The role of the nurse has shifted from one of "hand- maiden" to one of an autonomous partner in

health care delivery. The impact of technological expansion and the increased acuity level of
patients, combined with consumer demand for accountability and responsibility, have fueled this
change. Currently, novice nurses must possess cognitive skills that require critical thinking. The
nurse uses critical thinking to solve problems, make decisions, and establish priorities in the
clinical setting. The framework for solving patient problems is called the nursing process. Critical
thinking is inherent to the nursing process.
DEFINITION
Critical thinking is an essential skill in the administration of safe, competent nursing care. Critical
thinking may be defined as "the process of purposeful, self regulatory judement. The process gives
reasoned consideration to evidence, contexts, conceptualization, method, and criteria" (American
Philosophical Association, 1990, p. 2) Ennis describes critical thinking as 'reasonable, reflective
thingking that is focused on deciding what to believe or do" (Nosich, 2001, p. 2).
Critical thinking is goal directed; it is thinking with a purpose. Critical thinking also involves
questioning. These questions include: why? Who? What if? When? Where? Data are collected and
organized withinthe critical thinking process. Pertinent data are separated from irrelevant data.
Related data are clustered together to encourage the recognition of patterns. These clusters of data
are then analyzed, and successful solutions to problems are identified.
RELATIONSHIP TO PROBLEM SOLVING AND DECISION MAKING
The practice of nursing involves setting priorities, making decisions, and solving problems. If
these activities were approched in a haphazard fashion, patient outcomes would suffer. The
purpose of this book is to outline a systematic process that can be used to perform these activities.
Frequently, terms such as crirical thinking, problem solving, and decision making are used
interchangeably in nursing literature, resulting in confusion for the reader. Although these
processes are related, they are also distinct and can be studied individually.
Problem solving is a systematic approach, resulting in the formation of solutions. It involves the
identification of the root problem through analysis. The nursing process is a type of problem
solving used in developing a plan of care for each patient. The nursing process can be applied to
solve problems relating to issues that affect patients as well as staff, such as cost containment,
productivity, and quality of care.
Decision making involves choosing from among options. It is a step in the problem-solving
process. However, not all decisions are the result of a problem. Therefore, the term decision
making is not synonymous with problem solving. Priority setting is included in the decision-
making process. Because o the complex nature of these processes, decision making and priority
setting are discussed in separate chapters of this book.
Critical thinking is a style of thinking that is necessary for success with all the other processes. lt
reresents the rational thought process that underlies problem solving and decision making.
THE CRITICAL THINKER
The critical thinker has many typical characteristics. This individual is an independent thinker who
is not influenced by the people who state, "We have always done it that way." Critical thinkers
question conventions and habits, basing decisions on sound reasoning. They recognize biases and
assumptions, and they possess an open mind. Critical thinkers are observant and able to organize
and prioritize data. Good judgment intuition, and past experiences are all used by the critical
thinker to develop solutions and analyze actions.
 Nurses can cultivate critical thinking by questioning and by seeking knowledge. Paul and Elder
(2001c, p. 1) state:
A well-cultivated thinker:
1. Raises vital questions and problems, formulating them clearly and precisely.
2. Gathers and assesses relevant information, and can effectively interpret it.
3. Comes to well-reasoned conclusions and solutions, testing them against relevant criteria and
standards.
4. Thinks open-mindedly within alternative systems of thought, recognizing, and assessing, as
need be, their assumptions, implications, and practical consequences.
5. Communicates effectively with others in figuring out solutions to complex problems.
Critical thinking is, in short, self-directed, self-disciplined, self-monitored, and self-corrective
thinking.

INTELLECTUAL STANDARDS IN THINKING

Thinking occurs spontaneously in daily life without consideration of the process. This
nonanalytical thinking can be filled with biased, preconceived notions and incorrect information.
Second-order thinking, as identified by Paul and Elder, raises the level of thought process so that
the parts of a situation are consciously reviewed. This involves assessing each aspect and
restructuring thinking to focus on central issues. "Critical thinkers routinely take their thinking
apart" (Paul and Elder, 2001a. p. 52).
Standards are essential to increasing the quality of thinking. Increased skill in the application

Accurmcy The need Foraccuracyln health careis sdf-wkk,u Ampularing the wnmglimb.
administerin! incor- reci mdicarions. and pedorming irntmerns an the wranU poriem ore all
examples of Front-page news (nvolving inoccuracy Atcuraa in (JKirtter- preuuion of e,ddence and
data are eruieaJ io the autc'ome of nursing ore The criiicalihinker ob- rains informatJon from
reliable sources. PucisiON Nurses experlenct many demands in the delivery o heahh cart in an
eFFort to meet thesedemands. the mue may fail to tmWhe critical need of being exncl Prrci,e
reflection of timughts takes ilme Errors in pailent care can tx:cur whtn the nu"e takes shoncuts.
For example. rhe nurse wha Fails to identify pailcnts before mediation ad- ministration has
sacrificed precision. Nosich (ZOO1. p 13V advised nursing siudaus to u,e the followinl
measures for dwelopinB pre'cision: . Aruldpate where oihers will need detalls to follow your
rtuoning. . When you repori what other people say. o, ihe rrsulrs of an exrxrurwnt. or a
pmcedutt. try to sayit exacrly. , Look up detalls in the tcn. . When yuu mke dcrailed notes. do so
in out- line form. . Keep golnB From ihc gentml to the spedfic and From the sycific to tl'e
Seneral: whnt is a ,ycifFe instance of this generality? . How does this detail Fit iruo the whole
pidure? . Get feedback on where you need io be more sVciFic. more exact , 'kk fellow scudents
where they need you to supply more d.tail. RdEVOWt All data putirwnt to the situation
orconccpt ,huuld be collectcd Then. nonperrirenr or insilydficam data am be deleted The mind can
become cku- tewl uilh i,relwaru faas: therefore. the individLurl needs to fillure out what ts mo't
imponant ond swy focused Suppose. Foreample. OW the nurse is:u-

sessing a paLicm with a diagnosis oF congestive hear, Failure WhiJe eheddngXr paipheraledema.
tJw nurse noks an oldlattoo on Ae paUienCs ankJe This is mosllilciv trivialinformaoon not relaW
to chc asse"ment. The nune should nm allow it toln. mfer! with his or her thougM pmcesses at (his
time. There are enough imponam facis ro remcm. kTwMeptrformingtlerssnsmem DEpTh Deoling
wirh a very complex issue in a ,upvhdal 'vay does not addre the underlying cause of the pmblem
Being able to pcrceive the complexities of a Slluation and co visualize the reLuianship amonS
vanous aspeas i.irnportant. For example. if diabetic puieni is admiaed with a blood sugar levelof
SOO to bDO mgkIL. the health care team will quickly trcat the blood sugar elevation to get it
under control. However.iF the problem that cmwd tix ele.ated blood sugar is nat treated. the
patient will rctum with more prublems later The mind works in a similar Fashion. Controlling the
way irformalion is proceual produces beue. out. ,omes The critical ihinker musl explore deeply
enough to get beyond the surface issues BnEAdrh Bradrh cononns thinking abour a situation from
sc.rml different points of dew.At times. people are so adamant about thelrown point of view that
they cannot see the mmplexities ktwived in the prob- lem. The mdcalrhinker g:uhers more
infonnation and gives n:tsond consideration toother yints of view. DiFferiW points of vIew ocarr
frequently in health are seuings. For example. cmulder the fol- lowing ,ircumstances surTounding
a patient who has been placed o. a ventihtor Her son. wholives .OOO miles a"uy. would like the
ventilatory assis- tance to continue. He states. 7m not n:ady to give up on Mom ' Howtver. the
potlent's dauShter hu been the primary caregwer. She feels her mothe, hu suffexd enough.The
nurse must conaider both points of view before iaking action Loc,ic When using logic. one seeks
to discovu whether rhings make sense To anive clu.ion. aisumplicms num be valid ne cunclusion
musr be hased an the evidence Nursing proce- durts rmm be performd in a logical order. For