Critical Thinking Skills in Nursing

PREPARED BYSAMEER ABDULMALIK ALKUBATI

SUPERVISED BYPROF. DR. NAGWA A. IBRAHIM

2011

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Alexandria UniversityFaculty of NursingDoctorate Program

Foundation of Nurs-ing Science

2011

Outline

1. Introduction

2. Definition of critical thinking

3. Components of Critical Thinking

4. Critical Thinking Competencies

5. Standards for Critical Thinking

6. Importance of critical thinking in nursing education and practice

7. Aspects of Critical Thinking

8. Levels of critical thinking in nursing

9. Dimensions of critical thinking

a. Critical thinking skills

b. Critical thinking dispositions

10.The relationship between Critical Thinking and Problem Solving, De-

cision making, Creative thinking

11.Development of critical thinking in nursing

12.Concepts in Critical Thinking

13.The Nursing Process and Critical Thinking

14.References

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Goal

At the end of this seminar the doctoral students will be able to understand

the concept of critical thinking in nursing

Intended learning outcomes of course (ILOS)

I- knowledge and understanding:

1. Define critical thinking

2. Differentiate between critical thinking, problem solving, decision

making, nursing process and creative thinking

3. Enumerate 10 importance of critical thinking in nursing education

and practice

4. Identify 4 measures for assessment of critical thinking

II- Intellectual skills:

1. Distinguish between critical thinking skills and dispositions

2. Develop strategies for promoting critical thinking in nursing

III- General and transferable skills:

1. Apply critical thinking strategies in nursing practice and education

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Introduction

In clinical settings, it is common for nurses to deal with a group of

complicated and high-risk patient-care situations that require decisions to

be made quickly. As an integral part of the health care system, nurses and

nursing are impacted by all the challenges and changes in the health care

system. These include (a) quality, cost, and access issues; (b) continuous

technological growth; (c) new knowledge and treatments emerging on an

ongoing basis; and (d) continuous expansion as the population ages, with

the associated increase in disease processes. These changes have been asso-

ciated with current ethical and moral dilemmas that are borne out in the

daily practice of nurses.

Thus, nurses should be skilled in critical thinking, in order to deal effec-

tively with complex change, and provide the best nursing care. Conse-

quently, a major paradigm change in nursing education from focusing on

curricular content to curricular outcomes, with a major emphasis on helping

students learn to think critically; they must be taught how to think, not what

to think.

Definition of critical thinking

American Philosophical Association (APA, 1990) who did use a Delphi re-

search project on critical thinking. "purposeful, self-regulatory judgment

which results in interpretation, analysis, evaluation and inference as well

as explanation of the evidential conceptual, methodological, criteriological

or contextual considerations upon which that judgment was based".

• Chaffee (2002) Active, organized, cognitive process used to exam-

ine one’s thinking and that of others.

• Profetto-McGrath and others (2003) Critical thinking is both a

process and set of skills.

• Settersten and Lauver (2004) Recognize, analyze, evaluate, and draw

conclusions.

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Components of Critical Thinking

When a nurse enters into any clinical experience there are five compo-

nents of critical thinking that lead the nurse to make the clinical judg-

ments that are necessary for safe, effective nursing care:

1- Scientific Knowledge Base

The depth and extent of knowledge influence the nurse’s ability to think

critically about nursing problems.

2- Experience

-Unless a nurse has the opportunity to practice and make decisions about

client care, critical thinking in clinical decision making will not develop.

3- Critical Thinking Competencies

a. General critical thinking which include the scientific method,

problem solving, and decision making.

b. Specific critical thinking competencies in clinical situations

which include diagnostic reasoning, clinical inferences, and clinical de-

cision making. These competencies are used by physicians, social

workers, nurses and other health care professionals in deciding about

the clinical care and support of clients.

c. The specific critical thinking competency in nursing which is

the nursing process. The format for the nursing process is unique to

nursing and offers one approach to critical thinking in clinical decision

making.

4. Attitudes for Critical Thinking

These attitudes are the values that an individual must practice or show to

be successful critical thinker. (Confidence, Independence, fairness, Re-

sponsibility, Risk taking, Discipline, Perseverance, Creativity, Curiosity,

Integrity, Humility).

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Critical thinking attitudes and applications in nursing practice

Critical thinking atti-

tude

application in practice

ConfidenceIntroduce yourself to client…etc

IndependenceRead the nursing literature

fairnessListen to both sides in any problem

ResponsibilityAsk for help if you are uncertain about an

aspect of client care

Risk takingIf your knowledge causes you question a

physician’s order, do so

DisciplineBe thorough in whatever you do

PerseveranceBe wary of an easy answer

CreativityLook for different approaches if interven-

tions are not working

CuriosityAlways ask ”why”

IntegrityDecide how best to proceed to reach mutu-

ally beneficial outcomes

HumilityRecognize when you need more informa-

tion to make a decision

4. Standards for Critical Thinking

These standards are the criteria for determining the soundness, justness,

and appropriateness of critical decisions and judgments.

a. Intellectual standards

Paul(1993) identified 14 intellectual standards that are universal for criti-

cal thinking, (Clear, Precise, Specific, Accurate, Relevant, Plausible,

Consistent, Logical, Deep, Broad, Complete, Significant, Adequate, Fair)

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b. Professional standards: that refer to;

1. Ethical criteria for nursing judgment. Client care requires more

than just the application of scientific knowledge.

2. Criteria for evaluation. Critical thinking requires the use of cri-

teria for evaluation when clinical judgments are made.

3. Professional responsibility. The standards of professional re-

sponsibility that a nurse strives to achieve are those standards cited in

nurse practice acts, national regulatory and treatment, and institutional

practice guidelines.

Importance of critical thinking

A. In nursing education

1. Improve student understanding of their own thought process

2. Improve student ability to transfer learned content and skills to

new applications

3. Improve student motivation

4. Facilitate students' autonomy and self-confidence

5. Students are able to raise vital questions and problems, as well

as formulate and present them clearly

6. Students can gather and assess information and interpret it ef-

fectively

7. Students can reach well-reasoned conclusions and solutions to

problems while testing them against relevant criteria and standards

8. Students can be open-minded

9. Students can clearly communicate ideas, positions, and solu-

tions to others

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B. In nursing practice

1. It is an essential component of communication, problem-solving

ability, theoretical and conceptual understanding of nursing concerns

and research that advance the knowledge base of nursing

2. Improve nurses clinical competence

3. Critical thinking skills aid in the “delivery of safe, comprehen-

sive, individualized, effective and innovative care which stems from

the competent clinical judgment of thinking professionals”

In conclusion, critical thinking is a cornerstone of nursing education and

practice and it is one of the essential keys of nursing education outcomes.

The importance of critical thinking to nursing emerged as the National

League for Nursing (NLN, 1989), an accrediting agency for nursing ed-

ucation programs, recognized this need for critical thinking skills and

mandated the integration of teaching and assessment of critical thinking

skills into the nursing curriculum. The NLN (2000, 2002), Pew Health

Professions Commission (1998), and the American Association of

Colleges of Nursing (2002) have cited critical thinking skills as one of

the core competencies and essential cognitive abilities needed by health

care workers of the 21st century.

Aspects of Critical Thinking

1. Reflection

Review what you did and ways to improve

Did you follow the standards?

2. Language

Always communicate clearly to the patient and staff

To become a critical thinker, a nurse must be able to use lan-

guage, precisely and clearly.

3. Intuition

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Develop a “gut feeling” based on your experience and knowl-

edge

Realize what you do not know and then find out.

e.g: An experienced neurosurgical nurse may enter the room of a head in-

jury client and know immediately if the client behavior change suggests

an increase in ICP.

Levels of critical thinking in nursing

a. Basic critical thinking: Basic – learner believes that the experts are

correct and do thing according to the book. E.g, a nurse uses an institu-

tion’s procedure manual to confirm how to insert a foley catheter.

b. Complex critical thinking: Complex – the critical thinker begins to

develop their own way of thinking. E.g, physician orders state the patient

must walk four times per day but he is vomiting and is unable to do as or-

dered

c. Commitment: Commitment – person accepts responsibility of mak-

ing own decisions or is accountable for actions

The Dimensions of Critical Thinking

The dimensions of critical thinking comprise both cognitive skills and af-

fective dispositions. Facione and Sanchez state that having the requisite

cognitive critical thinking skills is essential to being a good critical

thinker. The concept of critical thinking is also associated with a set of

personal attitudes or dispositions that can be used to describe an individ-

ual who is inclined to use critical thinking.

A. Critical thinking skills

Critical thinking skills are Interpretation, Analysis, Evaluation, Inference,

Explanation, and Self-regulation.

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1. Interpretation involves

- Clarifying meaning about a wide variety of experiences, beliefs,

procedures, rules, etc.

- Understanding the meaning of a patient's behavior or state-

ments.

- Interpreting problems as well as objective and subjective data

from common information sources, related to the care of the patient.

For example, determining the significance of laboratory values, vital

signs, and physical assessment data.

2. Analysis involves:

- Identifying the intended & actual inferential relationships

among statements, questions, concepts, descriptions, or other forms of

representation intended to express belief, judgment, experiences, rea-

sons, information, or opinion.

- Examining ideas, identifying arguments, analyzing arguments.

3. Evaluation includes

- Assessing the logical strength of statements, descriptions or

questions.

- Evaluating information to ascertain its probable trustworthiness

as well as its relevance to particular patient care situations.

- For example, identifying expected patient outcomes and assess-

ing whether or not they are met. If not met, the nurse ascertains why.

4. Inference includes

- Querying claims

- Assessing arguments (recognizes faulty reasoning)

- Reaching conclusions that are appropriate to the care of the pa-

tient

- For example, the nurse determines when a patient's health status

improves or declines through careful monitoring.

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5. Explanation includes:

- Stating results of one’s reasoning

- justifying that reasoning

- Presenting one’s reasoning in the form of strong arguments

- For example, nurse implements interventions based on research

or other sources of evidence.

6. Self-regulation includes:

- Self examination

- Self correction

B. Critical thinking dispositions (CTDs)

Critical thinking dispositions are the affective components of critical

thinking. These affective dispositions are coupled with cognitive skills as

essential components of ideal critical thinker. They are Consistent will-

ingness, motivation, inclination and force to be engaged in critical think-

ing while making decisions and solving problems. Facione (1992) identi-

fied a specific seven attributes for critical thinking dispositions which are

analyticity, open-mindedness, truth-seeking, systematicity, critical think-

ing self-confidence, inquisitiveness and cognitive maturity.

1. Truth-seeking is a tendency to seek the best knowledge in a

given situation, be courageous about asking questions and be honest and

objective about pursuing inquiry even if the finding do not support one's

self interests.

2. Open-mindedness: having an appreciation of alternate perspec-

tives and willingness to respect the right of others to hold different opin-

ions. Understanding other cultural traditions in order to gain perspectives

on self and for others.

3. Analyticity targets the disposition of being alert to problem sit-

uations, anticipating potential outcomes or consequences of situations,

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choices, idea or plans and prizing the use of reason and evidence to solve

problems.

4. Systematicity measures one's inclination to be organized and

focused in inquiry.

5. Critical thinking self-confidence measures the trust of indi-

viduals placed in their reasoning and reflective process and their ability to

guide others to resolution of problems.

6. Inquisitiveness measures intellectual curiosity and the desire to

learn new things even if their immediate application is not apparent.

7. Cognitive maturity represents the attribute of being judicious

in the individual's decision making and the habit of making a judgment in

a timely way, not prematurely based on standards, ethics and evidences.

The relationship between Critical Thinking and Problem Solving,

Decision making, Creative thinking

Critical thinking in nursing has also been used interchangeably with other

terms such as problem solving, clinical decision making, and creative

thinking. Simpson and Courtney (2002) indicated that these terms have

different meanings and there is a need to understand the differences.

Critical Thinking versus Problem Solving

Problem solving is used to seek solutions, whereas critical thinking con-

siders all aspects and judges the solutions rather than focusing solely on

finding an answer.

Critical Thinking versus Clinical Decision Making

- Decision making, is a systematic process of assessment of actions, eval-

uation and judgment making that will contribute to the achievement of a

desired outcome.

- Incorporating critical thinking skills during the clinical de-

cision making process will provide clarification, a range of

potential solutions appropriate to the circumstances or

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setting and reasoning to support the clinical decision

made.

- Lipman and Deatrick(1997) affirm that requisite to clini-

cal decision making is the use of critical thinking.

Critical Thinking and Creative Thinking

Creative thinking is a combination of knowledge and imagination. A cre-

ative thinker typically has an attitude of interest in every thing, continu-

ously exploring of new ideas, options, alternatives and approaches and

then trying to manipulate the understanding into new knowledge or mean-

ing. Creative thinking is ultimately stimulated through posing Socratic

questions, such as “What else” and “Why” or “What if?”

Paul(1990) emphasizes that critical and creative thinking

“have an intimate relationship to figuring things out.

So, Critical Thinking is considering a broad umbrella under which

several forms of thinking occur.

Development of critical thinking in nursing

It is a gradual process of enhancing one’s ability to use critical thinking in

his/her personal and professional life. This can be occurred through the

following:-

1. Nursing programs play an important role to prepare well-qual-

ified students to become well-prepared nurses who are able to use critical

thinking. Thus, critical thinking should fit within all nursing programs

parts include objectives, teaching-learning strategies and evaluation

methods.

a. Learning objectives: should be based on the developing of crit-

ical thinking skills and dispositions rather than the lower level of cog-

nitive domain

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b. Curriculum there is a need to teach critical thinking as a sub-

ject, even before it can be integrated into the program content and

linked it to every lesson given.

c. Teaching-learning strategies:

Nurse educators realize the importance of teaching critical-thinking skills

to students and are aware that these skills can be developed by devising

teaching methods that stimulate higher-level thinking in theory and prac-

tice. Therefore, how can nurse educators stimulate these skills or abili-

ties in themselves and in their students?

Various strategies are offered to enhance critical-thinking abilities.

1. Questioning

2. Small-group activities

3. Role-playing

4. Debate

5. Case studies

6. Journals

7. Simulations

8. Problem solving

9. Cooperative learning

10. Computer assisted instruction

11. Concept mapping

Although these strategies are very important to apply in nursing program,

there are many several barriers to teaching for critical thinking in bac-

calaureate programs, including student resistance to active learning, inad-

equate class time, insufficient time to prepare critical thinking activities,

and the need to cover content.

d. Evaluation tool: tool to measure critical thinking skills and dis-

positions involved in the course report or specification.

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2. Nurse educators

- Nurse educators play an important role in the facilitation of critical

thinking dispositions of their graduates. In fact, the external measure of

nurse educators' effectiveness is their graduates' abilities to think criti-

cally. Hence, they should demonstrate competence related to critical

thinking in order to be role model, open doors to new perspectives of the

world for their students, as well as foster self-confidence and encourage

lifelong learning.

- Nurse educators should grasp the knowledge about the dimensions of

critical thinking by reading research articles, participating in seminars,

workshops and conferences on critical thinking and introducing these

competencies to colleagues and students.

- They should continuously reflect on their teaching practice, skills and

beliefs to enhance their critical thinking skills and dispositions

- They should work under an umbrella of peer cognitive coaching through

collaboration and reflection in an effort to become better decision-makers

- Use of research evidence in practice supports the cultivation of critical

thinking disposition in nurse educators

3. Educational institution

- It should provide support to critical thinkers' efforts, listening attentively

to them, and motivating them to think critically because the process of

dispositions development requires intrinsic motivation, rewards, re-

sources and reinforcement to those who are able and willing to think criti-

cally

Concepts in Critical Thinking

Critical thinking involves the use of several concepts, including: explor-

ing, analyzing, prioritizing, explaining, deciding, and evaluating to iden-

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tify solutions and determine a course of action to solve patient care prob-

lems.

Exploring encourages you to identify all the variables within a situation.

Analyzing is the process of studying each variable to understand its

meaning and its relationship to the other variables.

Prioritizing requires you to weigh the relative importance of each vari-

able to the others, at a given point in time.

Explaining the variables involves the exercise of amplifying each vari-

able to understand its meaning in the situation and to the involved parties.

Deciding means to choose a specific course of action.

Evaluating requires the thinker to assess how correct the thinking

process was, and if further action is needed.

The Nursing Process and Critical Thinking

The nursing process and critical thinking are complementary processes.

And, it may be useful for nurses to correlate these tools to improve criti-

cal thinking skills, while at the same time, improve the level of care de-

livered to patients.

Nurses use critical thinking skills in each step of the nursing process. Ev-

erything nurses do requires high level thinking, Rubenfeld & Scheffer

1999 cited that "no action is performed without critical thinking”

The following table is designed to help you correlate the nursing process

with critical thinking steps.

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NURSING

PROCESSCRITICAL THINKING

AssessmentOrganized process, based on knowledge, contains

subjective and objective data. Exploring

DiagnosisRequires inference, hypotheses, analysis, synthesis,

and problem solving. Analyzing

Planning

 

Involves prioritizing, decision making and setting

goals for care outcomes

Implementation

Use of nursing interventions and skills, family and

other staff involved, includes medial interventions.

Prioritizing and deciding .

EvaluationInvolves analyzing results, reassessing, revisiting

goals and projected outcomes. Evaluating.

References

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1 -Potter P, Perry A. Fundamentals of nursing. 6th ed, St. Louis. Mosby

Company, 2005; 262-275.

2 -Simpson E, Courtney M. Critical thinking in nursing

education: A literature review. Available on

http://eprints.qut.edu.au/263/1/SIMPSON_CRITICAL_

THINKING.PDF.

3- Lipman TH, Deatrick JA. Preparing advanced practice

nurses for clinical decision making in speciality practice.

Nurse Educator 1997; 22(2): 47-50.

4 -Taylor C, LeMone P, Lillis C, Lynn P. Fundamentals of nursing: the

art and science of nursing care. 6th ed, Philadelphia. Lippincott

Company, 2008; 218-23.

5 -Kuckyt C. nursing process & critical thinking, 2008. Available at:

http://home.cogeco.ca/~nursingprocess/think.htm

6 -Daniels R. Nursing fundamentals: caring & clinical decision making.

2nd edition. Delmar Cengage Learning, 2008.

 

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