Critical Thinking in Nursing Practice Chapter 15 Critical Thinking in Nursing Practice Clinical judgment is an essential skill that involves the interpretation of a patient’s needs, concerns, or health problems and the decision to take action or not, to use or modify standard approaches, or to improvise new approaches on the basis of a patient’s response. Nurses apply knowledge, clinical experiences, and professional standards when thinking critically and making decisions about patient care. As nurses develop professionally, it is important to acquire critical thinking skills that allow you to face each new patient care experience or problem with open-mindedness, creativity, confidence, and continual inquiry. Critical thinking is acquired through experience, commitment, and active curiosity. Critical thinking is not a simple step-by-step linear process that is learned in a short period of time. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Clinical Judgment in Nursing Practice Registered nurses (RNs) are responsible for making accurate and appropriate clinical decisions or judgments. Nurses must learn to question, wonder, and explore different perspectives and interpretations to find a solution that benefits the patient. Clinical decision making separates RNs from technicians. Technical personnel are directed by nurses to perform certain aspects of care and report back any important observations to keep RNs informed. The RN is responsible for making decisions on the basis of clinical information. An RN relies on knowledge and experience when deciding if a patient is having complications that call for notification of a health care provider or if a teaching plan for a patient is ineffective and needs revision. When a clinical situation develops the RN must learn to recognize it, interpret the meaning, and respond appropriately. Each patient’s health problems are unique, a product of the patient’s physical health, lifestyle, culture, relationship with family and friends, living environment, and experiences. With experience you learn to creatively seek new knowledge, act quickly when events change, and make quality decisions for patients’ well-being. You will find nursing to be rewarding and fulfilling through the clinical judgments you make. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Critical Thinking Defined Critical thinking is: The ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process A continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant Recognizing that an issue exists, analyzing information, evaluating information, and drawing conclusions A critical thinker considers what is important in each clinical situation, imagines and explores alternatives, considers ethical principles, and makes informed decisions about the care of patients. Critical thinking is a way of thinking about a situation that always asks “Why?”, “What am I missing?”, “What do I really know about this patient’s situation?”, and “What are my options?” The use of evidence-based knowledge, or knowledge based on research or clinical expertise, makes you an informed critical thinker. Critical thinking requires cognitive skills and the habit of asking questions, staying well informed, being honest in facing personal biases, and always being willing to reconsider and think clearly about issues. [Review Table 15-1, Critical Thinking and Clinical Judgment Skills, with the students.] Nurses who apply critical thinking in their work focus on options for solving problems and making decisions rather than rapidly and carelessly forming quick, simple solutions. Critical thinking is more than just problem solving. It is a continuous attempt to improve how to apply yourself when faced with problems in patient care. [Review Table 15-2, Concepts for a Critical Thinker, with the students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Reflection The ability to act on the basis of critical thinking comes with experience. Turning over a subject in the mind and thinking about it seriously is reflection. Reflection is not intuitive. When you care for patients, begin by thinking about previous situations and considering relevant issues: What did I notice before? How did I act? What could I have done differently? What should I do next time in the same situation? Research shows that when nurses reflect on past experiences, they perceive that their knowledge increases and their critical thinking moves to a higher level. Reflection involves playing back a situation in your mind and taking time to honestly review everything you remember about it. Reflective reasoning improves the accuracy of making diagnostic conclusions. By reviewing your previous actions you see successes and opportunities for improvement. Always be cautious in using reflection. Reliance on it can block thinking and not allow you to look at newer evidence or subtle aspects of situations that you have not encountered. [Review Box 15-1, Tips on Using Reflection, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study Carla is a third year nursing student assigned to a surgical nursing unit. Mr. Javier Ramirez is a 55-year-old construction worker, admitted after falling off scaffolding on a construction site. His x-ray films reveal a right femur fracture and right wrist fracture. An abdominal computed tomography (CT) scan shows bruising of the liver. Mr. Ramirez has not been hospitalized in the past. When he first meets Carla, he is very quiet and asks few questions. [Ask students: What do we know so far about the patient in this case study? What reasons might there be for Mr. Ramirez to be so quiet and ask so few questions? What kinds of responsibilities might Carla have when caring for Mr. Ramirez? Do you think that because Mr. Ramirez is “very quiet and asks few questions,” he will be easy for Carla to care for? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Levels of Critical Thinking in Nursing At the basic level of critical thinking a learner trusts that experts have the right answers for every problem. Thinking is concrete and based on a set of rules or principles. A basic critical thinker learns to accept the diverse opinions and values of experts (e.g., instructors and staff nurse preceptors). However, inexperience, weak competencies, and inflexible attitudes can restrict a person’s ability to move to the next level of critical thinking. Complex critical thinkers begin to separate themselves from experts and analyze the clinical situation and examine choices more independently. In complex critical thinking, each solution has benefits and risks that you weigh before making a final decision. In complex critical thinking each solution has benefits and risks that you weigh before making a final decision. There are options. Thinking becomes more creative and innovative. The complex critical thinker is willing to consider different options from routine procedures when complex situations develop. You learn to gather additional information and take a variety of different approaches for the same therapy. At the commitment level, nurses anticipate when to make choices without assistance from others and accept accountability for decisions made. As a nurse you do more than just consider the complex alternatives that a problem poses. The nurse chooses an action or belief that is based on the available alternatives and support it. Because they take accountability for the decision, nurses consider the results of the decision and determine whether it was appropriate. [Shown is Figure 15-1: Critical thinking model for nursing judgment.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Mr. Ramirez’s leg is in skeletal traction and his right arm is in a soft cast. Carla decides that she needs to begin her care by assessing Mr. Ramirez and determining his health status. She begins by reviewing his medical history. She learns that he has a history of smoking and was diagnosed with type 2 diabetes just 5 years ago. • [Ask students: Do you think Carla is making the right decision to begin her care of Mr. Ramirez by assessing his health status? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Critical Thinking Competencies General critical thinking Scientific method Problem solving Decision making Specific critical thinking Diagnostic reasoning and inference Clinical decision making The scientific method is a systematic, ordered approach to gathering data and solving problems and has five steps: identify the problem, collect data, formulate a question or hypothesis, test the question or hypothesis, and evaluate results of the test or study. [Review Box 15-2, Using the Scientific Method to Solve Nursing Practice Questions, with students.] Effective problem solving involves evaluating a situation over time, identifying possible solutions, and trying a solution over time to make sure that it is effective. It becomes necessary to try different options if a problem recurs. Decision making is a product of critical thinking that focuses on problem resolution. Following a set of criteria helps to make a thorough and thoughtful decision. The criteria may be personal; based on an organizational policy; or, in the case of nursing, a professional standard. The person has to weigh each option against a set of personal criteria, test possible options, consider the consequences of the decision, and make a final decision. Decision making involves moving back and forth when considering all criteria. It leads to informed conclusions that are supported by evidence and reason. Diagnostic reasoning is the analytical process for determining a patient’s health problems. Accurate recognition of a patient’s problems is necessary before you decide on solutions and implement action. It requires you to assign meaning to the behaviors and physical signs and symptoms presented by a patient. An expert nurse sees the context of a patient situation, observes patterns and themes, and makes decisions quickly. Part of diagnostic reasoning is clinical inference, the process of drawing conclusions from related pieces of evidence and previous experience with the evidence. When making an inference, you form patterns of information from data before making a diagnosis. When uncertain of a diagnosis, continue data collection. You have to critically analyze changing clinical situations until you are able to determine a patient’s unique situation. Clinical decision making makes a decision that identifies the problem, reducing the severity of the problem or resolving the problem completely. Skilled clinical decision making occurs through in-depth knowledge of a patient’s patterns of responses within a clinical situation and knowing the patient as a person. It has two components: a nurse’s understanding of a specific patient and his or her subsequent selection of interventions. To foster knowing your patients: Spend more time during initial patient assessments to observe patient behavior and measure physical findings as a way to improve knowledge of your patients. Determine what is important to them and make an emotional connection. Patients perceive meaningful time as that involving personal rather than task-oriented conversation. When talking with patients, listen to their accounts of their experiences with illness, watch them, and come to understand how they typically respond. Consistently check on patients to assess and monitor problems to help you identify how clinical changes develop over time. Ask to have the same patient assigned to you over consecutive days. Researchers have noted that a nurse-patient relationship develops from getting to know a patient and building a foundation for connecting on the first day of care, to deepening understanding of the patient and sustaining a connection by the second day, to being comfortable with the patient by the third day. Social conversation and continuity are important for developing knowing and nurse-patient relationships. Always keep a patient as your center of focus as you try to solve clinical problems. When you work in a busy setting, use criteria that includes the clinical condition of the patient. To manage the wide variety of problems associated with groups of patients, skillful, prioritized clinical decision making is critical. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Critical Thinking Competencies (Cont.) Nursing process as a competency Assessment Diagnosis Planning Implementation Evaluation [Review Box 15-3, Clinical Decision Making for Groups of Patients, with students.] The purpose of the nursing process is to diagnose and treat human responses to actual or potential health problems. Use of the process enables nurses to help patients meet agreed-on outcomes for better health. [Shown is Figure 15-2: Five-step nursing process model.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

A Critical Thinking Model for Clinical Decision Making Model components: Specific knowledge base Experience Nursing process competency Attitudes for critical thinking Professional standards [Review Box 15-4, Components of Critical Thinking in Nursing, with students.] The ability to think critically, improve clinical practice, and decrease errors in clinical judgments are aims of nursing practice. Learning to apply each element of this model in the way you think about patients will help you become a more confident and effective professional. Knowledge prepares you to better anticipate and identify patients’ problems by understanding their origin and nature. As a nurse your knowledge base includes information and theory from the basic sciences, humanities, behavioral sciences, and nursing. Nurses use their knowledge base in a different way than other health care disciplines because they think holistically about patient problems. The depth and extent of knowledge influence your ability to think critically about nursing problems. Clinical learning experiences are necessary to acquire clinical decision-making skills. Knowledge combined with clinical expertise from experience defines critical thinking. With experience you begin to understand clinical situations, anticipate and recognize cues of patients’ health patterns, and interpret the cues as relevant or irrelevant. The nursing process competency is the third component of the critical thinking model. In your practice you will apply critical thinking components during each step of the nursing process. Eleven attitudes define the central features of a critical thinker and how a successful critical thinker approaches a problem: confidence (belief in oneself); thinking independently (considering other ideas and concepts before forming an opinion); fairness (justly dealing with a situation); responsibility and accountability (knowledge that you are accountable for your decisions, actions, and critical thinking); risk taking (leads to advances in care); discipline (misses few details, is orderly or systematic when collecting information); perseverance (determination to find effective solutions); creativity (finding solutions outside the standard routines of care while following standards of practice); curiosity (asking “why?” and “what if?”); integrity (questioning and testing their own knowledge and beliefs); and humility (admitting limitations in knowledge and skill). [Review Table 15-3, Critical Thinking Attitudes and Applications in Nursing Practice, with the students.] Professional standards for critical thinking refer to ethical criteria for nursing judgments, evidence-based criteria used for evaluation, and criteria for professional responsibility. Excellent nursing practice is a reflection of ethical standards. Nurses routinely use evidence-based criteria to assess patients’ conditions and determine the efficacy of nursing interventions. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Carla knows that Mr. Ramirez is likely to be in pain because he is reluctant to move and take part in any activity. Her options include conducting a thorough pain assessment and learning how Mr. Ramirez feels about his pain. She must also be culturally sensitive and consider how Mr. Ramirez’s Hispanic heritage may influence his response to pain. Carla will then take what she learns and use pain control therapies Mr. Ramirez will be likely to accept. [Ask students: Do you think Carla is following the nursing process? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) When Carla notices that Mr. Ramirez is slow to respond to her questions, grimaces when shifting weight on his back, and is reluctant to have a bed bath, her critical thinking leads to the inference that Mr. Ramirez is in pain. Carla decides to assess the situation more thoroughly by asking Mr. Ramirez specific questions about his comfort, such as, “Tell me if you are hurting,” “Show me where the pain is located,” and “Is this pain you have felt before?” [Ask students: What does Carla notice about Mr. Ramirez? What does Carla infer from Mr. Ramirez’s behavior? How does Carla’s decision to ask Mr. Ramirez specific questions fit with your understanding of clinical decision making? Which of the 11 attitudes that we have covered would you say Carla is exhibiting? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Before Carla begins her questions, she repositions Mr. Ramirez to make him more comfortable. As she does so, she observes an area of redness over his left heel. Redness could be due to inflammation or pressure on the skin. Carla palpates the area, noting that it is tender to touch and warm. She asks Mr. Ramirez if he has been moving his leg much, and he says, “No, I haven’t. I am afraid I will hurt my other leg.” These initial findings imply that excess pressure is being applied to the heel. [Ask students: What discovery does Carla make as she is helping to reposition Mr. Ramirez? What knowledge does Carla possess that helps her in this part of the assessment? We know that every patient a nurse cares for will not have the exact same health status and needs. How does a nurse prepare to meet the challenge of each new patient’s care needs? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Quick Quiz! 1. The use of diagnostic reasoning involves a rigorous approach to clinical practice and demonstrates that critical thinking cannot be done: A. logically. B. haphazardly. C. independently. D. systematically. Answer: B Rationale: Critical thinking should be done using a systematic approach, using knowledge and experience to formulate an opinion. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Carla gently applies pressure to the area with her finger and notes that after pressure is released, the area does not blanch or turn white, a key sign of excess pressure. She thinks about what she knows about normal skin integrity, the effect of immobility, and the effects of pressure on the skin. The information she collects leads her to determine that Mr. Ramirez has an early-stage pressure ulcer. The nursing diagnosis would be “Impaired skin integrity.” [Ask students: How would you rate Carla as to her competencies at each step of the nursing process? Discuss.] [Ask students: Carla is clearly showing curiosity. What other attitudes and competencies is Carla displaying or employing? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Carla continues to gently encourage Mr. Ramirez to describe any symptoms or sensations that he is experiencing. He tells Carla that he does have pain in his stomach. Carla asks him to place his hand over the area of discomfort. Mr. Ramirez places his hand over the lower right quadrant of his abdomen. On a scale of 0 to 10, Mr. Ramirez rates his pain at 7. Carla inspects the area more closely and palpates gently over the abdomen for the presence of tenderness. She notes that the abdomen feels very tight. [Ask students: Do you think Carla anticipated this latest information from Mr. Ramirez? How important do you think it is for a nurse to be adaptable? What do you think Carla will do next? Discuss.] [Ask students: What intellectual standards did Carla apply when she asked Mr. Ramirez to rate his pain? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Critical Thinking Synthesis Critical thinking and the nursing process go hand-in-hand in making quality decisions about patient care. Critical thinking is a reasoning process by which you reflect on and analyze your thoughts, action, and knowledge. As a beginning nurse it is important to learn the steps of the nursing process and incorporate the elements of critical thinking. [Shown is Figure 15-3: Synthesis of critical thinking with the nursing process competency.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Developing Critical Thinking Skills Reflective journaling Define and express clinical experiences in your own words Meeting with colleagues Discuss and examine work experiences and validate decisions Concept mapping Visual representation of patient problems and interventions that shows their relationships to one another Reflective journal writing is a tool for developing critical thought and reflection by clarifying concepts. These concepts are embedded in the day-to-day clinical situations and problems you face. Tips for exploring clinical experience include: Which experience, situation, or information in your clinical experience is confusing, difficult, or interesting? What is the meaning of the experience? What feelings did you have? What feelings did your patient or family have? What influenced the experience? Do the feelings, guesses, or questions remind you of any experiences from the past or something that you think is a desirable future experience? How does it relate? What are the connections between what is being described and what you have learned about nursing science and theory? Nurses depend on others to help them think like nurses. The way to develop critical thinking skills is to meet regularly with colleagues, such as faculty members or preceptors, to discuss and examine work experiences and validate decisions. Connecting with others will help you learn that you do not need to know everything because support is available from other colleagues. Concept mapping is a nonlinear picture of a patient to be used for comprehensive care planning. The primary purpose of concept mapping is to better synthesize relevant data about a patient, including assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures. Mapping organizes or connects information in a unique way so the diverse information that you have about a patient begins to form meaningful patterns and concepts. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Managing Stress The work of professional nursing is difficult as you see patients endure suffering from disease and painful therapies and as you try to manage care responsibilities in busy, fast-paced work settings. Stress over a prolonged period or when extreme can lead to poor work productivity, impaired decision making and communication, and reduced ability to cope with clinical situations. The connection between stress in a health care setting and its effects on a nurse’s mental and physiological state is receiving more attention. Autonomic control of decision making, error detection, speech, memory, and emotions during stressful situations are disrupted because of continued sympathetic nervous system stimulation. Research shows that the stress of working 12-hour shifts, for example, impairs medical judgment, in part because of the way stress affects attention. [Review Box 15-5 , Evidence-Based Practice: Impact of Stressful Work Environments on Thinking and Decision Making, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Quick Quiz! 2. The nursing process organizes your approach while delivering nursing care. To provide the best professional care to patients, nurses need to incorporate nursing process and: A. decision making. B. problem solving. C. intellectual standards. D. critical thinking skills. Answer: D Rationale: The nursing process and critical thinking go hand-in-hand in providing patient-centered care. The nursing process cannot be completed without critical thinking in forming nursing diagnoses, setting goals, interventions, and evaluation. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Carla does what she can to position Mr. Ramirez more comfortably and makes sure his leg discomfort is under control. She knows that the increased pain and tightness he is experiencing suggest that something is causing pressure in the abdomen. It could mean the patient is having bleeding from his bruised liver. Carla decides to call Mr. Ramirez’s physician immediately. [Ask students: What critical thinking competency is Carla's thought that Mr. Ramirez has pressure developing in his abdomen? Discuss.] [Ask students: What knowledge did Carla apply in this clinical situation? Do you think Carla made the right decision? Why? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.