10.

Critical Thinking and the Nursing Process

LEARNING OUTCOMES

After completing this chapter, you will be able to:

1. Discuss the skills and attitudes of critical thinking.

2. Describe the significance of developing critical-thinking abilities in order to practice safe,
effective, and professional nursing care.
3. Discuss the relationships among the nursing process, critical thinking, the problem-solving
process, and the decision-making process.
4. Explore ways of demonstrating critical thinking.

KEY TERMS

creativity, 163
critical analysis, 164
critical thinking, 163
decision making, 168
deductive reasoning, 164
inductive reasoning, 164
intuition, 168
nursing process, 167
problem solving, 167
Socratic questioning, 164

INTRODUCTION

Although critical thinking has many definitions, one of the most useful for nursing is from the
National League for Nursing (2000): "Critical thinking in nursing practice is a discipline specific,
reflective reasoning process that guides a nurse in generating, implementing, and evaluating
approaches for dealing with client care and professional concerns" (p. 2). Nurses are expected to use
critical thinking to solve client problems and make better decisions. Thus, critical thinking, problem
solving, and decision making are interrelated processes, with creativity enhancing the result.

CRITICAL THINKING

Critical thinking is essential to safe, competent, skillful nursing practice. The amount of knowledge
that nurses must use and the continuing rapid growth of this knowledge prevent nurses from being
effective practitioners if they attempt to function with only the information acquired in school or
outlined in books. Decisions that nurses must make about client care and about the distribution of
limited resources force them to think and act in areas where there are neither clear answers nor
standard procedures and where conflicting forces turn decision making into a complex process.
Nurses therefore need to embrace the attitudes that promote critical thinking and master critical-
thinking skills in order to process and evaluate both previously learned and new information. Box 10-
1 lists some reasons supporting the importance of critical thinking.

Nurses use critical-thinking skills in a variety of ways:

• Nurses use knowledge from other subjects and fields. Because nurses deal holistically with human
responses, they must draw meaningful information from other subject areas (i.e., make
interdisciplinary connections) in order to understand the meaning of client data and to plan effective
interventions. Nursing students take courses in the biologic and social sciences and in the humanities
so that they can acquire a strong foundation on which to build their nursing knowledge and skill. For
example, the nurse might use knowledge from nutrition, physiology, and physics to promote wound
healing and prevent further injury to a client with a pressure ulcer.

• Nurses deal with change in stressful environments. Nurses work in rapidly changing situations.
Treatments, medications, and technology change constantly, and a client's condition may change from
minute to minute. Routine actions may therefore not be adequate to deal with the situation at hand.
Familiarity with the routine for giving medications, for example, does not help the nurse deal with a
client who is frightened of injections or with one who does not wish to take a medication. When
unexpected situations arise, critical thinking enables the nurse to recognize important cues, respond
quickly, and adapt interventions to meet specific client needs.

• Nurses make important decisions. During the course of a workday, nurses make vital decisions of
many kinds. These decisions often determine the well-being of clients and even their very survival, so
it is important that the decisions be sound. Nurses use critical thinking to collect and interpret the
information needed to make decisions. Nurses must use good judgment, for example, to decide which
observations must be reported to the primary care provider immediately and which can be noted in the
client record for the primary care provider to address later, during a routine visit with the client.

Creativity is a major component of critical thinking. When nurses incorporate creativity into their
thinking, they are able to find unique solutions to unique problems. Creativity is thinking that results
in the development of new ideas and products. Creativity in problem solving and decision making is
the ability to develop and implement new and better solutions.

Creativity is required when the nurse encounters a new situation or a client situation in which
traditional interventions are not effective. For example, a pediatric home health nurse is caring for a
9-year-old girl who has ineffective respirations following abdominal surgery. The primary care
provider has ordered incentive spirometry (a treatment device that promotes alveolar expansion). The
child is frightened by the equipment and tires quickly during the treatments. The nurse offers her a
bottle of blow bubbles and a blowing wand. She is delighted with blowing bubbles. The nurse knows
that the respiratory effort in blowing bubbles will promote alveolar expansion and suggests that she
blow bubbles between incentive spirometry treatments.

BOX 10-1 Top 10 Reasons to Improve Thinking

10. Things aren't what they used to be or what they will be. 9. Patients are sicker, with multiple
problems. 8. More consumer involvement (patients and families). 7. Nurses must be able to move
from one setting to another. 6. Rapid change and information explosion requires us to develop new
learning and workplace skills. 5. Consumers and payers demand to see evidence of benefits,
efficiency, and results. 4. Today's progress often creates new problems that can't be solved by old
ways of thinking. 3. Redesigning care delivery and nursing curricula is useless if students and nurses
don't have the thinking skills required to deal with today's world. 2. It can be doneit doesn't have to
be that difficult. 1. Your ability to focus your thinking to get the results you need can make the
difference between whether you succeed or fail in this fast-paced world.

Note: Reprinted from Critical Thinking in Nursing: A Practical Approach 3rd ed., R. Alfaro-LeFevre,
Copyright 2004, with permission from Elsevier.

Creative thinkers must have knowledge of the problem. They must have assessed the present problem
and be knowledgeable about the underlying facts and principles that apply. For example, in the
previous situation, the nurse knows the anatomy and physiology of respiratory function and is aware
of the purpose of incentive spirometry. The nurse also understands pediatric growth and development.
In trying to assist the child, the nurse builds on this knowledge and comes up with a creative solution.
Using creativity, nurses

• Generate many ideas rapidly.

• Are generally flexible and natural; that is, they are able to change viewpoints or directions in
thinking rapidly and easily.

• Create original solutions to problems.

• Tend to be independent and self-confident, even when under pressure.

• Demonstrate individuality.

SKILLS IN CRITICAL THINKING

Complex mental processes such as analysis, problem solving, and decision making require the use of
cognitive critical-thinking skills. These skills include critical analysis, inductive and deductive
reasoning, making valid inferences, differentiating facts from opinions, evaluating the credibility of
information sources, clarifying concepts, and recognizing assumptions.

Critical analysis is the application of a set of questions to a particular situation or idea to determine
essential information and ideas and discard superfluous information and ideas. The questions are not
sequential steps; rather, they are a set of criteria for judging an idea. Not all questions will need to be
applied to every situation, but one should be aware of all the questions in order to choose those
questions appropriate to a given situation. Socrates (born about 470 BC) was a Greek philosopher
who developed the Socratic method of posing a question and seeking an answer. Box 10-2 lists
Socratic questions to use in critical analysis. Socratic questioning is a technique one can use to look
beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple
points of view, and differentiate what one knows from what one merely believes. Nurses should
employ Socratic questioning when listening to an end-of-shift report, reviewing a history or progress
notes, planning care, or discussing a client's care with colleagues.

Two other critical-thinking skills are inductive and deductive reasoning. In inductive reasoning,
generalizations are formed from a set of facts or observations. When viewed together, certain bits of
information suggest a particular interpretation. Inductive reasoning moves from specific examples
(premises) to a generalized conclusionfor example, after touching several hot flames (premise), we
conclude that all flames are hot. A nurse who observes a client who has dry skin, poor turgor, sunken
eyes, and dark amber urine and who is otherwise determined to be dehydrated (premise) concludes
that the presence of those signs indicate that other clients are dehydrated.

BOX 10-2 Socratic Questions

QUESTIONS ABOUT THE QUESTION (OR PROBLEM)

• Is this question clear, understandable, and correctly identified?

• Is this question important?

• Could this question be broken down into smaller parts?

• How might ___________ state this question?

QUESTIONS ABOUT ASSUMPTIONS

• You seem to be assuming ___________; is that so?

• What could you assume instead? Why?

• Does this assumption always hold true?

QUESTIONS ABOUT POINT OF VIEW

• You seem to be using the perspective of ___________. Why?

• What would someone who disagrees with your perspective say?

• Can you see this any other way?

QUESTIONS ABOUT EVIDENCE AND REASONS

• What evidence do you have for that?

• Is there any reason to doubt that evidence?

• How do you know?

• What would change your mind?

QUESTIONS ABOUT IMPLICATIONS AND CONSEQUENCES

• What effect would that have?

• What is the probability that will actually happen?

• What are the alternatives?

• What are the implications of that?

Deductive reasoning, by contrast, is reasoning from the general premise to the specific conclusion. If
you begin with the premise that the sum of the angles in any triangle is always 180 degrees, you can
then conclude that the sum of the angles in the triangle you happen to have is also 180 degrees. A
nurse might start with a premise that all children love peanut butter sandwiches. If the client is a child,
then the child will love peanut butter sandwiches. This is an example in which the premise is not
always valid and, thus, the conclusion also may not be valid. Nurses use critical thinking to help
analyze situations and establish which premises are valid.

In critical thinking, the nurse also differentiates statements of fact, inference, judgment, and opinion.
Table 10-1 shows how these may be applied to a client. Evaluating the credibility of information
sources is an important step in critical thinking. Unfortunately, we cannot always believe what we
read or are told. The nurse may need to ascertain the accuracy of information by checking other
documents or with other informants.

To comprehend a client situation clearly, the nurse and the client must agree on the meaning of terms.
For example, if the client says to the nurse "I think I have a tumor," the nurse needs to clarify what
this word means to the clientthe medical definition of tumor (a solid mass) or the common lay
meaning of cancerbefore responding.
Persons also live their lives under certain assumptions. Some people view humans as having a
basically generous nature whereas others believe that the human tendency is to act in their own best
interest. The nurse may believe that life should be considered worth living no matter what the
condition whereas the client believes that quality of life is more important than quantity of life. If they
recognize that they make choices based on these assumptions, they can still work together toward an
acceptable plan of care. Difficulty arises when people do not take the time to consider what
assumptions underlie their beliefs and actions.

ATTITUDES THAT FOSTER CRITICAL THINKING

Certain attitudes are crucial to critical thinking. These attitudes are based on the assumption that a
rational person is motivated to develop, learn, and grow. A critical thinker works to develop the
following attitudes or traits: independence, fair-mindedness, insight, intellectual humility, intellectual
courage, integrity, perseverance, confidence, and curiosity.

Independence

Critical thinking requires that individuals think for themselves. People acquire many beliefs as
children, not necessarily based on reason but in order to have an explanation they comprehend. As
they mature and acquire knowledge and experience, critical thinkers examine their beliefs in the light
of new evidence. Critical thinkers consider seriously a wide range of ideas, learn from them, and then
make their own judgments about them. Nurses are open-minded about considering different methods
of performing technical skillsnot just the single way they may have been taught in school. They are
not easily swayed by the opinions of others but take responsibility for their own views (Catalano,
2003).

Fair-Mindedness

Critical thinkers are fair-minded, assessing all viewpoints with the same standards and not basing
their judgments on personal or group bias or prejudice (Catalano, 2003). Fair-mindedness helps one to
consider opposing points of view and to try to understand new ideas fully before rejecting or
accepting them. Critical thinkers strive to be open to the possibility that new evidence could change
their minds. The nurse listens to opinions of all the members of a family, young and old.

Insight into Egocentricity

Critical thinkers are open to the possibility that their personal biases or social pressures and customs
could unduly affect their thinking. They actively try to examine their own biases and bring them to
awareness each time they think or make a decision. For example, a nurse spends extensive time trying
to teach a client how to prevent a future recurrence of some problem but is mystified when the client
appears uninterested and does not follow the nurse's advice. The nurse's egocentric tendency to
assume that all clients are motivated and interested in preventive care (just because the nurse is)
resulted in an inaccurate assessment of the client's desire to learn; both the nurse's and the client's time
was wasted. Had the nurse assessed the client's background and beliefs about the problem and
collected sufficient evidence, the nurse might have identified a problem more relevant to the client's
priorities and, thus, developed a better care plan.

Intellectual Humility

Intellectual humility means having an awareness of the limits of one's own knowledge. Critical
thinkers are willing to admit what they do not know; they are willing to seek new information and to
rethink their conclusions in light of new knowledge. They never assume that what everybody believes
to be right will always be right, because new evidence may emerge. A hospital nurse might be unable
to imagine how the elderly wife will care for her husband who has recently had a stroke. However,
the nurse also recognizes that it is not really possible to know what the couple can achieve.
Intellectual Courage to Challenge the Status Quo and Rituals

With an attitude of courage, one is willing to consider and examine fairly one's own ideas or views,
especially those to which one may have a strongly negative reaction. This type of courage comes from
recognizing that beliefs are sometimes false or misleading. Values and beliefs are not always acquired
rationally. Rational beliefs are those that have been examined and found to be supported by solid
reasons and data. After such examination, it is inevitable that some beliefs previously held to be true
will be found to contain questionable elements and that some truth will emerge from ideas considered
dangerous or false. Courage is needed to be true to new thinking in such cases, especially if social
penalties for nonconformity are severe. As an example, previously many nurses believed that
allowing family members to observe an emergency (such as cardiopulmonary resuscitation) would be
psychologically harmful to the family and that members would get in the health care team's way.
Others felt that blanket exclusion of family members was unnecessary and extremely stressful for
some of them. As a result, nurses initiated research that has demonstrated that family presence can be
accomplished without detrimental effects to the nurse, the client, or the family.

Integrity

Intellectual integrity requires that individuals apply the same rigorous standards of proof to their own
knowledge and beliefs as they apply to the knowledge and beliefs of others. Critical thinkers question
their own knowledge and beliefs as quickly and thoroughly as they challenge those of another. They
are readily able to admit and evaluate inconsistencies within their own beliefs and between their own
beliefs and those of another. A nurse might believe that wound care always requires sterile technique.
Reading a new article on the use and outcomes of clean technique for some wounds leads the
critically thinking nurse to reconsider.

Perseverance

Nurses who are critical thinkers show perseverance in finding effective solutions to client and nursing
problems. This determination enables them to clarify concepts and sort out related issues, in spite of
difficulties and frustrations. Confusion and frustration are uncomfortable, but critical thinkers resist
the temptation to find a quick and easy answer. Important questions tend to be complex and confusing
and therefore often require a great deal of thought and research to arrive at an answer. The nurse
needs to continue to address the issue until it is resolved. For example, the nurses on a unit have tried
to establish a policy for selected clients to leave the hospital on a pass rather than have to be
discharged and readmitted in the same day. The need for involvement of nursing, medical,
administrative, and accounting staff gradually generates solutions to obstacles. The development of
the policy moves forward, although very slowly.

Confidence

Critical thinkers believe that well-reasoned thinking will lead to trustworthy conclusions. Therefore,
they cultivate an attitude of confidence in the reasoning process and examine emotion-laden
arguments using the standards for evaluating thought, by asking questions such as these: Is that
argument fair? Is it based on sufficient evidence? Consider nurses attempting to determine the best
way to allocate holiday time off for staff. Should they go by seniority, use random selection (lottery),
give preference to those who have children, use "first-come, first-served," or use another method?

The critical thinker develops skill in both inductive reasoning and deductive reasoning. As the nurse
gains greater awareness of the thinking process and more experience in improving such thinking,
confidence in the process will grow. This nurse will not be afraid of disagreement and indeed will be
concerned when others agree too quickly. Such a nurse can serve as a role model to colleagues,
inspiring and encouraging them to think critically as well.

Curiosity
The mind of a critical thinker is filled with questions: Why do we believe this? What causes that?
Does it have to be this way? Could something else work? What would happen if we did it another
way? Who says that is so? The curious nurse may value tradition but is not afraid to examine
traditions to be sure they are still valid. The nurse may, for example, apply these questions to the issue
of moving responsibility for a procedure such as the drawing of arterial blood samples among the
nursing, respiratory therapy, or laboratory department staff.

STANDARDS OF CRITICAL THINKING

How can one know whether one's thinking is critical thinking? Paul and Elder (2005) proposed that
thinkers can use universal standards, shown in Table 10-2. Explicitly stating the standards for critical
thinking promotes the reliability and validity of the thinking and thus makes appropriate action more
likely. Forneris (2004), building on the work of many modern educational theorists, described core
attributes of critical thinking: reflection, context, dialogue, and time. Reflection involves determining
what data are relevant and making connections between that data and the decisions reached. Context
is an essential consideration in nursing since care must always be individualized, taking knowledge
and applying it to real people. Dialogue, which need not involve other persons, refers to the process of
serving as both teacher and student in learning from situations, questioning, making connections, and
determining motivation. Finally, the attribute of time emphasizes the value of using past learning in
current situations that then guide future actions.

APPLYING CRITICAL THINKING TO NURSING PRACTICE

Nurses function effectively some part of every day without thinking critically. Many small decisions
are based primarily on habit with minimal thinking involved; examples include selecting what
uniform to wear, choosing which route to take to work, and deciding what to eat for lunch.
Psychomotor skills in nursing often involve minimal thinking, such as operating a familiar piece of
equipment. However, the higher order skills of critical thinking are put into play as soon as a new idea
is encountered or a less-than-routine decision must be made.

The nursing process is a systematic, rational method of planning and providing individualized
nursing care. The phases of the nursing processassessing, diagnosing, planning, implementing, and
evaluatingare discussed in detail in the chapters that follow. The phases of the nursing process and
application to a clinical example of critical thinking are shown in Table 10-3. This demonstrates the
use of critical thinking with individual clients. In addition, a nurse employs critical thinking when
setting priorities for the day. When analyzing a situation and planning strategies for conflict resolution
or change, the nurse manager uses critical-thinking attitudes and skills. The nurse clinician and nurse
manager seek awareness of their thinking as they are thinking, as they apply standards for thinking,
and as their thinking progresses.

Nurses use critical thinking in nursing practice primarily when solving problems and making
decisions. These two processes are described in more detail.

Problem Solving

In problem solving, the nurse obtains information that clarifies the nature of the problem and
suggests possible solutions. The nurse then carefully evaluates the possible solutions and chooses the
best one to implement. The situation is carefully monitored over time to ensure its initial and
continued effectiveness. The nurse does not discard the other solutions but holds them in reserve in
the event that the first solution is not effective. The nurse may also encounter a similar problem in a
different client situation where an alternative solution is determined to be the most effective.
Therefore, problem solving for one situation contributes to the nurse' s body of knowledge for
problem solving in similar situations. Commonly used approaches to problem solving include trial
and error, intuition, the research process, and the scientific/modified scientific method.
Trial and Error
One way to solve problems is through trial and error, in which a number of approaches are tried until
a solution is found. However, without considering alternatives systematically, one cannot know why
the solution works. Trial-and-error methods in nursing care can be dangerous because the client might
suffer harm if an approach is inappropriate. However, nurses often use trial and error in the home
setting where, due to logistics, equipment, and client lifestyle, hospital procedures cannot work as
effectively (e.g., there may be no pole from which to hang an IV bag or no electricity to plug in a
device).

REAL WORLD PRACTICE

When you hear the words, "critical thinking" many things enter your mind. It is more than just having
the knowledge or psychomotor skill to do a task. In client care, it is the ability to recognize deviations
from normal, the ability to prioritize, manage those deviations, and justify your actions. Traditionally,
technical skills were considered the only measure of competency. That is no longer true.

The key to critical thinking is to use strategies that focus on your thought process to make decisions.
Using critical thinking skills in the nursing process, you need to assess, identifying any risk factors;
diagnose, including analyzing data, predicting any potential problems, and diagnosing any actual
problems; plan your client care; and implement appropriate interventions; reassess, and finally
evaluate each problem, determining if the interventions are effective to the desired outcome.

Ask yourself the following questions: What are the potential problems for this client and why? What
would you do about these problems if they should occur? How would you prioritize and why? Critical
thinking ability is developed over time through many experiences.

With the complexity of client care today and increasing all the time, the need to use critical thinking is
crucial in the nursing world. The key area for development of new graduates is urgency and problem
management. Both require coaching, mentoring and time for the development of critical thinking
skills.

Jan Knudsen MSN, RN, Saint Elizabeth Regional Medical Center Lincoln, NE

Intuition
Intuition is the understanding or learning of things without the conscious use of reasoning. It is also
known as sixth sense, hunch, instinct, feeling, or suspicion. As a problem-solving approach, intuition
is viewed by some people as a form of guessing and, as such, an inappropriate basis for nursing
decisions. However, others view intuition as an essential and legitimate aspect of clinical judgment
acquired through knowledge and experience. The nurse must first have the knowledge base necessary
to practice in the clinical area and then use that knowledge in clinical practice. Clinical experience
allows the nurse to recognize cues and patterns and begin to reach correct conclusions.

Experience is important in improving intuition because the rapidity of the judgment depends on the
nurse having seen similar client situations many times before. Sometimes nurses use the words "I had
a feeling" to describe the critical-thinking element of considering evidence. These nurses are able to
judge quickly which evidence is most important and to act on that limited evidence. Nurses in critical
care often pay closer attention than usual to a client when they sense that the client's condition could
change suddenly.
Although the intuitive method of problem solving is gaining recognition as part of nursing practice, it
is not recommended for novices or students, however, because they usually lack the knowledge base
and clinical experience on which to make a valid judgment.

Research Process and Scientific/Modified Scientific Method

The research process, discussed in Chapter 2, is a formalized, logical, systematic approach to solving
problems. The classic scientific method is most useful when the researcher is working in a controlled
situation. Health professionals, often working with people in uncontrolled situations, require a
modified approach to the scientific method for solving problems. For example, unlike experiments
with animals, the effects of diet on health are complicated by a person's genetic variations, lifestyle,
and personal preferences.

Table 10-4 compares the research process or scientific method with the modified scientific method.
Critical thinking is important in all problem-solving processes as the nurse evaluates potential
solutions to a given problem and makes a decision to select the most appropriate solution for that
situation.

Decision Making

Decision making is a critical-thinking process for choosing the best actions to meet a desired goal.
Decisions must be made whenever several mutually exclusive choices are available or when there is
an option to act or not. For example, the individual who wishes to become a nurse in the United States
has several possible courses of action: a diploma program, an associate degree program, or a
baccalaureate program. Prospective students must choose. Therefore, they must evaluate the different
types of programs, as well as personal circumstances, to make a decision appropriate to their
situations.

Nurses make decisions in the course of solving problems. Decision making, however, is also used in
situations that do not involve problem solving. Nurses make value decisions (e.g., to keep client
information confidential), time management decisions (e.g., taking clean linens to the client's room at
the same time as the medication in order to save steps), scheduling decisions (e.g., to bathe the client
before visiting hours), and priority decisions (e.g., which interventions are most urgent and which can
be delegated).

Nurses must make decisions and assist clients to make decisions. When faced with several client
needs at the same time, the nurse must prioritize and decide which client to assist first. The nurse may
(a) look at advantages and disadvantages of each option, (b) apply Maslow's hierarchy of needs, (c)
consider which tasks can be delegated to others, or (d) use another priority-setting framework. When
a client is trying to make a decision about what course of treatment to follow, the nurse may need to
provide information or resources the client can use in making a decision. Nurses must make decisions
in their own personal and professional lives. For example, the nurse must decide whether to work in a
hospital or community setting, whether to join a professional association, and whether to carry
professional liability insurance.

Here are sequential steps to the decision-making process:

1. Identify the purpose. The nurse identifies why a decision is needed and what needs to be
determined.

2. Set the criteria. When the nurse sets the criteria for decision making, three questions must be
answered: What is the desired outcome, what needs to be preserved, and what needs to be avoided?
For example, for a client with pain, the criteria would be as follows:

a. What is the desired outcome? Relief of pain.

b. What needs to be preserved? Physical functioning, cognitive functioning, psychologic functioning.

c. What needs to be avoided? Central nervous system depression, respiratory depression, nausea.

3. Weight the criteria. In this step, the decision maker sets priorities or ranks activities or services
from least important to most important as they relate to the specific situation. Because the weighting
is specific to the situation, an activity may be ranked as most important in one situation and of less
importance in another situation. For example, the nurse avoids medication that can cause sedation of a
client with a head injury, but for a client with terminal cancer, pain relief may be more important than
avoiding the sedative side effects of the pain medication.

4. Seek alternatives. The decision maker identifies possible ways to meet the criteria. In clinical
situations, the alternatives may be selected from a range of nursing interventions or client care
strategies. Pain may be treated with oral or injectable medications, as needed (prn) or on a schedule,
or without pharmacologic intervention at all, instead using complementary alternative modalities
(CAM).

5. Examine alternatives. The nurse analyzes the alternatives to ensure that there is an objective
rationale in relation to the established criteria for choosing one strategy over another. For pain that
results from a procedure (such as removal of a foreign object), CAM may not be strong enough relief,
and oral medication may be effective but act too slowly, so an intravenous narcotic might be the
better choice.

6. Project. The nurse applies creative thinking and skepticism to determine what might go wrong as a
result of a decision and develops plans to prevent, minimize, or overcome any problems. If the
intravenous narcotic is selected, what safety procedures need to be in placefor example, a narcotic
antidote and supplemental oxygen?

7. Implement. The decision plan is placed into action. The pain treatment is begun.

8. Evaluate the outcome. As with all nursing care, in evaluating, the nurse determines the
effectiveness of the plan and whether the initial purpose was achieved. How does the client rate the
level of pain following the procedure?

The decision-making process and the nursing process share similarities, and the nurse uses decision
making in all phases of the nursing process. Table 10-5 compares these processes. It is essential that
the nurse use critical thinking in each step or phase of these processes so that decisions and care are
well considered and delivered with the highest possible quality.

DEVELOPING CRITICAL-THINKING ATTITUDES AND SKILLS

After gaining an idea of what it means to think critically, solve problems, and make decisions, nurses
need to become aware of their own thinking style and abilities. Acquiring critical-thinking skills and a
critical attitude then becomes a matter of practice. Critical thinking is not an "either-or" phenomenon;
people develop and use it more or less effectively along a continuum. Some people make better
evaluations than others do, some people believe information from nearly any source, and still others
seldom believe anything without carefully evaluating the credibility of the information. Critical
thinking is not easy. Solving problems and making decisions is risky. Sometimes the outcome is not
what was desired. With effort, however, everyone can achieve some level of critical thinking to
become an effective problem solver and decision maker.

RESEARCH NOTE Are Education, Experience, and Critical-Thinking Ability Related to

Clinical Decision Making?
This pilot study investigated the premise that there would be relationships between the education and
experience of critical care nurses and their ability to make consistent clinical decisions. Critical-
thinking ability, as measured by skills and dispositions tests, was also expected to correlate with
decision making. Fifty-four nurses with a BSN or MSN working in adult critical care units in teaching
hospitals were included in the study. Results showed that, overall, the more complex the clinical
situation, the less consistent the nurses were in their decisions. Intuition, as a decision-making
strategy, was most related to consistent decisions. No correlation was found between education or
total years of experience and consistency in decision making. There was an association between years
of experience in critical care and decision consistency.

IMPLICATIONS

This study reinforces that decision making and critical thinking are complex when applied in real
clinical situations. That the results showed greater consistency in decisions when intuition was used
and when the nurse had more years of critical care nursing experience (not just overall nursing
experience) suggests that there is a type of nurse thinking in that clinical specialty that does not
necessarily evolve with more global exposure to client care. It also suggests that the method of
thinking used by nurses who choose critical care practice may be an inherent characteristic.

Note: From "Critical Thinking and Clinical Decision Making in Critical Care Nursing: A Pilot
Study," by F. D. Hicks, S. L. Merritt, & A. S. Elstein, 2003, Heart & Lung, 32, pp. 169-180.

Self-Assessment

The nurse should consider some of the attitudes discussed earlier that facilitate critical thinking, such
as curiosity, fair-mindedness, humility, courage, and perseverance. A nurse might benefit from a
rigorous personal assessment to determine which attitudes he or she already possesses and which need
to be cultivated. This could also be done with a partner or as a group. The nurse first determines
which attitudes are held strongly and form a base for thinking and which are held minimally or not at
all. The nurse also needs to reflect on situations where he or she made decisions that were later
regretted, and analyzes thinking processes and attitudes or asks a trusted colleague to assess them.
Identifying weak or vulnerable skills and attitudes is also important.

Reflection, at every step of critical thinking and nursing care, helps examine the ways in which the
nurse gathers and analyzes data, makes decisions, and determines the effectiveness of interventions.
Reflection requires the nurse to pause in order to consider his or her beliefs, knowledge, values, and
abilities in the particular situation at hand. The purpose of this reflection is to determine if the current
course of action is the best one and to improve future actions. Figure 10-1, the Mind Map for Critical
Thinking in Nursing, is a visual depiction of the interactive loops of concepts used in critical thinking.
Note that the action of reflection appears as part of three of the steps shown: the starting points,
processes, and outcomes.

Tolerating Dissonance and Ambiguity

The nurse needs to take deliberate efforts to cultivate critical-thinking attitudes. For example, to
develop fair-mindedness, one could deliberately seek out information that is in opposition to one's
own views; this provides practice in understanding and learning to be open to other viewpoints. It is a
human tendency to seek out information that corresponds to one's previously held beliefs and to
ignore evidence that may contradict cherished ideas. This perspective is true for both the nurse and
the client. Elders may have great difficulty accepting the pervasiveness of technology or that people
don't stay in the hospital as long as they did in the 1970s or that having a diagnosis of cancer doesn't
always mean that one is going to die. On the other hand, elders have a wealth of knowledge and
experience and often know better than the health care provider knows what will work well and be
acceptable to them. Nurses should increase their tolerance for ideas that contradict previously held
beliefs, and they should practice suspending judgment.

Suspending judgment means tolerating ambiguity for a time. If an issue is complex, it may not be
resolved quickly or neatly, and judgment should be postponed. For a while, the nurse will need to say,
"I don't know" and be comfortable with that answer until more is known. Although postponing
judgment may not be feasible in emergency situations where fast action is required, it is usually
feasible in other situations.

Seeking Situations Where Good Thinking Is Practiced

Nurses will find it valuable to attend conferences in clinical or educational settings that support open
examination of all sides of issues and respect for opposing viewpoints. Cultivating a questioning
attitude, using either Socratic questioning or another technique, is vital. Nurses need to review the
standards for evaluating thinking and apply them to their own thinking. If nurses are aware of their
own thinkingwhile they are doing the thinkingthey can detect thinking errors.

Creating Environments that Support Critical Thinking

A nurse cannot develop or maintain critical-thinking attitudes in a vacuum. Nurses in leadership

positions must be particularly aware of the climate for thinking that they establish, and they must
actively create a stimulating environment that encourages differences of opinion and fair examination
of ideas and options. Nurses must embrace exploration of the perspectives of persons from different
ages, cultures, religions, socioeconomic levels, and family structures. As leaders, nurses should
encourage colleagues to examine evidence carefully before they come to conclusions, and to avoid
"group think," the tendency to defer unthinkingly to the will of the group.

LIFESPAN CONSIDERATIONS Health Care Decisions

CHILDREN

Parents most often make decisions about the health care of children. Growing children can participate
in those decisions in age-appropriate ways. As described by Piaget, the ability of children to reason

and critically think about themselves and their situation develops gradually (see Chapter 20). At
each stage, nurses should be aware of the ways children think and sensitive to how they can be
involved in health care decisions:

• Infants progress from reflexive behavior to simple, repetitive behavior and then to imitative
behaviors, learning the concepts of cause and effect and object permanence. Though not involved in
making decisions, they need to be comforted and secure as care is given.

• Toddlers and preschoolers are very egocentric and engage in magical thinking. They cannot reason
out the implications of care, but need explanations in language they can understand. Play therapy and
use of dolls and toys can help them adjust to care, and they can sometimes be given options (e.g., do
you want your dressing changed before breakfast or after?).

• School-age children tend to be concrete thinkers. They benefit from simple, direct explanations;
hands-on exploration of equipment and materials; and helping the care provider as appropriate during
procedures. Involving these children in care can increase cooperation and decrease anxiety.

• Adolescents are increasingly able to think abstractly and may make many of their own health care
decisions. They should be actively consulted as a part of the family system.
ELDERS

It is important to include all adult clients in decision making and planning nursing care, but it is
especially difficult to do this when working with elders who have impaired cognitive abilities such as
Alzheimer's disease. The nurse should allow them as much control and input as possible, keeping
things simple and direct so they understand. Elders with impairments are usually unable to perform
multiple tasks or even to think of more than one step at a time. The nurse must have patience and be
willing to calmly repeat instructions if necessary. Presenting and discussing issues in basic terms
helps to maintain respect and dignity and allows elders to participate in their own care for as long as
possible. If the elder is unable to perform self-care activities such as bathing or health-related
activities such as a dressing change, the nurse seeks appropriate alternative methods for assisting the
elder with these.

Critical Thinking Checkpoint

Mr. W. is a 53-year-old recently retired engineer with a history of irritable bowel syndrome that
causes frequent diarrhea and rectal bleeding. His wife is a schoolteacher. It is mid-December when he
comes to your clinic complaining about "not feeling good." You conclude he is having a reoccurrence
of his intestinal problem.

1. What questions would you ask yourself to check this assumption? 2. How would you demonstrate
that you are using the critical-thinking attitude of "confidence in reasoning" ? 3. Socrates might ask
you about the consequences of your conclusion by posing the question "What are the implications of
your thinking?" How would you answer? Consider the implications if you are correct and if you are
incorrect in your assumption. 4. Critical thinkers look for subtle cues. Which cues in this situation
require follow-up?

See Critical Thinking Possibilities in Appendix A.

Figure 10-1. Mind Map for Critical Thinking in Nursing Note: Duphorne, P. & Giddens, J.
(2004) Critical Thinking in Nursing Resource funded by intramural grant of College of Nursing,
University of New Mexico.

CHAPTER 10 REVIEW

CHAPTER HIGHLIGHTS

• Nurses need critical-thinking skills and attitudes to be safe, competent, skillful practitioners.

• Critical thinking is a process that guides a nurse in generating, implementing, and evaluating
approaches for dealing with client care and professional concepts (NLN, 2000).

• Nurses use critical thinking as they apply knowledge from other subjects and fields to nursing
practice, deal with change in stressful environments, and make important decisions related to client
care. When nurses incorporate creativity into their thinking, they are able to find unique solutions to
unique problems.
• Creativity enhances critical thinking. Creative nurses generate many ideas rapidly, are flexible and
natural, create original solutions to problems, tend to be independent and self-confident, and
demonstrate individuality.

• Critical-thinking skills include the ability to do critical analysis, perform inductive and deductive
reasoning, make valid inferences, differentiate facts from opinions, evaluate the credibility of
information sources, clarify concepts, and recognize assumptions.

• Critical thinkers have certain attitudes: independence, fair-mindedness, insight, intellectual humility,
intellectual courage to challenge the status quo and rituals, integrity, perseverance, confidence, and
curiosity.

• Critical thinking consists of high-level cognitive processes that include problem solving and
decision making. There are several problem-solving methods: trial and error, intuition, the nursing
process, the scientific method, and the modified scientific method. Nurses use the scientific method or
research process when they participate in nursing and health research.

• The nursing process and critical thinking are interrelated and interdependent, but they are not
identical. Both involve problem solving, decision making, and creativity.

• Nurses must make decisions in both their personal and professional lives. The steps of the decision-
making process include identifying the purpose of the decision, setting the criteria, weighting the
criteria, seeking alternatives, examining alternatives, projecting, implementing, and evaluating the
action.

• Everyone has at least some level of critical-thinking skill, and that skill can be developed with
practice. Some guidelines to enhance critical-thinking skills and attitudes include performing a self-
assessment, tolerating dissonance and ambiguity, seeking situations where good thinking is
productive, and creating environments that support critical thinking.

TEST YOUR KNOWLEDGE

1. A client with diarrhea also has a physician's order for a bulk laxative daily. The nurse, not realizing
that bulk laxatives can help solidify certain types of diarrhea, concludes "The physician does not
know the client has diarrhea." This statement is an example of:

1. A fact.
2. An inference.
3. A judgment.
4. An opinion.

2. A client reports feeling hungry, but does not eat when food is served. Using critical-thinking skills,
the nurse should perform which of the following?

1. Assess why the client is not ingesting the food provided.

2. Continue to leave the food at the beside until the client is hungry enough to eat.
3. Notify the primary care provider that tube feeding may be indicated soon.
4. Believe the client is not really hungry.

3. Although one nurse feels the manager prepared the holiday work schedule unfairly, the manager
states that it is the same type of schedule used in the past and other nurses have no problems with it.
The nurse continues to feel uncomfortable about how the schedule was created. Which response
indicates the nurse is displaying an attitude of critical thinking?

1. Accepting the preferences of the other nurses since there are several of them
 2. Recognizing that the nurse must have reached a false conclusion
3. Considering going to a higher authority than the manager for an explanation
4. Continuing to query the manager until the nurse understands the explanation

4. The client who is short of breath benefits from the head of the bed being elevated. Because this
position can result in skin breakdown in the sacral area, the nurse decides to study the amount of
sacral pressure occurring in other positions. This decision is an example of which of the following?

1. The scientific method

2. The trial-and-error method
3. Intuition
4. The nursing process

5. In the decision-making process, the nurse sets and weights the criteria, examines alternatives, and
performs which of the following before implementing the plan?

1. Reexamines the purpose for making the decision

2. Consults the client and family members to determine their view of the criteria
3. Identifies and considers various means for reaching the outcomes
4. Determines the logical course of action should intervening problems arise

See Answers to Test Your Knowledge in Appendix A.

EXPLORE MEDIALINK WWW.PRENHALL.COM/BERMAN

COMPANION WEBSITE

• Additional NCLEX Review

• Case Study: Examining an Increase in Pressure Ulcers

• Application Activity: Practicing Critical Thinking

• Links to Resources

READINGS AND REFERENCES

SUGGESTED READINGS

Edwards, S. (2003). Professional issues. Critical thinking at the bedside: A practical perspective.
British Journal of Nursing, 12, 1142-1149.

This article provides a comprehensive review of critical thinking from theoretical and practical
perspectives. The many models from the literature are often complex and difficult to interpret in
relation to clinical practice situations. If theory cannot be integrated into practice, then its value to
nursing should be questioned. The task now is to formalize and cement the connections between the
two concepts at the bedside.

Oermann, M. H. (2004). Using active learning in lecture: Best of "both worlds." International
Journal of Nursing Education Scholarship, 1(1), Article 1.

The lecture mode of content delivery has sometimes been viewed negatively. This well-known author
in teaching and critical thinking explores another approach: integrating active learning within
lecture, gaining the benefits of both methods. This article examines benefits of an integrated
approach to teaching and presents strategies for active learning intended for use with lecture.
RELATED RESEARCH

Gurney, D. (2004). Triage decisions. Exercises in critical thinking at triage: Prioritizing patients with
similar acuities. Journal of Emergency Nursing, 30, 514-516.

Hoffman, K., & Elwin, C. (2004). The relationship between critical thinking and confidence in
decision-making. Australian Journal of Advanced Nursing, 22(1), 8-12.

REFERENCES

Alfaro-LeFevre, R. (2004). Critical thinking in nursing: A practical approach (3rd ed.). Philadelphia:
W. B. Saunders.

Catalano, J. T. (2003). Nursing now! Today' s issues, tomorrow' s trends (3rd ed.). Philadelphia: F. A.
Davis.

Forneris, S. G. (2004). Exploring the attributes of critical thinking: A conceptual basis. International
Journal of Nursing Education Scholarship, 1 (1), Article 9, 1-19. Retrieved June 18, 2006, from
http://www.bepress.comlijnes/vol1/iss1/art9

Hicks, F. D., Merritt, S. L., & Elstein, A. S. (2003). Critical thinking and clinical decision making in
critical care nursing: A pilot study. Heart & Lung, 32, 169-180.

National League for Nursing. (2000). Think tank on critical thinking. New York: Author.

Paul, R., & Elder, L. (2005). A guide for educators to critical thinking competency standards. Dillon
Beach, CA: Foundation for Critical Thinking.

SELECTED BIBLIOGRAPHY

Allen, G. D., Rubenfield, M. G., & Scheffer, B. K. (2004). Reliability assessment of critical thinking.
Journal of Professional Nursing, 20(1), 15-22.

Benner, P. E., Hooper-Kyriakidis, P. L., & Stannard, D. (1999). Clinical wisdom and interventions in
critical care: A thinking-in-action approach. Philadelphia: W. B. Saunders.

Elder, L., & Paul, R. (2003). A miniature guide for students and faculty to the foundations of analytic
thinking: How to take thinking apart and what to look for when you do. Dillon Beach, CA:
Foundation for Critical Thinking.

Hood, L. J., & Leddy, S. K. (2003). Leddy & Pepper's conceptual bases of nursing practice (5th ed.).
Philadelphia: Lippincott Williams & Wilkins.

Jackson, M., Ignatavicius, D. D., & Case, B. (2006). Conversations in critical thinking and clinical
judgment. Boston: Jones & Bartlett.

Moore, B. N., & Parker, R. (2007). Critical thinking (8th ed.). Boston: McGraw-Hill.

Rubenfeld, M. G., & Scheffer, B. (2006). Critical thinking TACTICS for nurses. Boston: Jones &
Bartlett.

Staib, S. (2003). Teaching and measuring critical thinking. Journal of Nursing Education, 42, 498-
507.Wilkinson, J. M. (2007). Nursing process and critical thinking (4th ed.). Upper Saddle River, NJ:
Prentice Hall Health.