with this diagnosis apply to him.

A more detailed discussion of nursing diagnosis is located in the next section of this chapter.

The nursing process as a method of clinical problem solving is taught in schools of nursing across the United States, and many states refer to it in their nurse practice acts. The nursing process has sometimes been the subject of criticism among nurses. In recent years, some nursing leaders have questioned the use of the nursing process, describing it as linear, rigid, and mechanistic. They believe that the nursing process contributes to linear thinking and stymies critical thinking. They are concerned that the nursing process format, and rigid faculty adherence to it, encourages students to copy from published sources when writing care plans, thus inhibiting the development of a holistic, creative approach to patient care (Mueller, Johnston, and Bligh, 2002). Certainly the nursing process can be taught, learned, and used in a rigid, mechanistic, and linear manner. Ideally the nursing process is used as a creative approach to thinking and decision making in nursing. Because the nursing process is an integral aspect of nursing education, practice, standards, and practice acts nationwide, learning to use it as a mechanism for critical thinking and as a dynamic and creative approach to patient care is a worthwhile endeavor. Despite reservations among some nurses about its use, the nursing process remains the cornerstone of nursing standards, legal definitions, and practice and, as such, should be well understood by every nurse.