Ch. 15 Critical Thinking in Nursing Practice
Commitment Level of critical thinking
nurses anticipate needs and make choices without assistance from others
During a home health visit the nurse prepares to instruct a patient in how to perform range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an analgesic 30 minutes before arrival at the patient's home. After discussing the purpose for the exercises and demonstrating each one, the nurse has the patient perform them. After two attempts with only the second of three exercises, the patient stops and says, "This hurts too much. I don't see why I have to do this so many times." The nurse applies the critical thinking attitude of integrity in which of the following actions?
"I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax."
Critical Thinking
- 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
A nurse is working with a nursing assistive personnel (NAP) on a busy oncology unit. The nurse has instructed the NAP on the tasks that need to be performed, including getting patient A out of bed, collecting a urine specimen from patient B, and checking vital signs on patient C, who is scheduled to go home. Which of the following represents successful delegation?
- A nurse explains to the NAP the approach to use in getting the patient up and why the patient has activity limitations - The nurse sees the NAP preparing to help a patient out of bed, goes to assist, and thanks the NAP for her efforts to get the patient up early - The nurse is in patient B's room to check an intravenous (IV) line and collects the urine specimen while in the room.
Reflective Journaling
- A tool used to clarify concepts through reflection by thinking back or recalling situations - Gives you the opportunity to define and express the clinical experience in your own words - you will keep a journal for 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 journal improves your observation and descriptive skills - writing skills improve through the develpment of conceptual clarity
Concept Mapping
- A visual representation of patient problems and interventions that illustrates an interrelationship - concept maps become more detailed, integrated, and comprehensive as you learn more about the care of a patients - 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
Nursing Process steps
- Assessment - Nursing Diagnosis - Planning - Implementation - Evaluation
A nurse who is working on a surgical unit is caring for four different patients. Patient A will be discharged home and is in need of instruction about wound care. Patients B and C have returned from the operating room within an hour of each other, and both require vital signs and monitoring of their intravenous (IV) lines. Patient D is resting following a visit by physical therapy. Which of the following activities by the nurse represent(s) use of clinical decision making for groups of patients?
- Consider how to involve patient A in deciding whether to involve the family caregiver in wound care instruction - Decide which activities can be combined for patients B and C
The nurse cared for a 14 year old with renal failure who died near the end of the work shift. The health care team tried for 45 minutes to resuscitate the child with no success. The family was devastated by the loss, and, when the nurse tried to talk with them, the mother said, "You can't make me feel better, you don't know what it's like to lose a child." Which of the following examples of journal entries might best help the nurse reflect and think about this clinical experience?
- Description of the efforts to restore the child's blood pressure, what was used, and questions about the child's response - The meaning the experience had for the nurse with respect to her understanding of dealing with a patient's death - A description of what the nurse said to the mother, the mother's response, and how the nurse might approach the situation differently in the future
Professional Standards
- Ethical criteria for nursing judgment- Code of Ethics - Promote the highest level of quality nursing care - Standards of professional responsibility that nurses strive to achieve are cited in Nurse Practice Acts, Joint Commission guidelines, Institutional policy and procedure, ANA Standards of Nursing Practice
Scientific Knowledge Base (Critical thinking model for clinical decision making)
- First component of the critical thinking model - A nurse's knowledge base is drawn from nursing school education, as well as from knowledge obtained from basic sciences, humanities, and behavioral sciences - A nurse's knowledge base is continually changing
How do nurses accomplish critical thinking?
- Good problem solving skills- "What am I missing?" - Not always a clear textbook answer- "Why?" - Nurse must learn to question, look at alternatives- "What are my options?"
Critical Thinking Skills
- Interpretation - Analysis - Inference - Evaluation - Explanation - Self-regulation
Competencies (Critical think model for clinical decision making)
- Is obtained from clinical situations in actually working with patients and their families - Clinical experience is the laboratory for testing your nursing knowledge
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
Thinking and Learning
- Lifelong process - Flexible, open process - Learn to think and to ANTICIPATE - What, why, how questions - Look beyond the obvious - Reflect on past experience - New knowledge challenges the traditional way
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
Evaluation
- Look at the situation objectively - Use criteria (expected outcomes, pain characteristics, learning objectives) to determine nursing actions - Reflect on your own behavior
Basic Level of critical thinking
- 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
Critical Thinking in Nursing
- Purposeful, outcome-directed - Essential to safe, competent, skillful nursing practice - Based on principles of nursing process and the scientific method (assessment) - Requires specific knowledge, skills, and experience - New nurses must ask questions
Thinking Independently
- Read the nursing literature, especially when different views on the same subject are presented - Talk with other nurses and share ideas about nursing interventions
Self-Regulation/Reflection
- Reflect on your own experiences - Improve a plan of care while thinking back on interventions performed - Identify ways you can improve your own performance - What will make you believe that you have been successful
Components of Critical Thinking
- Scientific knowledge base - Experience - Competencies - Attitudes - Standards
Nursing Process
- Systematic approach that is used by all nurses to gather data, critically examine and analyze the data, identify client responses, design outcomes, take appropriate action, then evaluate the effectiveness of action - Involves the use of critical thinking skills - Common language for nurses to "think through" clinical problems - New graduate nurses use the nursing process to guide them
A 67 year old patient will be discharged from the hospital in the morning. The health care provider has ordered three new medications for her. Place the following steps of the nursing process in the correct order.
- The nurse asks the patient if she is in pain, feels tired, and is willing to spend the next few minutes learning about her new medication (assessment) - The nurse considers what she learns for the patient and identifies the patient's nursing diagnosis (nursing diagnosis) - The nurse talks with the patient and family about who will be available if the patient has difficulty taking medicines and considers consulting with the health care provider about a home health visit (Planning) - The nurse brings the containers of medicines and information leaflets to the bedside and discusses each medication with her (Intervention) - The nurse returns to the patient's room and asks her to describe the medications she will be taking at home (evaluation)
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 judgements
Analyticity
- analyze potentially problematic situations - anticipate possible results or consequences - value reason - use evidence-based knowledge
Complex Level of 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
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
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
Inquisitiveness
- be eager to acquire knowledge and learn explanations even when applications of the knowledge are not immediately clear - value learning - ask a lot of questions
Analysis
- be open-minded as you look at information - do not make careless assumptions - does the data reveal what you believe to be true - are there other options
Interpretation
- be orderly in data collection - look for patterns to categorize data - clarify any data you are uncertain about
Systematicity
- be organized - be focused - work hard in any inquiry
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
Open-Mindedness
- be tolerant of different view points - be sensitive to the possibility of your own prejudices - respect the right that other have different opinions
Professional nurse recognizes:
- changes in patients - potential problems - identify new problems - and takes immediate action when a patient's clinical condition worsens
11 Attitudes that Foster Critical Thinking
- confidence - thinking independently - fairness - responsibility and authority - risk taking - discipline - perseverance - creativity - curiosity - integrity - humility
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
Inference
- look at the meaning and significance of the finding - are there relationships between findings - does the data help you see that a problem exist
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
Maturity
- multiple solutions are acceptable - reflect on your own judgments - you have cognitive maturity
Developing Critical Thinking Attitudes/Skills
- not easy - not "either, or" it's everything - self-assessment - tolerating dissonance and ambiguity - seeking situations where good thinking practiced (ask nurse who uses the best critical thinking skills to help you when you need it) - creating environment that support critical thinking
Critical thinking synthesis
- reasoning process by which individuals reflect on and analyze their own thoughts, actions & decision and those of others - not a step-by-step process
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 RN's regularly assigned to the area for assistance with approaches to care
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
Critical Thinking Competencies
- scientific method - problem solving - decision making - diagnostic reasoning and inferences - clinical decision making - nursing process
Truth Seeking
- seek the true meaning of a situation - be courageous - be honest - and be objective when asking questions
Critical Thinking Behaviors
- truth seeking - open mindedness - analyticity - systematicity - self-confidence - inquisitiveness - maturity
Developing critical thinking skills
- when you use critical thinking, you need to connect knowledge and theory - this can be done through reflective journaling and concept mapping
A nurse has worked on an oncology unit for 3 years. One patient has become visibly weaker and state, "I feel funny." The nurse knows how patients often have behavior changes before developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking skills and notices the patient shivering. The nurse goes to the phone, calls the physician, and begins the conversation by saying, "I believe that your patient is developing sepsis. I want to report symptoms I'm seeing." What examples of critical thinking concepts does the nurse show?
Analyticity and self-confidence
Which of the following is unique to the commitment level of critical thinking?
Anticipates when to make choices without others' assistance
A nurse has been working on a surgical unit for 3 weeks. A patient requires a Foley catheter to be inserted, so the nurse reads the procedure manual for the institution to review how to insert it. The level of critical thinking the nurse is using is:
Basic critical thinking
A patient on a surgical unit develops sudden shortness of breath and a drop in blood pressure. The staff respond, but the patient dies 30 minutes later. The manager on the nursing unit calls the staff involved in the emergency response together. The staff discusses what occurred over the 30-minute time frame, the actions taken, and whether other steps should have been implemented. The nurse in this situation are:
Conducting reflective practice
The surgical unit has initiated the use of a pain-rating scale to assess patients' pain severity during their postoperative recovery. The RN looks at the pain flow sheet to see the pain scores recorded for a patient over the last 24 hours. Use of the pain scale is an example of which intellectual standard?
Consistent
The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The patient reports she is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks her to clarify the type of trouble. The patient explains she can't concentrate or even solve simple problems. The nurse records the results of the assessment, describing the patient as having ineffective coping. This is an example of:
Diagnostic reasoning
A patient had hip surgery 16 hours ago. During the previous shift the patient had 40mL of drainage in the surgical drainage collection device for an 8-hour period. The nurse refers to the written plan of care, noting that the health care provider is to be notified when drainage in the device exceeds 100mL for the day. On entering the room, the nurse looks at the device and carefully notes the amount of drainage currently in it. This is an example of:
Evaluation
Experience (Critical thinking model for clinical decision making)
Is obtained from clinical situations in actually working with patients and their families
The nurse asks a patient how she feels about her impending surgery for breast cancer. Before the discussion the nurse reviewed the description of loss and grief and therapeutic communication principles in his textbook. The critical thinking component involved in the nurse's review of the literature is:
Knowledge application
While assessing a patient, the nurse observes that the patient's intravenous (IV) line is not infusing at the ordered rate. The nurse assesses the patient for pain at the IV site, checks the flow regulator on the tubing, looks to see if the patient is lying on the tubing, checks the point of connection between the tubing and the IV catheter, and then checks the condition of the site where the intravenous catheter enters the patient's skin. After the nurse readjusts the flow rate, the infusion begins at the correct rate. This is an example of:
Problem solving
In which of the following examples is the nurse not applying critical thinking skills in practice?
The nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care