1. Critical Thinking in Nursing Practice
Chapter 15
Critical Thinking in Nursing Practice
•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.
•You will soon learn that critical thinking and the nursing process are interwoven. One does not exist without the other.
•You will find that throughout the clinical chapters of your textbook, the components of critical thinking are emphasized to help you better understand their relationship to the nursing process.
•When caring for patients and their family members, nurses need to “think smart” to make sensible judgments, so the patient can receive appropriate nursing care.

2. Critical Thinking Defined
Critical thinking is:
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 making conclusions
•Critical thinking is 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 (Heffner and Rudy, 2008).
•Critical thinking encompasses the following: Recognizing that an issue exists, analyzing information, evaluating information, and making conclusions (Settersten and Lauer, 2004).
•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.
•Thinking and learning are related processes.
•Nurses will use observations and judgments to make choices.
•You will always want to ask “why” and “how” when caring for patients.
•The use of evidence-based knowledge (see Chapter 5) helps you become a critical thinker.

3. 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 to the unit after falling off scaffolding on a construction site.
His x-ray films revealed a right fractured femur 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.
[This case study will be presented in several sections throughout this presentation. To initiate a discussion, you might ask the following questions:
•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?]

4. Clinical Decisions in Nursing Practice
Clinical decision making requires critical thinking.
Clinical decision-making skills separate professional nurses from technical and ancillary staff.
Patients often have problems for which no textbook answers exist.
Nurses need to seek knowledge, act quickly, and make sound clinical decisions.
•Clinical decision making is judgment that includes critical and reflective thinking and action and application of scientific and practical logic.
•Critical thinking challenges you to think creatively, search for the answer, collect data, make inferences, and draw conclusions.
[The critical thinking skills presented in Table 15-1 on text p. 193 are covered in the next slide.]

5. Critical Thinking Skills
Interpretation
Analysis
Inference
Evaluation
Explanation
Self-regulation
•Table 15-1 (on text p. 193) presents the critical thinking skills that you will employ in your nursing career.
•These skills are:
•Interpretation: Be orderly in data collection. Look for patterns to categorize data (e.g., nursing diagnoses [see Chapter 17]). Clarify any data you are uncertain about.
•Analysis: Be open-minded as you look at information about a patient. Do not make careless assumptions. Do the data reveal what you believe is true, or are there other options?
•Inference: Look at the meaning and significance of findings. Are there relationships between findings? Do the data about the patient help you see that a problem exists?
•Evaluation: Look at all situations objectively. Use criteria (e.g., expected outcomes, pain characteristics, learning objectives) to determine results of nursing actions. Reflect on your own behavior.
•Explanation: Support your findings and conclusions. Use knowledge and experience to choose strategies to use in the care of patients.
•Self-regulation: Reflect on your experiences. Identify ways that you can improve your own performance. What will make you believe that you have been successful?

6. Thinking and Learning Learning is a lifelong process.
Intellectual and emotional growth involves learning new knowledge, as well as refining the ability to think, solve problems, and make judgments.
The science of nursing continues to grow. Nurses need to be flexible and open to new information.
•In Chapter 1, we talked about the attributes of a profession. One of them was having a knowledge base.
•As you have more clinical experiences and apply the knowledge you acquire, you will become better at forming assumptions, presenting ideas, and making valid conclusions.
•When you care for a patient, always think ahead.
•The following questions are questions a nurse should ask when caring for a patient:
•What is the patient’s status now?
•How might it change and why?
•Which physiological and emotional responses do I anticipate?
•What do I know to improve the patient’s condition?
•In which way will specific therapies affect the patient?
•What should be my first action?
•Do not let your thinking become routine or standardized. Instead, learn to look beyond the obvious in any clinical situation, explore the patient’s unique responses to health alterations, and recognize which actions are needed to benefit the patient.

7. Case Study (cont’d)
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.
•Here we find out a little more about the patient, Mr. Ramirez, and how Carla will care for him.
[On our last slide, we covered the questions that a nurse should ask when caring for a patient. Let’s review them now:
•What is the patient’s status now?
•How might it change and why?
•Which physiological and emotional responses do I anticipate?
•What do I know to improve the patient’s condition?
•In which way will specific therapies affect the patient?
•What should be my first action?
•Note that Carla decides that she will begin caring for Mr. Ramirez by assessing his health status. Do you think Carla is making the right decision? (Discuss.)]

8. Concepts for a Critical Thinker
Truth seeking
Open-mindedness
Analytic approach
Systematic approach
Self-confidence
Inquisitiveness
Maturity
[See Table 15-2 on text p. 194.]
•Truth seeking: Seek the true meaning of a situation. Be courageous, honest, and objective about asking questions.
•Open-mindedness: Be tolerant of different views; be sensitive to the possibility of your own prejudices; respect the right of others to have different opinions.
•Analytic approach: Analyze potentially problematic situations; anticipate possible results or consequences; value reason; use evidence-based knowledge.
•Systematic approach: Be organized and focused; work hard in any inquiry.
•Self-confidence: Trust in your own reasoning processes.
•Inquisitiveness: Be eager to acquire knowledge and learn explanations, even when applications of knowledge are not immediately clear. Value learning for learning’s sake.
•Maturity: Multiple solutions are acceptable. Reflect on your own judgments; have cognitive maturity.

9. Critical Thinking Competencies
Scientific method
Problem solving
Decision making
Diagnostic reasoning and inference
Clinical decision making
Nursing process as a competency
•Critical thinking competencies are cognitive processes.
•Critical thinking processes are not unique to nursing but are used in everyday life in many situations.
•Critical thinking processes include scientific method, problem solving, and decision making.
•Specifically in nursing, we use diagnostic reasoning and inference, clinical decision making, and nursing processes.
•In diagnostic reasoning, a nurse collects patient data and analyzes them to determine the patient’s problems.
•In clinical decision making, a nurse identifies a patient’s problem and selects a nursing intervention.
•The nursing process is a five-step clinical decision-making approach: assessment, diagnosis, planning, implementation, and evaluation.

10. •Let’s look at a critical thinking model for nursing judgment
•Let’s look at a critical thinking model for nursing judgment. [This is Fig from text p The model’s levels of critical thinking in the pyramid at the top of the model are discussed on this slide. The components of critical thinking, at the bottom of the model, are discussed on the next slide.]
•This model presents three levels of critical thinking:
•Level 1 is Basic: At the basic level, nurses think concretely on the basis of a set of rules or principles, following a step-by-step process without deviation from the plan. Following a procedure step by step without adjusting to a patient’s unique needs is an example of basic critical thinking.
•Level 2 is Complex: Complex critical thinking analyzes and examines choices independently. Nurses learn to think beyond and synthesize knowledge. In complex critical thinking, a nurse learns that alternative and perhaps conflicting solutions exist.
•Level 3 is Commitment: Commitment is the third level of critical thinking. Nurses anticipate needs and make choices without assistance from others.

11. Five Components of Critical Thinking
Knowledge base
Experience
Nursing process competencies
Attitudes
Standards
•The nursing process is a blueprint for patient care that involves both general and specific critical thinking competencies in a way that focuses on a particular patient’s unique needs.
•The critical thinking model also includes five components of critical thinking, which combine a nurse’s knowledge base, experience, competence in the nursing process, attitudes, and standards to explain how nurses make clinical judgments that are necessary for safe, effective nursing care.
•Let’s review what the five components of critical thinking are and what meaning they have for nurses:
•A nurse’s knowledge base is drawn from nursing school education, as well as from knowledge obtained from basic sciences, humanities, and behavioral science.
•Experience is obtained from clinical situations in actually working with patients and their families.
•The nursing process is a five-step clinical decision-making approach: assessment, diagnosis, planning, implementation, and evaluation. We will discuss this further on the next slide. [Note that the nursing process is also discussed in greater detail in the following chapters: Chapter 16: Nursing Assessment; Chapter 17: Nursing Diagnosis; Chapter 18: Planning Nursing Care; Chapter 19: Implementing Nursing Care; and Chapter 20: Evaluation.]
•A new nurse needs 11 attitudes when thinking critically. We will review these after we learn a little more about our case study. [Slides 14 and 15 cover the 11 attitudes a nurse needs, from Table 15-3 on text p. 200.]
•Two standards should be considered when thinking critically: intellectual and professional.
•An intellectual standard is a guideline or principle for rational thought. The use of intellectual standards during assessment ensures that you obtain a complete database of information.
•Professional standards refer to ethical criteria for nursing judgments, evidence-based criteria used for evaluation, and criteria for professional responsibility. Professional standards for critical thinking refer to ethical criteria for nursing judgments, evidence-based criteria for evaluation, and criteria for professional responsibility.

12. Nursing Process Assessment Diagnosis
The nursing process is a five-step clinical decision-making approach:
Assessment
Diagnosis
Planning
Implementation
Evaluation
•Nursing process is a scientific method with five specific steps.
•Nursing process is essentially the process of applying the scientific method to caring for a patient. The scientific method has five steps:
1. Identifying the problem
2. Collecting data
3. Formulating a question or hypothesis
4. Testing the question or hypothesis
5. Evaluating results of the test or study
[Discuss with students how the five steps of nursing process relate to the five steps of the scientific method.]

13. Case Study (cont’d)
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 that Mr. Ramirez will be likely to accept.
•We just covered the nursing process, a five-step clinical decision-making approach: assessment, diagnosis, planning, implementation, and evaluation.
•Do you think Carla is following this process? [Discuss.]

14. Attitudes a Nurse Needs
Confidence
Independence
Fairness
Responsibility
Risk taking
Discipline
•Critical thinking attitudes help you to know when more information is necessary and when it is misleading and to recognize your own knowledge limits.
•A nurse needs 11 attitudes when thinking critically. [The 11 attitudes a nurse needs are presented in Table 15-3 on text p. 200.] These attitudes include confidence, independence, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, and humility. Let’s discuss the first six attitudes. [The remaining five are covered in the next slide.]
•To acquire and show confidence, learn how to introduce yourself to a patient; speak with conviction when you begin a treatment or procedure. Do not lead a patient to think that you are unable to perform care safely. Always be well prepared before performing a nursing activity. Encourage a patient to ask questions.
•To develop independence, read the nursing literature, especially when different views on the same subject are presented. Talk with other nurses and share ideas about nursing interventions.
•To practice and extend fairness, listen to both sides in any discussion. If a patient or a family member complains about a coworker, listen to the story and then speak with the coworker. If a staff member labels a patient as uncooperative, assume the care of that patient with openness and a desire to meet that patient’s needs.
•To take on responsibility and authority, ask for help if you are uncertain about how to perform a nursing skill. Refer to a policy and procedure manual to review steps of a skill. Report any problems immediately. Follow standards of practice in your care.
•To become comfortable with risk taking , if your knowledge causes you to question a health care provider’s order, do so. Be willing to recommend alternative approaches to nursing care when colleagues are having little success with patients.
•To develop discipline, be thorough in whatever you do. Use known scientific and practice-based criteria for activities such as assessment and evaluation. Take the time to be thorough and manage your time effectively.

15. Attitudes a Nurse Needs
Perseverance
Creativity
Curiosity
Integrity
Humility
[The five remaining attitudes a nurse needs are covered here.]
•To develop perseverance, be cautious of an easy answer. If coworkers give you information about a patient and some fact seems to be missing, clarify the information or talk to the patient directly. If problems of the same type continue to occur on a nursing division, bring coworkers together, look for a pattern, and find a solution.
•To employ creativity, look for different approaches if interventions are not working for a patient. For example, a patient in pain may need a different positioning or distraction technique. When appropriate, involve the patient’s family in adapting your approaches to care methods used at home.
•To show curiosity, always ask why. A clinical sign or symptom often indicates a variety of problems. Explore and learn more about the patient so as to make appropriate clinical judgments.
•To develop integrity, recognize when your opinions conflict with those of a patient; review your position, and decide how best to proceed to reach outcomes that will satisfy everyone. Do not compromise nursing standards or honesty in delivering nursing care.
•To show humility, recognize when you need more information to make a decision. When you are new to a clinical division, ask for an orientation to the area. Ask registered nurses (RNs) regularly assigned to the area for assistance with approaches to care.

16. Case Study (cont’d)
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?”
[You might encourage a discussion of this portion of the case study by asking the following questions.]
•What does Carla notice about Mr. Ramirez in this case study?
•What does Carla infer from Mr. Ramirez’s behavior?
•How does Carla’s decision to ask Mr. Ramirez specific questions fit in with your understanding of clinical decision making?
•Which of the 11 attitudes that we have covered would you say Carla is exhibiting?

17. Case Study (cont’d)
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.
[Encourage discussion of this portion of the case study.]
•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?

18. Case Study (cont’d)
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.”
[You might choose to review the five steps of the nursing process clinical decision-making approach: assessment, diagnosis, planning, implementation, and evaluation; and/or the 11 attitudes that a nurse will need: confidence, independence, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, and humility. Then continue to encourage discussion of the case study. ]
•How would you rate Carla as to her competencies at each step of the nursing process?
•Carla is clearly showing curiosity. What other attitudes and competencies is Carla displaying or employing?

19. Case Study (cont’d)
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.
[Encourage discussion of the case study.]
•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?

20. Developing Critical Thinking Skills
Reflective Journaling:
A tool used to clarify concepts through reflection by thinking back or recalling situations
Concept Mapping:
A visual representation of patient problems and interventions that illustrates an interrelationship
•When you use critical thinking, you need to connect knowledge and theory. This can be done through reflective journaling and concept mapping.
•Reflective journaling:
•Reflective journal writing is a tool for developing critical thought and reflection by clarifying concepts.
•Reflective writing gives you the opportunity to define and express the clinical experience in your own words (Di Vito-Thomas, 2005).
•By keeping a journal of each of your clinical experiences, you are able to explore personal perceptions or understanding of each experience and develop the ability to apply theory in practice.
•The use of a journal improves your observation and descriptive skills.
•Writing skills improve through the development of conceptual clarity.
•Concept mapping:
•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 (Hill, 2006).
•Through drawing a concept map, you learn to organize or connect information in a unique way so the diverse information that you have about a patient begins to form meaningful patterns and concepts.
•You begin to see a more holistic view of a patient.
•When you see the relationship between the various patient diagnoses and the data that support them, you better understand a patient’s clinical situation.
•Concept maps become more detailed, integrated, and comprehensive as you learn more about the care of a patient and the care you provide similar patients (Ferrario, 2004).

21. Critical Thinking and Delegation
Effective communication is needed between registered nurses (RNs) and nursing assistive personnel (NAP) for giving feedback and clarifying tasks and patient status.
When patients’ clinical conditions change, warranting attention by RNs, clear directions are necessary to avoid missed care.
Applying critical thinking can help an RN make the decision about when to appropriately delegate care.
[This slide covers the content of Box 15-1 on text p. 197: Critical Thinking and Delegation, which is drawn from the results of two separate studies in which nurses were asked to describe the process of delegation in their clinical practice.]
•Nurses synthesize large amounts of information and think through complex and often emergent clinical situations to make decisions about patient care, including delegation.
•An important delegation issue is the right circumstances. Registered nurses (RNs) are responsible for making clinical decisions when patients’ conditions change, including determining what and when to delegate.
•When an RN makes the clinical decision to delegate care, it is expected that nursing assistive personnel (NAP) must report significant findings, and that the RN must follow up on tasks that have been delegated.
•Delegation is ineffective if RNs fail to carry out proper supervision and evaluation of care. When delegation is ineffective, often activities such as ambulation, feedings, and turning are missed by NAP.
•Successful delegation depends on good communication, developing a trusting and respectful relationship, and showing initiative.

22. Reflective Journaling
The Circle of Meaning model adapted to nursing encourages concept clarification and a search for meaning in nursing practice.
The Circle of Meaning model uses a series of questions to help you through a clinical experience and to find meaning.
[The Circle of Meaning model adapted to nursing encourages concept clarification and a search for meaning in nursing practice (Bilinski, 2002).]
•The series of questions that the Circle of Meaning Model uses are as follows:
1. Which experience, situation, or information in your clinical experience seems confusing, difficult, or interesting?
2. What is the meaning of the experience? What feelings did you have? What feelings did your patient have? What influenced the experience? Which guesses or questions developed with the first connection in question 1? Give examples.
3. Do the feelings, guesses, or questions remind you of any experience from the past or present or something that you think is a desirable future experience? How does it relate? What are the implications/significance?
4. What are the connections between what is being described and what you have learned about nursing science, research, and theory? What are some possible solutions? Which approach or solution would you choose and why? How is this approach effective?

23. Caring for Groups of Patients
Identify the nursing diagnoses and collaborative problems of each patient.
Decide which are most urgent.
Consider the time it will take to care for those patients.
Consider the resources that you have to manage each problem.
Consider how to involve the patients as participants in care.
Decide how to combine activities.
Decide which nursing care procedures to delegate.
Discuss complex cases with the health care team.
•Box 15-2 (on text p. 197) covers the important issues of clinical decision making for groups of patients.
•Identify the nursing diagnoses and collaborative problems of each patient (see Chapter 17).
•Analyze patients’ diagnoses/problems and decide which are most urgent on the basis of basic needs, the patients’ changing or unstable status, and problem complexity (see Chapter 18).
•Consider the time it will take to care for patients whose problems are of high priority (e.g., do you have the time to restart a critical intravenous [IV] line when medication is due for a different patient?).
•Consider the resources you have to manage each problem, nursing assistive personnel assigned with you, other health care providers, and patients’ family members.
•Consider how to involve the patients as decision makers and participants in care.
•Decide how to combine activities to resolve more than one patient problem at a time.
•Decide which, if any, nursing care procedures to delegate to assistive personnel so you are able to spend your time on activities requiring professional nursing knowledge.
•Discuss complex cases with other members of the health care team to ensure a smooth transition in care requirements.

24. Meeting With Colleagues
When nurses have a formal means to discuss their experiences such as a staff meeting or a unit practice council, the dialogue allows for questions, differing viewpoints, and sharing of experiences.
When nurses are able to discuss their practices, the process validates good practice and offers challenges and constructive criticism.
•Meeting with colleagues gives you the chance to discuss and examine work experiences.
•Discussing anticipated and unanticipated outcomes in any clinical situation allows you to continually learn and develop your expertise and knowledge (Cirocco, 2007).
•Much can be learned by drawing from others’ experiences and perspectives to promote reflective critical thinking.

25. Five-Step Nursing Process Model
[Fig from text p. 198 is a model of the five-step nursing process.]
•This model of the five-step nursing process illustrates that the critical thinking and clinical decision making that you will engage in as nurses are not part of a simple, linear process.
•Each step of the process is affected by the step before and will affect the steps that follow.
•The purpose of the nursing process is to diagnose and treat human responses to actual or potential health problems (American Nurses Association, 2010).
•Human responses include patient symptoms and physiological reactions to treatment, the need for knowledge when health care providers make a new diagnosis or treatment plan, and a patient’s ability to cope with loss.
•Use of the process allows nurses to help patients meet agreed-on outcomes for better health.
•The nursing process requires a nurse to use the general and specific critical thinking competencies that we have reviewed to focus on a particular patient’s unique needs.
•Within each step of the nursing process, you apply critical thinking to provide the very best professional care to your patients.

26. Components of Critical Thinking in Nursing
I. Specific knowledge base in nursing
II. Experience
III. Critical thinking competencies
IV. Attitudes for critical thinking
V. Standards for critical thinking
A. Intellectual standards
B. Professional standards
[Review Box 15-3 on text p. 199: Components of Critical Thinking in Nursing.]
I. Specific knowledge base in nursing
II. Experience
III. Critical thinking competencies
A. General critical thinking
B. Specific critical thinking
C. Specific critical thinking in nursing: nursing process
IV. Attitudes for critical thinking
Confidence, Independence, Fairness, Responsibility, Risk taking, Discipline,
Perseverance, Creativity, Curiosity, Integrity, Humility
V. Standards for critical thinking
A. Intellectual standards
Clear, Precise, Specific, Accurate, Relevant, Plausible, Consistent, Logical, Deep, Broad, Complete, Significant, Adequate (for purpose), Fair
B. Professional standards
1. Ethical criteria for nursing judgment
2. Criteria for evaluation
3. Professional responsibility

27. 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 [Discuss.]

28. Synthesis of Critical Thinking With the Nursing Process Competency
[This is Fig from text p. 203, a synthesis of critical thinking with the nursing process competency, or the five steps of the nursing process.]
•As a beginning nurse, it is important to learn the steps of the nursing process and incorporate the elements of critical thinking.
•Critical thinking is a reasoning process by which you reflect on and analyze your own thoughts, actions, and knowledge.
•To be a good critical thinker requires dedication and a desire to grow intellectually.
•The two processes, dedication and the desire to grow intellectually, go hand in hand in making quality decisions about patient care.
[Discuss the QSEN Box on text p. XXX: Building Competency in Quality Improvement.]

29. Case Study (cont’d)
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.
[Encourage discussion of the conclusion of the case study with the following questions:
Ask the class: Carla's thought that Mr. Ramirez has pressure developing in his abdomen is an example of what critical thinking competency? Explain.
Ask the class to describe the intellectual standards that Carla applied when asking Mr. Ramirez to rate his pain.
Ask the class: What knowledge did Carla apply in this clinical situation? Do you think Carla made the right decision? Why?]

30. Critical Thinking Synthesis
A reasoning process used to reflect on and analyze thoughts, actions, and knowledge
Requires a desire
to grow intellectually
Requires the use of nursing process
to make nursing care decisions
•Critical thinking is a reasoning process used to reflect on and analyze thoughts, actions, and knowledge.
•Critical thinking requires a desire to grow intellectually.
•Critical thinking requires the use of nursing process to make nursing care decisions.
•Critical thinking and the nursing process are inseparable.
•As a new nurse, you will rely on the nursing process to guide your practice.
•The next five chapters thoroughly discuss nursing process and application to patient care.