Q&A: What is critical thinking and when would you use critical thinking in the clinical setting?
(Write 2-3 paragraphs)
In literature ‘critical thinking’ is often used, and perhaps confused, with problem-solving and clinical decision-making skills and clinical reasoning. In practice, problem-solving tends to focus on the identification and resolution of a problem, whilst critical thinking goes beyond this to incorporate asking skilled questions and critiquing solutions.
Critical thinking has been defined in many ways, but is essentially the process of deliberate, systematic and logical thinking, while considering bias or assumptions that may affect your thinking or assessment of a situation. In healthcare, the clinical setting whether acute care sector or aged care critical thinking has generally been defined as reasoned, reflective thinking which can evaluate the given evidence and its significance to the patient’s situation. Critical thinking occasionally involves suspension of one’s immediate judgment to adequately evaluate and appraise a situation, including questioning whether the current practice is evidence-based. Skills such as interpretation, analysis, evaluation, inference, explanation, and self-regulation are required to interpret thinking and the situation. A lack of critical thinking may manifest as a failure to anticipate the consequences of one’s actions.
Critical thinking is that mode of thinking – about any subject, content, or problem — in which the thinker improves the quality of his or her thinking by skillfully taking charge of the structures inherent in thinking and imposing intellectual standards upon them.
The Paul-Elder framework has three components:
- The elements of thought (reasoning)
- The intellectual standards that should be applied to the elements of reasoning
- The intellectual traits associated with a cultivated critical thinker that result from the consistent and disciplined application of the intellectual standards to the elements of thought.
Critical thinking can be defined as, “the art of analysing and evaluating thinking with a view to improving it”. The eight Parts or Elements of Thinking involved in critical thinking:
- All reasoning has a purpose (goals, objectives).
- All reasoning is an attempt to figure something out, to settle some question, to solvesome problem.
- All reasoning is based on assumptions (line of reasoning, information taken for granted).
- All reasoning is done from some point of view.
- All reasoning is based on data, information and evidence.
- All reasoning is expressed through, and shaped by, concepts and ideas.
- All reasoning contains inferences or interpretations by which we draw conclusions and give meaning to data.
- All reasoning leads somewhere or has implications and consequence.
Q&A: To become a nurse requires that you learn to think like a nurse. What makes the thinking of a nurse different from a doctor, a dentist or an engineer?
(Write 2-3 paragraphs)
It is how we view the health care consumer or aged care consumer, and the type of problems nurses deal with in clinical practice when we engage in health care patient centred care. To think like a nurse requires that we learn the content of nursing; the ideas, concepts, ethics and theories of nursing and develop our intellectual capacities and skills so that we become disciplined, self-directed, critical thinkers.
As a nurse you are required to think about the entire patient/s and what you have learnt as a nurse including; ideas, theories, and concepts in nursing. It is important that we develop our skills so that we become highly proficient critical thinkers in nursing.
In nursing, critical thinkers need to be:
- Precise
- Complete
- Logical
- Accurate
- Clear
- Fair
Nurses need to use language that will clearly communicate a lot of information that is key to good nursing care, for handover and escalation of care for improving patient safety and reducing adverse outcomes, some organisations use the iSoBAR (identify–situation–observations–background–agreed plan–read back) format. Firstly, the “i”, for “identify yourself and the patient”, placed the patient’s identity, rather than the diagnosis, in primary position and provided a method of introduction. (This is particularly important when teams are widely spread geographically.) The prompt, “S” (“situation”) “o” for “observations”, was included to provide an adequate baseline of factual information on which to devise a plan of care. and “B” (“background”), “A” “agreed plan” and “R” “read back” to reinforce the transfer of information and accountability.
In clinical practice experienced nurses engage in multiple clinical reasoning episodes for each patient in their care. An experienced nurse may enter a patient’s room and immediately observe significant data, draw conclusions about the patient and initiate appropriate care. Because of their knowledge, skill and experience the expert nurse may appear to perform these processes in a way that seems automatic or instinctive. However, clinical reasoning is a learnt skill.
To support nursing students in the clinical setting, breakdown the critical thinking process into phases;
- Look
- Collect
- Process
- Decide/identify
- Plan
- Act
- Evaluate
- Reflect
This is a dynamic process and nurses often combine one or more of the phases, move back and forth between them before reaching a decision, reaching outcomes and then evaluating outcomes.
For nursing students to learn to manage complex clinical scenarios effectively, it is essential to understand the process and steps of clinical reasoning. Nursing students need to learn rules that determine how cues shape clinical decisions and the connections between cues and outcomes.
Start with the Patient – what is the issue? Holistic approach – describe or list the facts, people.
Collect information – Handover report, medical and nursing, allied health notes. Results, patient history and medications.
- New information – patient assessment
Process Information – Interpret- data, signs and symptoms, normal and abnormal.
- Analyse – relevant from non-relevant information, narrow down the information
- Evaluate – deductions or form opinions and outcomes
Identify Problems – Analyse the facts and interferences to make a definitive diagnosis of the patients’ problem.
Establish Goals – Describe what you want to happen, desired outcomes and timeframe.
Take action – Select a course of action between alternatives available.
Evaluate Outcomes – The effectiveness of the actions and outcomes. Has the situation changed or improved?
Reflect on process and new learning – What have you learnt and what would you do differently next time.
Scenario: Apply the clinical reasoning cycle, see below, to a scenario that occurred with a patient in your clinical practice setting. This could be the doctor’s orders, the patient’s vital signs or a change in the patient’s condition.
(Write 3-5 paragraphs)
Some skills are more important than others when it comes to critical thinking. The skills that are most important are:
- Interpreting – Understanding and explaining the meaning of information, or a particular event.
- Analysing – Investigating a course of action, that is based upon data that is objective and subjective.
- Evaluating – This is how you assess the value of the information that you have. Is the information relevant, reliable and credible?
This skill is also needed to determine if outcomes have been fully reached.
Based upon those three skills, you can use clinical reasoning to determine what the problem is.
These decisions have to be based upon sound reasoning:
- Explaining – Clearly and concisely explaining your conclusions. The nurse needs to be able to give a sound rationale for their answers.
- Self-regulating – You have to monitor your own thought processes. This means that you must reflect on the process that lead to the conclusion. Be on alert for bias and improper assumptions.
Errors that occur in critical thinking in nursing can cause incorrect conclusions. This is particularly dangerous in nursing because an incorrect conclusion can lead to incorrect clinical actions.
Illogical Processes
A common illogical thought process is known as “appeal to tradition”. This is what people are doing when they say it’s always been done like this. Creative, new approaches are not tried because of tradition.
Bias
All people have biases. Critical thinkers are able to look at their biases and not let them compromise their thinking processes.
Biases can complicate decision making, communication and ultimately effect patient care.
Closed Minded
Being closed-minded in nursing is dangerous because it ignores other team members points of view. Essential input from other experts, as well as patients and their families are also ignored which ultimately impacts on patient care. This means that fewer clinical options are explored, and fewer innovative ideas are used for critical thinking to guide decision making.
So, no matter if you are an intensive care nurse, community health nurse or a nurse practitioner, you should always keep in mind the importance of critical thinking in the nursing clinical setting.
It is essential for nurses to develop this skill: not only to have knowledge but to be able to apply knowledge in anticipation of patients’ needs using evidence-based care guidelines.
References
American Management Association (2012). ‘AMA 2012 Critical Skills Survey: Executive Summary’. (2012). American Management Association. http://playbook.amanet.org/wp-content/uploads/2013/03/2012-Critical-Skills-Survey-pdf.pdf Accessed 5 May 2020.
Korn, M. (2014). ‘Bosses Seek ‘Critical Thinking,’ but What Is That?,’ The Wall Street Journal. https://www.wsj.com/articles/bosses-seek-critical-thinking-but-what-is-that-1413923730?tesla=y&mg=reno64-wsj&url=http://online.wsj.com/article/SB12483389912594473586204580228373641221834.html#livefyre-comment Accessed 5 May 2020.
School of Nursing and Midwifery Faculty of Health, University of Newcastle. (2009). Clinical reasoning. Instructors resources. https://www.newcastle.edu.au/__data/assets/pdf_file/0010/86536/Clinical-Reasoning-Instructor-Resources.pdf Accessed 11 May 2020
The Value of Critical Thinking in Nursing + Examples. Nurse Journal social community for nurses worldwide. 2020. https://nursejournal.org/community/the-value-of-critical-thinking-in-nursing/ Accessed 8 May 2020.
Paul And Elder (2009) Have Defined Critical Thinking As: The Art of Analysing And Evaluating …
Cody, W.K. (2002). Critical thinking and nursing science: judgment, or vision? Nursing Science Quarterly, 15(3), 184-189.
Facione, P. (2011). Critical thinking: What it is and why it counts. Insight Assessment, ISBN 13: 978-1-891557-07-1.
McGrath, J. (2005). Critical thinking and evidence- based practice. Journal of Professional Nursing, 21(6), 364-371.
Porteous, J., Stewart-Wynne, G., Connolly, M. and Crommelin, P. (2009). iSoBAR — a concept and handover checklist: the National Clinical Handover Initiative. Med J Aust 2009; 190 (11): S152.
