RESEARCH FACILITATING CRITICAL THINKING WITHIN THE NURSING...

RESEARCH

FACILITATING CRITICAL THINKING WITHIN THE NURSING PROCESS FRAMEWORK: ALITERATURE REVIEW

Prof MM ChabeliD CurAssociate Professor: Department of Nursing Science, University Of Johannesburg, JohannesburgCorresponding author: [email protected]

Keywords: critical thinking; nursing process; facilitation; clinical nursing education

ABSTRACT

This article intends to describe how critical thinking of learners can be facilitated or infused in clinical nursingeducation using the identified core cognitive critical thinking skills, their related sub-skills and the affective dispo-sitions. The desire of the researcher to apply these critical thinking skills in clinical nursing education was inresponse to the recommendations made by experts in critical thinking who conducted the Delphi research projectabout the concept analysis of critical thinking (Facione, 1990:6, 13). The recommendations made urge educators todevelop programmes and teaching and assessment instruments to facilitate or measure critical thinking using theidentified core cognitive thinking skills. Nurses should be critical thinkers because they deal with the lives ofpatients. They are faced with challenges in their daily practice which require the ability to make rational and criticalclinical decisions and also make astute clinical judgment that are logical to solve health related problems. Criticalthinking is understood to be purposeful, self-regulatory judgments which result in interpretation, analysis, evaluationand inference, as well as explanation of the evidential, conceptual, methodological, criteriological or contextualconsiderations upon which that judgment is based (Facione, 1990:2). The core cognitive thinking skills are sup-ported and driven by the identified affective dispositions such as inquisitiveness, analytical thinking, open- and fair-mindedness, flexibility, self-confidence, being systematic, truth-seeking and a mature attitude. An exploratory anddescriptive approach was used to describe how critical thinking of learners can be facilitated in clinical nursingeducation. Since critical thinking can not be facilitated in a vacuum, the author used the theoretical framework ofcritical thinking identified by critical thinking experts in a Delphi study (Facione, 1990:6, 13) within the nursingprocess framework (Wilkinson, 1992:29) and other relevant literature to demonstrate how critical thinking can befacilitated were used. Content validity of the study is ensured based on the two theoretical frameworks. Recommen-dations to apply the identified critical thinking skills and the dispositions are made.

OPSOMMING

Hierdie artikel het ten doel om te beskryf hoe kritiese denke by leerders in kliniese verpleegonderwys gefasiliteerkan word deur die geïdentifiseerde kern-kognitiewe kritiese denkvaardighede, hul verwante sub-vaardighede asookaffektiewe disposisies te gebruik. Die navorser het in reaksie op aanbevelings wat gemaak is deur kundiges op diegebied van kritiese denke wat die Delphi-navorsingsprojek oor die konsepanalise van kritiese denke geloods het(Facione, 1990:13) die behoefte ervaar om hierdie kritiese denkvaardighede in kliniese verpleegonderwys toe te pasDie aanbevelings moedig opvoeders aan om programme en assesseringsinstrumente te ontwikkel wat kritiesedenke kan meet deur van die geïdentifiseerde kern-kognitiewe denkvaardighede gebruik te maak. Verpleegkundigesbehoort kritiese denkers te wees aangesien hulle met die lewens van pasiënte werk. In hul daaglikse praktyk staarhulle uitdagings in die gesig wat ‘n bevoegdheid vereis om rasionele en kritiese kliniese besluite te neem asook omintelligente, kliniese oordele te maak wat logies is vir die oplossing van gesondheidsverwante probleme. Kritiesedenke word verstaan as ‘n doelgerigte, self-regulerende beoordeling wat kulmineer in interpretasie, analise, evalueringen inferensie, sowel as die verantwoording van die bewysgronde, konseptuele, metodologiese, kriteriologiese ofkontekstuele oorwegings waarop die beoordeling geskoei is (Facione, 1990:2). Die kern-kognitiewe denkvaardighedeword ondersteun en aangedryf deur die geïdentifiseerde affektiewe disposisies, soos weetgierigheid, analitiese

69HEALTH SA GESONDHEID Vol.12 No.4 - 2007

denke, openheid en regverdigheid van denke, buigbaarheid, selfvertroue, ‘n sistematiese ingesteldheid, ‘n soekena die waarheid en ‘n volwasse houding. ‘n Verkennende, beskrywende benadering is gebruik om te beskryf hoekritiese denke van leerders in kliniese verpleegonderwys gefasiliteer kan word. Aangesien kritiese denke nie in ‘nlugleegte gefasiliteer kan word nie, het die navorser gebruik gemaak van die teoretiese raamwerk van kritiesedenke soos deur die kundiges in die Delphi-studie geïdentifiseer (Facione, 1990:6, 13), asook ander relevanteliteratuur om te demonstreer hoe kritiese denke binne die verpleegprosesraamwerk gefasiliteer kan word (Wilkinson,1992:29). Inhoudsgeldigheid van die studie is verseker deur en gebaseer op die twee teoretiese raamwerke.Aanbevelings om die geïdentifiseerde kritiese denkvaardighede en disposisies toe te pas, word gemaak.

INTRODUCTION

The infusion of critical thinking skills in nursing educa-tion has been a worldwide quest of nurse educators toensure quality improvement and quality assurance inpractice. There is a great need for facilitation of criticalthinking in the preparation and assessment of nurselearners to care for patients with complex culturally di-verse health care needs and their families. To makerational clinical decisions about unique individual carerequires nurses to stretch their thinking beyond the bookknowledge. Learners have to reach out to meaningfulunderstanding, to stretch into areas beyond comfort-able concepts and be able to guide themselves by in-ternal mental processes (Vygotsky in Mellish, Brink &Paton, 1998:32).

Nurses deal with the lives of people holistically andtherefore critical analysis of health related issues be-comes mandatory to improve practice. Nurses who donot demonstrate a critical spirit, will not demonstrate aprobing inquisitiveness, a keenness of mind, a zealousdedication to reason, a hunger or eagerness for reli-able information (Facione, 1998:9; Edwards, 2003:1142).Nursing cannot afford nurses who are using strategiessuch as guessing, acting on inferences made from in-complete information, who are not willing to considerother people’s opinions, who are displaying disorganisedthoughts, applying unreasonable criteria, using illogi-cal reasoning for making rational, clinical judgmentsand who are not interested in facts, dialogue and argu-ments. Nurses who instead of engaging in the patients’health problems, jump to conclusions, make closurewithout absolute certainty or hold their own reasoningabilities in low esteem will not be helpful in practice. Anunfair, close-minded nurse who is inflexible, insensitiveand ready to give up in complex situations poses ahazard to patients.

The days of “just carry out the doctor’s prescriptionwithout understanding the effects and side effects ofthe treatment” and conformity based on fear, are over.The nursing profession does not need nurses who willjust carry out daily routines without question, rely onroutine activities and protocols to meet the divergenthealth needs of patients and nurses who are counter-productive. Nurses subjecting themselves to behandmaidens of other health professions, especiallywhen rational clinical decisions are to be made, shouldbe history. The traditional methods of teaching andassessment that do not foster critical thinking of learn-ers should be abandoned and approaches that encour-age interactive dialogue, cooperation and collaborationamong learners to stimulate their critical thinking shouldbe used. The nursing profession needs critical thinkersto maintain the credibility of the profession through theprovision of quality nursing care. The question thatemerges is: which critical thinking skills do the nursingprofession need to render excellent care to patients?

The nursing profession needs members of the teamwho are not in competition with each other but are col-laborating closely for the purpose of solving health re-lated problems. The profession needs nurses who arewilling to collect comprehensive and reliable informa-tion from the patient and who will identify and analysethe intended and actual inferential relationships amongstatements, questions, concepts, descriptions or otherforms of representation intended to express belief, judg-ment, experiences, reason, information or opinions.Nurses should examine ideas, detect, identify andanalyse underlying assumptions and arguments. Thenurse may paraphrase the information to give it mean-ingful interpretation. Nurses should decode and justifythe significance of the problem, categorise the infor-mation meaningfully and summarise complex ideas.They should be encouraged to access their own knowl-

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edge-base and experience to address a clinical prob-lem and work out a solution to the problem. The nurseshould offer various hypothesised physical, social orpsychological meanings and significance, interspersedwith queries to gain a better holistic understanding ofthe patient. Nurses should devise sensible alternativesto explore issues and should not become defensive ifthose alternatives do not work. Nurses should formu-late categories and create frameworks within which torender quality patient care. They should be able to evalu-ate the significance of the evidence and explain ex-actly how a particular conclusion was reached or whycertain criteria apply and not others. Nurses should beable to monitor and correct their actions if they werenot successful. The nurse should demonstrate orderli-ness, diligence, patience, reasonableness, persistence,willingness, flexibility and precision when dealing withhealth care issues (Facione & Facione, 1996:134;Facione, 1998:9; King & Kitchener, 1997: 77).

Critical thinking cannot be facilitated or assessed in avacuum for it is used to apply basic core knowledgeand skills to each situation (Wilkinson, 1992:21). It re-quires a sound domain-specific knowledge base, inte-grated with interdisciplinary knowledge for processingand analysing information, weighing alternatives anddeciding on actions to take in diverse clinical situa-tions (Alfaro-LeFevre, 1999:10). Clinical nursing edu-cation is the context in this article where critical think-ing skills of nurse learners are to be infused within thebroad nursing process framework. Clinical nursing edu-cation is a dynamic, constantly changing, real-life en-vironment in which theoretical knowledge is integratedwith practice. The facilitator is responsible for creatingan environment that is conducive to the development ofcritical thinking, while learners take the responsibilityfor constructing their own knowledge and skills throughactive interaction to promote critical thinking skills(Chabeli, 2001:348). Clinical nursing education formsan integral part of nursing education where the learneris able to marry the theoretical component with prac-tice using the nursing process approach.

The nursing process approach requires the nurse tosystematically collect data from the patient or familyduring the assessment phase, making a nursing diag-nosis, formulating the desired plans to solve them, ini-tiating the plan or assigning others to implement it,and evaluating the extent to which the plan was effec-

tive in resolving the identified problems. At every phaseof the nursing process, the nurse works closely withthe patient to individualise care and build a relationshipof mutual trust and respect (Kozier, Erb, Berman &Snyder, 2004:243).

The teaching and learning activities for critical thinking,if carefully planned, will form an integral part of the teach-ing and learning experience for learners rather than betaken as something that distracts learners from thebusiness of learning. The type and quality of instruc-tion or assessment can influence whether learners willadopt a merely reproductive style or rather deep-holis-tic strategies of understanding (Quinn, 2000:200).

Unfortunately, educators are not usually prepared bytheir training for such dynamic flux, unpredictability andcomplexity. Paul (1993:97) is of the opinion that edu-cators are in the firing line when instructing or assess-ing critical thinking of learners in practice. Educatorsshould be willing to bring rigour to their own disciplinedcritical thinking in order to help learners to attain thisideal. Educators must be willing to role model their criti-cal thinking abilities so that learners can internalisethese skills and become confident in their instructionand assessment activities. These are, according to Paul(1993:97), profound challenges to the profession sincecritical thinking is at the heart of well-conceived educa-tional reform and restructuring because it is at the heartof the educational changes of the 21st century. It is hopedthat the core cognitive critical thinking attributes willassist nurse educators to facilitate critical thinking ofnurse learners during instruction or assessment.

THE PROBLEM OR POINT AT ISSUE

Much is being said about how critical thinking shouldbe facilitated, but exactly how critical thinking shouldbe facilitated or assessed to identify the empirical indi-cators to demonstrate that critical thinking has takenplace, are under-researched in clinical nursing educa-tion (Kamin, O’Sullivan, Younger & Deterding, 2001:27-35; Beckie, Lowry & Barnett, 2001:18-26; Carolee &Marilyn, 2003:1-9; Miller, 1992:1401-1407; Angela,Duffey & Belyea, 2000:219-228).

The results of these studies do not indicate the eviden-tial reasoning of the critical thinking process and theoutcomes that are to be assessed, that is, the pres-


ence of critical thinking (Carolee & Marilyn, 2003:3).Bowden (1988:24-25) notes that typical instruction andassessment methods normally enhance passive, re-productive forms of learning, whilst at the same timehide the inadequate understanding caused by such formsof learning and assessment. Therefore, though learn-ers may successfully negotiate the assessment sys-tem by being successful in their examinations, theyend their educational experiences as uncritical think-ers with little or no understanding of what they havelearnt. They are unable to use the acquired informationto manage their affairs, improve practice and deal withthe real world. Thus educators’ theoretical intentionsare not mirrored in the learners’ practice.

Critical thinking is one of the core cognitive competen-cies required for learners to become metalearners withthe aim of being self-directed lifelong learners.Metalearning refers to the ability of the learners to plan,execute, monitor and evaluate their own learning anddevelop an awareness of their mental or cognitive abili-ties (Slabbert, 1991:88). The nursing process is re-garded as a vehicle to facilitate critical thinking. Thedevelopment of the learner’s critical thinking skills ismandatory since nursing is a challenging, complex andculturally diverse hands-on profession that requiresastute power of clinical judgment, decision-making andproblem-solving skills in nursing practice.

In spite of the benefits of the nursing process in facili-tating critical thinking, nurse educators seem unableto implement and manage the approach. The nursingprocess and its administrative implementation areheavily criticised as time-consuming for nurses. It isargued that the role of nurses is to provide care and notto be heavily engaged with the lengthy administrativerecords involved with the nursing process (Field, inVarcoe 1996:123). Varcoe’s argument is that there isconfusion between the theoretical critique of the nurs-ing process and the critique of the administrative imple-mentation such as documentation. Critical thinkingcannot be facilitated when the nursing process is usedin a robotic and dogmatic way, where nurses are me-chanically efficient as evidenced by focusing on rou-tine, mass production, assembly-line, task-orientatedmethods to provide efficient patient care (Karola,1995:36). It is for this reason that this paper seeks todescribe the core cognitive critical thinking skills andthe judicious use of these skills within the framework

of the nursing process for the benefit of the patient. Theemerging research question to guide this paper is: howcan critical thinking of nurse learners be facilitated us-ing the nursing process framework?

Purpose and objectives

The purpose of the paper is to describe how criticalthinking of nurse learners can be facilitated using theframework of the nursing process. This purpose isrealised by the description of the critical thinking corecognitive thinking skills, their related sub-skills and theaffective disposition within the phases of the nursingprocess. Recommendations will be made.

The assumptions of the researcher

The researcher believes that nursing is concerned witha unique and culturally diverse whole person, well or ill.It is the very nature of the profession that demandsnurses who are critical thinkers to save lives and topromote good health.

LITERATURE REVIEW

Varied perspectives on critical thinking exist in differ-ent contexts. Critical thinking is a complex behaviourwhich is much needed in practice of any discipline andfor personal survival, yet to date there is no single,simple definition for it (Wilkinson, 1992:24). Brief con-ceptual definitions of critical thinking will be provided.

Conceptual definitions of critical thinking

The concept ‘critical thinking’ is derived from its rootsin ancient Greek. According to Paul, Elder and Bartell(1995:1), the word ‘critical’ derives etymologically fromtwo Greek roots: ‘kriticos’, meaning discerning judg-ment, and ‘kriterion’, meaning standards. Etymologi-cally, the word implies the development of discerningjudgment based on standards.

The definition of critical thinking has been a concern tomost authors. Its clarification has been under scrutinyfor many years. Oermann (1998:322), a renowned nurseauthor in critical thinking, stated that clinical nursingeducation occurs in a dynamic, complex and challeng-ing situation where nurses are expected to use criticalthinking as a fundamental principle to guide their ratio-


nal decision-making process and clinical judgment logi-cally in a systematic manner. Nurse authors adopted adefinition of critical thinking, adapted from the Ameri-can Philosophical Association’s Delphi study conductedin 1990, describing critical thinking as the process ofpurposeful, self-regulatory judgment that includes thecognitive skills of interpretation, analysis, evaluation,inference, explanation, self-regulation and the relateddispositions (Oermann, 1998:322; Edwards,2003:1144; Spelic, Parsons, Hercinger, Beckie et al.2001:18; Facione & Facione, 1996:130). This defini-tion characterises the daily functioning of a professionalnurse responsible and accountable for own actions,omissions and commissions.

The American Philosophical Association’s definition ofcritical thinking links with almost all the definitions ofcritical thinking as defined by other authors indicatedbelow. The underlying common characteristic of thedefinition of critical thinking is the use of core cognitivethinking skills and justification based on evidence. Thesecognitive thinking skills are guided by the affective criti-cal thinking dispositions such as willingness, inquisi-tiveness, open-mindedness, being systematic, flexible,truth seeking and developing cognitive maturity dem-onstrated by perseverance, tolerance, honesty and fair-mindedness for the purpose of making rational deci-sions and solving problems in practice or in real lifesituations. If one has to break down a cognitive think-ing skill like analysis, one will realise that many think-ing techniques are involved during the process of analy-sis such as, first having to identify concepts, assump-tions, claims, thoughts and feelings, then examine,categorise each cluster of information and re-examinefor better understanding or clarity. It is therefore impor-tant that further clarification of the core cognitive think-ing skills be made later in this paper.

According to Bandman and Bandman (1988:5, 6) criti-cal thinking is the rational examination of ideas, infer-ences, assumptions, principles, arguments, conclu-sions, issues, statements, beliefs and actions. Thisexamination covers scientific reasoning (inductive anddeductive), including the nursing process where deci-sion-making and problem solving of controversial issuesare addressed. To elaborate on this definition, Bandmanand Bandman note that critical thinking is reasoning inwhich nurses analyse the use of language, formulateproblems, clarify and explicate assumptions, weigh

evidence, evaluate conclusions, discriminate betweengood and bad arguments, check inferences for plausi-bility and seek to justify those claims, beliefs, deci-sions, facts and values that result in credible beliefsand actions. The researcher agrees with the authorssince nurses seek reasons for their thoughts, actionsand feelings. Nurses develop criteria and principles thateffectively justify their value judgments by asking rel-evant and challenging questions, questioning assump-tions, assessing, investigating, inquiring and solvingcomplex health care problems of culturally diverse pa-tients.

Critical thinking is also defined as a goal-oriented, pur-poseful mental activity involving a number of intellec-tual skills such as analysing, making inferences, clari-fying ideas and evaluating the credibility of sources tomake accurate clinical nursing judgments. It is both anattitude and a reasoning process (Wilkinson, 1992:9).

According to Wilkinson (1992:25), the following char-acteristics will help to determine when critical thinkingis taking place: when critical thinking is rational andreasonable, and where the thinking is based on rea-sons using facts and observations to draw conclusionsrather than prejudice, preferences, self-interest or fears.Critical thinking is reflective in that one does not jumpto conclusions or make hurried decisions but takesthe time to collect evidential information, think the mat-ter through in a disciplined manner, weigh facts, makeconclusions and consider alternatives. Critical thinkingincludes creative thinking where original ideas are cre-ated by establishing relationships among thoughts andconcepts. It involves the ability to break up and transfera concept or idea to new settings or uses. Critical think-ing involves conceptualisation, which is the intellectualprocess of forming concepts. Critical thinking is an at-titude of inquiry. A critical thinker examines existingclaims and statements to see if they are true or validrather than blindly accepting them; critical thinkers aresceptical in a constructive manner.

Critical thinkers will neither accept nor reject a beliefthey do not understand. They will analyse and exam-ine beliefs, accepting them for rational reasons or re-jecting those they have been holding for the wrong rea-sons. They are not easily manipulated. Critical think-ing is fair thinking. The critical thinking learner attemptsto remove bias and one-sidedness from their own think-


ing and to recognise it in others. This requires learnersto examine the reasons for their choices and decisions,to evaluate arguments and conclusions, create newideas or alternatives for action, decide upon a courseof action, produce reliable observations, draw soundconclusions and solve problems. It also requires anawareness of the learner’s own values and feelings anda willingness to examine the basis for them. Criticalthinkers will explore the thinking that underlies theiremotions and feelings, suspend judgments when theylack sufficient evidence, develop criteria for evaluationand apply them fairly and accurately, and evaluate thecredibility of sources used to justify beliefs. Criticalthinkers make interdisciplinary connections and useinsights from one subject to illuminate and correct othersubjects, distinguish facts from ideals, examine as-sumptions that underlie thoughts and behaviour, distin-guish the relevant from the irrelevant and the importantfrom the trivial, make plausible inferences, distinguishconclusions from the reasoning that supports them,seek out evidence and give evidence when questioned(Bandman & Bandman, 1988:6; King & Kitchener,1997:77).

The idea behind critical thinking is to find new ways ofthinking and doing things so as to allow creativity andgrowth, personally as well as in practice. Developingcritical thinking is not an easy task. It requires one torealise that these skills are important in a particularcontext and deciding to commit and motivate oneselfto their development (Rossouw, 2003:10).

Nurses deal with the lives of the patients on a dailybasis where crucial clinical judgments have to be madeand therefore committing themselves in the develop-ment of critical thinking is mandatory. Through deduc-tive analysis, the author defines critical thinking as apurposeful, systematic, goal-orientated mental activitythat involves the core cognitive thinking skills supportedby the affective critical thinking dispositions. Criticalthinking is also described by the author as a reflective,creative and a constructive reasoning process that useevidential information to guide accurate, informed andrational clinical decisions and solve problems in prac-tice.

Nurses are expected to be purposeful in their actionsand consciously use intellectual standards of thoughtprocesses such as precision, relevance, accuracy,

persistence, depth and breadth (Paul, 1993:54). Nurseshave to be precise and accurate in procedures. Therelevance, appropriateness, depth and breadth of boththe subjective and objective data gathered play an inte-gral part in order to render comprehensive nursing careto diverse patients. These nursing thoughts and ac-tions require the use of critical thinking.

The author is of the opinion that nurses who are criti-cal thinkers will constantly ask questions during a com-prehensive assessment of the patient, such as howaccurate and relevant is the information collected, andto what extent is the information related to the previoushistory of the same problem. In some situations, nurseshave to paraphrase what the patient has said to deter-mine the accuracy and relevancy of the information.Such critical questions will generate in-depth informa-tion to enable the nurse to justify own decisions andactions.

In this age of information explosion, and a complex,challenging and culturally diverse health care deliverysystem where the rights of the patients takes priority,nurse learners are expected to be inquisitive, well-in-formed, trustful of reason, open and fair-minded. Nursesare expected to be flexible, honest in facing personalbiases, prudent in making judgments, willing to recon-sider, clear about issues, orderly in dealing with com-plex matters, diligent in seeking relevant information,reasonable in the selection of evaluative criteria, andpersistent in seeking results which are as precise asthe subject and the circumstances of inquiry permit.Nursing combines critical thinking skills with those dis-positions which consistently yield useful insights andwhich are the basis of a rational and democratic soci-ety (Facione, 1990:2, 13). This ideal is supported byRossouw (2003:10) who asserts that for an effectivedemocratic society or for success in almost any ca-reer in many other fields, critical thinking skills are im-portant.

For decades, nursing and nurses have been workingtoward the ideal of providing the best practice to indi-vidual patients using the nursing process as a scien-tific process, but to date, nurses have failed to developcritical thinking skills through the use of the nursingprocess (Botes, 2000:28). The researcher will makeuse of the identified core cognitive thinking skills andthe related affective critical thinking dispositions to guide


the teaching and learning of nurse learners in clinicalnursing education, however, nurse educators shouldrealise that a relaxed learning atmosphere with humourwill facilitate critical thinking and help offset the fearespecially during the assessment and evaluation situ-ation.

CRITICAL THINKING AND THE NURSINGPROCESS IN CLINICAL NURSING EDU-CATION

Since critical thinking cannot be facilitated or assessedin isolation, the contextual consideration within whichcritical thinking is to be facilitated or assessed in thisstudy becomes the hallmark of the activity (Facione,1990:2; Wilkinson, 1992:21; Rolfe, Freshwaters & Jas-per, 2001:72, 73; Rossouw, 2003:10; Simpson &Courtney, 2002:91). Because of the nature of work inthe nursing profession, nurses must be educated andassessed to promote critical thinking. A truly educatednurse is able to use critical thinking to do somethingcreatively with the information acquired. Through criti-cal thinking, one is able to form rational clinical judg-ment about what to believe or what actions to take in aparticular situation in practice (Ennis, 1985:45).

The nursing process, used effectively for the intendedpurpose, is a powerful scientific vehicle to facilitate criti-cal thinking. The nursing process is a special way ofthinking and acting that nurses use. It is also whatnurses do when giving patient care. It is a systematic,problem-solving approach used to identify, prevent andtreat actual or potential health problems and promotewellness. The nursing process provides the frameworkin which nurses use their knowledge, skills, attitudesand values to express human caring. The nursing pro-cess is a cognitive process that involves the use ofcritical and creative thinking skills in problem-solvingand decision-making activities. Nurses use critical think-ing to apply their nursing knowledge systematically andlogically to collect patient data. Critical thinking en-ables the nurse to determine the meaning of the dataand to plan appropriate nursing care (Wilkinson, 1992:1,2).

Varcoe (1996:865) is of the opinion that the nursingprocess is a systematic way of thinking, while Field (inVarcoe 1996:123) argues that the nursing process isan analytical thinking process used to guide system-

atic and rational decision-making in nursing practice.However, the nursing process and its administrativeimplementation have been criticised as time-consum-ing for nurses. The role of the nurse is to provide careand not to be heavily engaged with the lengthy admin-istrative records involved with the nursing process docu-mentation. Varcoe’s argument is that there is confu-sion between the theoretical critique of the nursing pro-cess and the critique of the administrative implementa-tion such as documentation. The widespread influenceof the nursing process on the nature of nursing prac-tice has been debated for the past decade, yet thecentrality of the concept has grown in the past thirtyyears within the educational, professional and economicarena of nursing (Hiraki, 1997:866).

Critical thinking cannot be facilitated when the nursingprocess is used in a robotic and dogmatic way, wherenurses are mechanically efficient (Karola, 1995:36).While lack of clarity regarding the definition of the nurs-ing process poses a problem in its use, and multipleinterpretations of it exist, it is argued that, with criticaland judicious use, the current benefits of the nursingprocess could be preserved in the service of clinicalnursing education to improve practice (Varcoe,1996:124). Nurse educators have the responsibility tofacilitate clinical nursing education within a broad frame-work of nursing process to stimulate critical thinking oflearners.

Nursing is concerned with the whole person, well or ill.What makes the clinical nursing education and assess-ment process complex and difficult for nurse learnersis that human beings are unique and their clinical pre-sentations are unique and diverse. These presentationsmay not reflect what Oermann (1998:322) refers to as“textbook characteristics” which were taught in theclassroom. This situation leaves the nurse unsure asto what nursing intervention to use in a real-life, au-thentic situation where unstructured problems shouldbe addressed. Oermann (1998:324, 327) suggests thatone way to curb this problem is to apply cognitive criti-cal thinking skills within the broad framework of thenursing process. The educator can ask thought-pro-voking questions that are unique to the patient’s prob-lems. The relationship between the core cognitive think-ing skills, their related sub-skills and the nursing pro-cess will be described (Wilkinson, 1992:29; Facione &Facione, 1996:133 Facione, 1990:6, 13).


Description of the core cognitive criticalthinking skills and their related sub-skillswithin the nursing process framework

The core cognitive thinking skills and their related sub-skills were identified by experts in critical thinking in

Table 1: Core cognitive thinking skills, their related sub-skills, affective dispositions and the nursingprocess (Facione, 1990:6, 13; Proferto-McGrath, 2003:571; Wilkinson, 1992:29)

the Delphi study on the status of critical thinking di-rected by doctor PA Facione from 1987 to 1990. Theresults also included the formulation of the consensusconceptual definition of critical thinking and the char-acteristics of a critical thinker as already described inthis text (Facione, 1990:2). The nursing process’s theo-


NURSING PROCESS (Wilkinson, 1992:29)

CORE COGNITIVE CRITICAL THINKING SKILLS AND SUB-SKILLS (Facione, 1990:6)

AFFECTIVE DISPOSITIONS OF CRITICAL THINKING (Facione, 1990:13; Proferto-McGrath, 2003:571)

Assessment Analysis Examining ideas, identifying arguments, analysing arguments Interpretation Categorisation, decoding significance, clarifying meaning

Analycity Inquisitiveness

Diagnosing Inference making; Synthesis; Hypothesise Querying evidence, conjecturing alternatives, drawing conclusions

Open-mindedness

Planning Inference making; Generalising; hypothesising

Systematicity

Implementation Explanation – applying the plan and testing the hypothesis Stating results, justifying procedures, presenting arguments

Self-confidence Truth-seeking

Evaluation Evaluation Assessing claims and arguments Self-regulation (assessing; making criterion-based evaluations Self-examination and self-correction

Cognitive maturity

retical framework and its phases through which criticalthinking of learners should be facilitated in clinical nurs-ing education is in accordance with Wilkinson (1992:29)indicated in Table 1 below. The core cognitive criticalthinking skills are bolded in the table.

A description of the core critical thinking skills, theirrelated sub-skills and the affective dispositions will bemade within the framework of the nursing process forthe purpose of formulating attributes that will assistnurse educators to facilitate the critical thinking of nurselearners in clinical nursing education. The generic na-ture of the attributes could be used widely within a givenclinical nursing context, since critical thinking is a nec-essary outcome of all educational programs (Staib,2003:489; South African Qualifications Authority Act,Act no 58 of 1996; South African Nursing Council 1999:Document A; Van der Horst & McDonald, 1997:6, 217).

The skills reflected in Table 1 do not necessarily sug-gest a linear form of reasoning. The skills are employed

interactively and interchangeably in the reflective-rea-soning process of making judgments about what tobelieve or do. Simpson and Courtney (2002:93) purportthat, in thinking critically, a person not only tries todetermine judiciously what to do or what to believe, butis also able to apply the core critical thinking skills tothe problem at hand. In other words, one may analyseone’s own inferences, explain one’s own interpretationor evaluate one’s own analysis. In practice, nursesconfronted with a patient with a severed femoral arteryfind themselves having to implement their knowledgeand skills immediately using all the cognitive and af-fective dispositions simultaneously to save the life ofthe patient. An experienced critical thinking nurse willintuitively use all the steps of the nursing process si-multaneously to provide specific emergency care to thepatient in any clinical situation.

Even though the steps of the nursing process are dis-cussed separately for ease in understanding them, theyare actually inter-related and overlapping as indicated

Figure 1: Interdependent nature of the phases of the nursing process (Wilkinson, 1992:1)


in Figure 1. Assessment and evaluation occur through-out all the phases as indicated by arrows and the over-lapping of the circles when more justification based onevidence is called for and to determine when the pro-cess of providing adequate nursing care is achieved.

Complete, accurate data provide the foundation for theother steps – for example, the usefulness and validityof the nursing diagnosis depend greatly upon the qual-ity of the data collected in the assessment phase(Wilkinson, 1992:41). The nurse has to be flexible inconsidering the first line of intervention in order of prior-ity, while considering other alternatives and opinions inresolving the problem. The nurse has to consider or-derliness and being systematic as well as persistenceand precision in working with a complex situation toavoid further complications (Facione, 1998:8).

The assessment phase

Assessment is the first crucial step of the nursing pro-cess. It is the phase where the nurse systematicallygathers comprehensive, relevant, valid, reliable andcomplete patient information from the patient and othercredible sources in order to identify health problems,make a diagnosis, and then plan, implement and evalu-ate the nursing care given. The use of critical thinkingduring the assessment phase is demonstrated in Fig-ure 2. The nurse uses critical thinking to identify thechief complaint and other health problems, collect in-formation, analyse ideas and arguments, examine andinterpret data, categorise and decode the significantdata from the insignificant data and clarify the meaningfor better understanding. The nurse has to verify thedata with credible sources where there is doubt.Throughout the assessment phase cognitive thinkingskills are supported by the affective critical thinking dis-positions as indicated in the figure. The nurse has tobe inquisitive and analytic and ask probing questionsto collect a comprehensive health history from the pa-tient. The nurse has to be open-minded, systematicwhen collecting data, seek for the truth, and demon-strate self-confidence and cognitive maturity to the pa-tient and relatives so as to build a good rapport anddevelop a respecting and a trusting relationship withthe patient.

The core cognitive critical thinking skills and the sub-skills required during the assessment phase as identi-

fied in Table 1 are:

Analysis (examining ideas, identifying andanalysing arguments)The first part of the assessment is to identify the mainor chief health problem from the patient or knowledge-able others. The nurse finds out what actually moti-vated the patient to seek health care. The chief com-plaint should be recorded in the patient’s own wordswhenever possible. It should describe the problem andits duration. The chief complaint gives direction to theinterview that follows. Thereafter the nurse should col-lect the demographic data, which consists of identify-ing data such as the patient’s name, date, age, maritalstatus, number of children, religion, occupation andeconomic status. The nurse then systematically col-lects comprehensive, accurate, relevant, valid and reli-able subjective and objective information from the pa-tient through observation and an interview. The subjec-tive data consist of the present and past health history,and the family health history. The objective data arecollected by observation, physical examination andexamining and interpreting other measurements suchas diagnostic results. Review of the body systems ismade by making use of inspection, auscultation, per-cussion and palpation. Throughout the data collectionthe nurse considers the patient’s input (Lewis & Collier,1992:30, 31).

The cognitive skills of identification and analysis playan important role in this phase. Analysing entails tak-ing apart, disassembling and deconstructing in orderto perceive or establish a pattern or relationship/s(Beyer, 1988:319). It is the process of breaking up awhole into its parts to examine these in detail so as todetermine the nature of a phenomenon (Paul, 1993:458).During the assessment phase the nurse learner is ex-pected to explore, examine and analyse the informa-tion in detail in order to be able to identify the mainideas, thoughts, key concepts, clues or patterns andthereby have an understanding of the patient’s healthproblem. The nurse inquisitively asks logical questionsto look for hidden, unstated and challenging assump-tions that are taken for granted. The nurse demonstratescritical thinking competencies of analysis by identify-ing and analysing arguments, by identifying the pur-pose of data collection, by scanning the data to iden-tify clues or patterns of significance, by examining thedata or ideas to find “something germane that is, worth-


Figure 2: Critical thinking during the assessment phase

while” to the purpose of assessment, by re-examiningthe data to find additional supporting evidence or evi-dence contradicting the original inference, and by com-paring and contrasting ideas and statements made bythe patient to confirm the evidence found in order toestablish patterns, conceptual links or other intercon-nections (Beyer, 1988:319).

Determining the significance or insignificance of data,interpreting meaning and detecting possible inferentialrelationships reflect the competencies of critical think-ing skills (Proferto-McGrath, 2003:571). Critical think-ing abilities are demonstrated when the learner is ableto determine and analyse relevant and irrelevant infor-mation. To determine reliable and unreliable informa-tion or sources and seeing similarities and differencesin the data collected characterise critical thinking abili-ties. Critical thinking is also demonstrated when learn-ers are able to summarise information, are able to seethe structure of an argument and identify conclusions.The ability to identify critical areas, predict conse-quences, observe cues and behavioural patterns thatadd value to the collected data as well as being able toassess and evaluate sources and make decisions

based on the available information demonstrate criticalthinking (Beyer, 1988:185). Analysis is a process ofweighing evidence and deciding if generalisations orconnections based on the given data are warranted. Itis imperative for nurse learners to verify data collectedwhen there are discrepancies in the information sourcewith the patient, significant others or any other relevantcredible source.

Interpretation (categorisation, decodingsignificance, clarifying meaning)Interpretation of data will be made when the informa-tion has been identified and critically analysed. Accord-ing to Paul (1993:473), to interpret is to give one’s ownconception of, to place in the context of one’s own ex-perience, perspective, point of view, or philosophy. It isimportant in nursing that interpretation should be dis-tinguished from the facts, the evidence and the situa-tion. For example, a nurse may interpret the patient’ssilence as an expression of hostility. Such interpreta-tion may or may not be correct. More facts, evidenceand justification are needed. The best interpretationstake the most evidence into account.


During the assessment phase, it is not enough for thenurse to state that the patient appears to be in pain.More evidence is needed to confirm the claim such asthe patient adopting a curling position, facial grimaceor the patient verbalising the pain. When facilitatingcritical thinking one should consider alternative inter-pretations and reconsider these interpretations in thelight of new evidence. Learning involves personal inter-pretation, since whatever a person learns must be inte-grated into one’s own thinking and action (Paul,1993:473). What a person learns must be meaningfulto other people. Interpretation involves examining thephenomenon and forming conclusions, considering theimplications, exploring the significance of the conclu-sions, generalising the findings and suggesting furtherstudies (Burns & Grove, 2001:771). Interpretation in-cludes weighing evidence and deciding if generalisationsor conclusions based on the given data are warranted(Watson & Glaser, 1980:2). Making interdisciplinaryconnections by using other related subjects likeanatomy, physiology, micro-biology, pharmacology,psychology, sociology, chemistry and physics will en-hance the process of interpretation of data. Interpreta-tion involves categorisation, decoding significance andclarifying meaning (Facione, 1990:6, 7).

Categorisation of the collected data involves thelearner’s ability to describe situations, events and ex-periences so that they take on comprehensible mean-ings in terms of appropriate categorisation, distinctionsor frameworks, for example, to categorise according tothe existing frameworks such as Maslow’s hierarchyof needs (Quinn, 2000:19), Orem’s self-care model orRoy’s adaptation model (George, 1985:124-136, 300-318). Decoding significance means to detect, to at-tend to, and describe the information content for betterunderstanding. Clarifying meaning ensures that the ar-gument is expressed as clearly as possible so that itis easy to tell whether the premises are true, whetherthe logic is good and whether the argument is relevantto the assessment of the patients’ health problems.The premises of a logical argument must strongly sup-port the conclusion – that is, one must believe in theconclusion.

Clarifying requires one to outline the argument in stan-dard format and paraphrase the argument for greaterclarity (Brookfield, 1987:68). During the assessmentphase of the nursing process the nurse learner should

demonstrate the ability to clarify and give meaning tothe data collected. If there is doubt the nurse can para-phrase the sentence (Simpson & Courtney, 2002:92).Paraphrasing or restating the patient’s ideas and sub-jective information in the nurse’s own words or clarify-ing the symptoms based on the information collectedindicates the occurrence of critical thinking. The as-sessment information must be recorded accurately inappropriate documents.

Diagnosis phase

Nursing diagnosing is the second phase of the nursingprocess which usually entails making a statement of ahealth problem as perceived by the nurse (Wilkinson,1992:76, 78). Diagnosis is an intellectual activity wherenurses use the diagnostic reasoning process to drawconclusions about the patient’s health status and de-cide whether nursing intervention is needed. Diagnosisprovides the basis for giving individual care. The formatof stating a nursing diagnosis is highlighted; the nurs-ing diagnosis is presented first and includes the prob-lem and etiological statement – for example, pain re-lated to surgical incision. Next, the defining character-istics that cue the nurse to this specific diagnosis arelisted – for example, complaints of pain, curled bodyposturing, groaning sounds indicating pain, unwilling-ness to move in bed or to ambulate. Nursing diagnosesmust be listed in order of their priority. Figure 3 demon-strates the use of critical thinking skills during the di-agnosis phase.

During the diagnosis phase, nurses use critical think-ing skills such as inference-making, where synthesisingand hypothesis-making play an integral part. The nurselearner is expected to query evidence as it comes,conjecture alternatives and draw conclusions (Facione,1990:9).

Inference-making (querying evidence, con-jecturing alternatives, drawing conclu-sions, synthesising and hypothesising)Inference is defined as the movement of thoughts thatproceeds from something given, a cue or data, to aconclusion as to what that data mean or signify(Bandman & Bandman, 1988:120). For example, atwenty-five-year-old patient in an intensive care unit,certified as being brain dead by a senior neurosurgeon,has a cardiac arrest. Nurse X infers that as the patient


Figure 3: Critical thinking and the diagnosis phase

cannot recover, given that the patient is brain dead,resuscitation is futile and therefore Nurse X does notcall for help. Nurse Y is committed to the oath thathuman life is so precious as to warrant all availableefforts by a nurse to save it. She infers that the youngpatient’s life can be saved by resuscitation and con-tinuous administration of oxygen to the brain cells.Therefore, Nurse Y calls for cardio-pulmonary resusci-tation. Bandman and Bandman (1988:113) further statethat making an inference is like leaping from the knownto the unknown, a hunch, a preliminary hypothesis, oran inference that is either confirmed or disconfirmed byfurther data until a diagnosis is reached.

Beyer (1988:112) believes that to infer is to draw con-clusions, make predictions, pose hypotheses, test andexplain hypotheses. Paul (1993:115), on the other hand,is of the opinion that inference is reasoning that pro-ceeds by steps. To make an inference, according toPaul, is to think as follows: because this is so, thatalso is so or probably so. From the researcher’s per-spective, another example of inference maybe: “I amnot sure I should have this surgery. It might not evenhelp, and it is so dangerous. I am scared”. This might

be inferred as: the patient is frightened of surgery. Anydefect in the inference one makes while one reasons isa possible problem in one’s reasoning. Information andsituations do not determine what one will deduce fromthem; one creates inferences through the concepts andassumptions which one brings to situations. Inferencesbring together all the various elements needed to queryevidence collected, to draw reasonable conclusions andto form conjectures and hypotheses (Proferto-McGrath,2003:571; Facione, 1990:6).

Querying evidence in practice can be seen when thenurse is not content with the evidence given. The nurserecognises the information that requires support andformulates strategies to seek and gather informationwhich might supply that support. The nurse criticallyexamines the depth and breadth of all the collecteddata, states the actual and potential health problemsand prioritises them. Conjecturing alternatives requiresnurses to develop a set of options or alternatives forresolving a given problem. They need to synthesise andclassify data into meaningful patterns and find patternsand relationships to assist in deriving accurate diagno-sis. The nurse will draw out prepositions and project


the range of possible consequences of decisions. Draw-ing conclusions entails bringing together all the variouselements needed to state a reasonable diagnosis(Proferto-McGrath, 2003:571).

However, the nurse may suspend judgment where thereis lack of sufficient evidence because evidence is re-quired to convince one of an argument. The nurse mustdemonstrate the affective critical thinking dispositionssuch as willingness, openness and fair-mindedness toaccept new evidence from credible information sources.The nurse must also show tolerance, flexibility andgenuine understanding of the patient’s opinion or pointof view. Diagnostic inference calls for more knowledge,experience and insight to classify data into variousthemes and patterns that will assist in the planningphase (Facione, 1990:6). Interdisciplinary connectionplays an integral part during the diagnostic phase todetermine whether the diagnosis is physiological, so-cial or psychological. Accurate recording of the diag-nosis in a manner that facilitates the determination ofthe expected outcomes using the appropriate format ofwriting nursing diagnosis is important.

Planning

Use of inferences, generalising,hypothesisingBoth nursing diagnosis and planning make use of theinference cognitive thinking skill. In this phase the nursetakes professional responsibility to work with the pa-tient, significant others or use other credible sourcesto develop individualised plans to prevent, eliminate orreduce the health problems through goals and nursingorders (Wilkinson, 1992:163). The nurse determinesproblems that need individually developed plans andthose that can be addressed by routine interventionscontained in standards of care, model care plans, pro-tocols and other forms of preplanned, routine care. Thisrequires critical thinking skills and creativity, as doesevery phase of the nursing process as indicated in Fig-ure 4.

Effective planning, like all other phases of the nursingprocess, depends on the accuracy of other previoussteps and the ability to make interdisciplinary connec-tions and use the insights from the behavioural and

Figure 4: Critical thinking during the planning phase


physical sciences. Sound knowledge, good judgmentand decision-making abilities are required to effectivelyplan and choose the methods the nurse will use tointervene. In addition, the nurse must use ingenuity,creativity and past experience, and must also considerthe patient’s cultural health care needs and practiceswhen tailoring a plan to meet the desired health goals,for example, adopting a squatting position during child-birth is a characteristic of some black cultures. Theplan should be tailored to take note of particular nurs-ing orders such as how, when, how long, how often, bywhom and with what to provide direction in the care ofthe patient (Lewis & Collier, 1992:25).

The assessment data have to be comprehensive, com-plete, accurate, valid and reliable. The data have to beverified with reliable and credible sources. The diag-nostic statements should be correct for the goals andnursing orders to flow logically for an individual, uniqueplan for the identified health problems. The goals andnursing orders serve to guide the nurse’s actions dur-ing the implementation phase and also serve later ascriteria for evaluating patient progress. Planning is on-going depending on the new information as the nursegets to know the patient better and as the patient re-sponds to the care given. During planning, the nurseuses more inferences, generalisation and hypothesisingcognitive thinking skills to make rational mutual clini-cal decisions with the patient. The nurse and the pa-tient derive goals from the diagnostic statements andidentify nursing measures to achieve those goals. Whengenerating nursing interventions, nurses use the cog-nitive skills of generalising, explaining and predicting.Generating nursing interventions is similar to generat-ing hypotheses in the scientific method in that the nursepredicts the interventions most likely to achieve thepatient’s health goals (Wilkinson, 1992:29-32).

It is important to note that planning of interventionsshould be mutual, research-based, realistic, simple andattainable, and must have measurable expected out-comes and time frames open to modifications basedon new evidence (Wilkinson, 1992:166). The nurseshould always create new ideas or alternative coursesof action regarding events or develop a variety of differ-ent courses of action to achieve the set goals if needed.The development of the evaluation criteria that shouldbe applied fairly and accurately to evaluate the effec-tiveness of the plan is necessary. The nurse should

plan for the consultation of other health professionalsfor the intervention not directly related to nursing. Theplan should be within the legal and professional bound-aries such as: the Constitution, Batho-Pele principles,Scope of practice, patient’s charter, regulations, proto-cols and policies. The affective critical thinking dispo-sitions are taken into consideration during the planningphase such as flexibility, willingness, being analyticaland inquisitiveness. The plan, interventions and ex-pected outcomes should be recorded accurately in theappropriate documents.

Implementation

Implementation is the fourth phase of the nursing pro-cess in which the nurse applies the plan and puts thehypothesis to test. The nurse carries out a specific,individualised plan. Specific nursing interventions thataddress the nursing diagnosis are then specified suchas the example made above of a patient suffering frompain. The nurse has to assess the pain half hourly, givepain medication every three to four hours as prescribed,splint incision with pillows during coughing, deep breath-ing and moving exercises, and position the patient com-fortably according to his or her needs. Finally, one ormore evaluation criteria are described that aid the nursein determining if the goals of the treatment have beenmet. These include verbalisation of a satisfactory levelof pain control and turning in bed without making ges-tures that indicate pain (Lewis & Collier, 1992:1084).

The nurse may perform or designate to other capablemembers the interventions that were developed in theplanning phase necessary for achieving the patient’shealth goals. When choosing an intervention, it is im-portant to ask the following questions: will the interven-tion facilitate the patient’s progress toward a desiredoutcome? Has the intervention been proven throughresearch, or is it based on experience or intuition, thatis, based on immediate insight of the nurse? The feasi-bility of successfully implementing the intervention mustbe considered, as must the acceptability of the inter-vention to the patient and the capability of the nurse toexecute the intervention safely with competence. There-after, the nurse ends up by recording the interventionsperformed and the resulting patient’s responses (Lewis& Collier, 1992:25; Wilkinson, 1992:214). Throughoutthe implementation phase the nurse must evaluate theeffectiveness of the method chosen to implement the


plan. Referrals to other professionals should also bemade when the nurse anticipates that expertise inspecialised areas would help the patient. Figure 5 dem-onstrates the use of critical thinking during the imple-mentation phase.

Figure 5: Critical thinking during the implementation phase

Patient participation in the implementation phase playsan integral part. However, it is important to note thatthe degree of participation in this phase depends onthe patient’s health status and the available resourcesas well as the type of action being considered. Forexample, interventions in relation to a child, a quad-riplegic or an unconscious patient would be very differ-ent and will require the participation of family mem-bers. The effectiveness of the implementation phasedepends largely on the nurse’s ability to create goodcommunication and building of good rapport with thepatient (Kozier et al. 2004:316). Critical thinking skillsare crucial in making a quick, on-the-spot rational de-cision in determining whether the interventions shouldbe dependent, interdependent/collaborative or indepen-dent/autonomous in nature (Lewis & Collier, 1992:18).The nurse has to think rapidly of alternative courses of

actions when the planned strategies do not work asanticipated. Explanation plays an integral part in theimplementation phases, as it is within the patients’rights to receive an explanation of the actions to beperformed on them.

Explanation (stating results, justifying pro-cedures, presenting arguments)Explanation means to state the results of one’s rea-soning, to justify that reasoning in terms of the eviden-tial, conceptual, methodological, criteriological andcontextual considerations upon which one’s resultswere based and to present one’s reasoning in the formof cogent arguments (Facione, 1990:10). When onestates the results, one produces accurate statements,descriptions or representations of the results of one’sreasoning activities so as to analyse, evaluate, inferfrom, or monitor those results. One justifies and pre-sents arguments based on one’s interpretations, analy-ses, evaluations or inferences, so that one can accu-rately record, evaluate, describe or justify those pro-cesses to oneself or to others, or so that one can rem-edy perceived deficiencies in the general way one ex-


ecutes those processes. When one is presenting ar-guments, one is expected to give reasons for accept-ing some claim, to meet objections to the method,conceptualisations, evidence, criteria or contextualappropriateness of inferential, analytical or evaluativejudgments.

Copi (1986:482) suggests the following aspects whenone asks the question “What is it that is wanted whenan explanation for something is required?”

An account: is a group of statements from which thething to be explained can logically be inferred and whoseacceptance removes or diminishes its problematic orpuzzling character. Explanation and inference appearto be closely related because, given certain premises,any conclusion/s that can logically be inferred from themcan be regarded as being explained by them. Given afact to be explained, we say that we have found anexplanation for it when we have found a set of premisesfrom which it can logically be inferred (Copi, 1986:483).The chief criterion for evaluating explanations is rel-evance. Any proposed explanation is regarded as amere hypothesis, more or less probable on the basisof the available facts or relevant evidence, and alsoconsidering the attitude taken toward the explanationin question (Copi, 1986:484). There is a continual searchfor more evidence to decide that question. The term‘evidence’ refers ultimately to experience: sense expe-rience is the test of truth for all its pronouncements.There are other criteria for deciding the worth or ac-ceptability of proposed explanations, such as the truth,for example, having an eye witness in an accident orwhere it is applicable, or the verifiability of the explana-tion by providing additional premises (Copi, 1986:486;Woolfolk, 1990:292).

Brown and Atkins (in Quinn, 2000:184) classify expla-nations as interpretive (that is they answer the ques-tion ‘What?’), descriptive (they answer the question‘How?’) and reason-giving (that is they answer the ques-tion ‘Why?’). Brown (in Quinn, 2000:185) is of the opin-ion that when one is planning an explanation, one shoulddecide precisely what is to be explained in the form ofa question, identify any hidden variables, analyse thetopic into its main parts or key points and then estab-lish any links between these, including any rules thatmight be involved. Nurses care for a variety of patientsand therefore better explanations have more keys and

a greater variety of cognitive levels of keys. Better ex-planations also involve the use of examples, elabora-tions, qualifying statements, visual aids and rhetoricalquestions and are more appropriately structured. Stimu-lating key points are also expressed in a simple state-ment. Writing a summary of the key points to be usedat the end of the explanation is important.

The implementation process uses cognitive thinkingskills such as justifying the decisions made and solv-ing problems in clinical practice. The use of critical think-ing, creative and reflective thinking skills with the re-lated affective dispositions are crucial to the provisionof safe and intelligent nursing care. A comprehensiveimplementation process must be specific enough andrecorded accurately and legibly in appropriate docu-ments so that everyone taking care of the patient willbe able to agree on whether the set goals have beenachieved and also to avoid repetition of interventions(Lewis & Collier, 1992:25). It must be explicit to enableevaluation of the effective or ineffective intervention andto decide whether referral to other health professionalsis necessary.

Evaluation phase

Evaluation (assessing claims and argu-ments)Evaluation, as the fifth phase of the nursing process, isa planned, ongoing, deliberate activity in which thepatient’s progress toward goal achievement and theeffectiveness of the nursing care plan are determined(Wilkinson, 1992:261). Evaluation is ongoing through-out the various phases of the nursing process. Thenurse evaluates whether sufficient assessment datahave been obtained to allow a nursing diagnosis to bemade. The diagnosis is in turn evaluated for accuracyand appropriateness to the patient’s health problem.The nurse evaluates whether the expected outcomeand interventions are realistic and achievable. If not, analternative plan should be formulated. Considerationmust be given to whether the plan should be maintained,modified or totally revised in the light of the patient’shealth status. The effectiveness of each interventionand its contribution to progress towards the goal arealso evaluated. The patient’s progress should be docu-mented in a systematic way according to the policy ofthe institution. Figure 6 demonstrates the use of criti-cal thinking during the evaluation phase.


Figure 6: Critical thinking during the evaluation phase

Critical thinking is an integral part of the evaluationphase. It is used to assess the credibility of statementsor other representations made by the patient. To as-sess claims, the contextual relevance of the informa-tion gathered should be considered. A distinction alsohas to be made between reasonable and fallacious in-ferences and the extent to which possible additionalinformation might strengthen or weaken an argumenthas to be determined (Facione, 1990:8). Relevant factshave to be identified, data analysed, and hypothesestested. When developing the criteria for evaluation, criti-cal thinking is used to apply knowledge of other relateddisciplines to the specific patient’s situation in order toknow what outcomes can reasonably be expected.When collecting evaluation data, one will use criticalthinking to determine the significant data for the goalbeing evaluated, to judge the congruence between pre-dicted and actual outcomes. For example, if onehypothesised during the planning phase that a particu-lar nursing intervention would produce a desired pa-tients’ outcome, in the evaluation phase one tests thathypothesis (Wilkinson, 1992:262). Without evaluation,nurses will not know whether the care they give actu-ally meets the patient’s needs. Evaluation enables thenurses to improve care and to promote efficiency by

eliminating unsuccessful interventions and focusing onactions that are more effective.

Evaluation is the process of judging or determining theworth or quality of a phenomenon. Evaluation has alogical component and should be carefully distinguishedfrom mere subjective or imaginary performance. Theelements of its logic may be put in the form of ques-tions which may be asked whenever an evaluation is tobe carried out (Paul, 1993:466), such as, do we havesufficient information about that which is to be evalu-ated, is the information relevant or irrelevant to the pur-pose of evaluation, given the purpose, what are the rel-evant criteria or standards for the evaluation, have weapplied the criteria accurately and fairly to the facts aswe know them? Blandshard (in Wilson, 1999:167) ar-gues that the main aim of education is practical andreflective judgment, a mind trained to be critical every-where in the use of evidence.

Self-regulation (self-examination, self-cor-rection)According to Facione (1990:10), self-regulation occurswhen one self-consciously monitors one’s cognitiveactivities, the elements used in those activities, and


the results deduced, particularly by applying skills inanalysis and evaluation to one’s own inferential judg-ment with a view to questioning, confirming, validatingor correcting either one’s reasoning or one’s results.

Self-regulation involves self-examination and self-cor-recting. The purpose of self-examination is to reflect onone’s reasoning and verify both the results producedand the correct application and execution of the cogni-tive skills involved. Self-correction, where self-exami-nation reveals errors or deficiencies, is important. Learn-ers should learn to design reasonable procedures toremedy or correct, if possible, those mistakes and theircauses. Woolfolk (1990:215) states that self-regulationis a very important aspect to learners. Nurse learnersmust learn to regulate and manage their own lives, settheir own goals, provide their own reinforcement, ob-serve their own work, keep track of their own dailyprogress, keep records of it and assess their own per-formance by keeping reflective diaries, charts, check-lists, and by recording their performance or behaviourin question. Knowles (in Mellish et al. 1998:36) statesthat learners with a positive self-concept have self-con-fidence, are self-regulatory and self-directed, takingresponsibility for their own learning. They can diagnosetheir own learning needs, formulate their own learningoutcomes, identify their own learning resources, findstrategies for using these resources and assess theirown progress. Critical thinkers monitor the set goalsand reinforce high standards.

Self-regulation makes one realise one’s potential needfor examining and correcting oneself. One has the de-sire to excel and strive for excellence. A nurse learnerwho has reached a self-regulatory level works harder tostrive for even greater knowledge and understanding.The nurse is motivated. This motivation is endlesslyrenewed (Woolfolk, 1990:314). The core cognitive think-ing skills of critical thinking are continually supportedby the affective dispositions. The evaluation processshould also be accurately recorded. Should evaluationreveal failure to meet the set goals and expected out-comes, the nurse should re-assess, re-diagnose, re-plan, re-implement and re-evaluate the process, thatis, the nursing process cycle begins.

Recording (accuracy, completeness, pre-cision, clarity, legibility)

Although recording is generally not regarded as one ofthe phases of the nursing process, it plays an integralpart in the process because it provides effective com-munication among health professionals necessary forthe continuity of care and for the maintenance of qual-ity of patient care. When staff members take over shifts,a report is handed over by the staff that was on duty toconvey information about the patient for continued healthcare. Records are formal, legal documents usually ad-missible in court as evidence of the patient’s care, andthus it is important that the nurse becomes account-able for recording on appropriate documents accordingto the standards and policies of the institution (Kozieret al. 2004:330). Whatever form of documentation isfollowed, the principles of recording remain the sameas indicated in Figure 7.

AccuracyAccuracy when recording is important. To be accuratedemonstrates that one is a thinking person. The pa-tients’ particulars must be clearly written on the cor-rect charts. Facts or observations rather than opinionsshould be clearly written, for example, the patient re-fused medication is a fact, whereas to write that thepatient was uncooperative, is instead, an opinion orown interpretation. Patient dissatisfaction or worry abouta diagnosis should be recorded verbatim and accurately,without the nurse’s interpretation. When a recordingmistake is made, a line should be drawn through it andthe word “mistaken entry” should be written next to theoriginal entry with the initials or name of the nurse. Theoriginal entry must remain clearly visible. Correct spellingis essential for accuracy in recording. Incorrect spell-ing gives a negative impression to the reader and de-creases the nurse’s credibility (Kozier et al. 2004:342).

Completeness/relevanceThe information that needs to be recorded must be logi-cally coherent, complete and helpful to the patient andto the health professionals. Detailed and systematicrecording of the phases of the nursing process is man-datory. The patient’s progress toward the pre-deter-mined goals must be communicated to other healthprofessionals through completeness of recording. Com-pleteness in recording requires thinking on the part ofthe nurse. Only relevant information about the patient’shealth problem and nursing care should be recorded.Recording irrelevant information may be considered aninvasion of the patient’s privacy. Only information that


Figure 7: Critical thinking during recording

has a direct bearing on the patient’s health problemshould be recorded and therefore relevant recording isa thinking activity (Kozier et al. 2004:344).

PrecisionPrecision in recording is a critical thinking activity be-cause recording needs to be brief as well as complete,yet be comprehensible (Kozier et al. 2004:344).

Legibility/ClarityAll entries should be legible and easy to read to pre-vent different interpretation errors. Signatures must alsobe legible with a clearly written initial and surname.The nurse should use only the acceptable and univer-sal abbreviations, symbols and terms that are speci-fied by the institution’s policy. It is important that thenurses should regard recording also as needing criticalthinking skills that demonstrate professional responsi-bility and accountability (Kozier et al. 2004:343).

RECOMMENDATIONS

Clinical nursing education is at the heart of the profes-sion and the provision of quality nursing care must beupheld. Centre to quality nursing care is the use ofcritical thinking in making rational clinical decisions andsolving problems. Nurse educators face challenges infacilitating or assessing critical thinking in nurse learn-ers – especially given that they were not trained in thisway. It is recommended that nurse educators be cre-ative and innovative when using the described core cog-

nitive critical thinking skills, their related sub-skills andthe affective dispositions to produce innovative pedagogicactivities such as programme development, teachingstrategies and assessment tools to promote criticalthinking. Nurse educators should engage in disciplin-ary, multi-disciplinary, interdisciplinary and trans-disci-plinary research to meet the broad challenges forchange in education.

CONCLUSION

This article has attempted to demonstrate how criticalthinking of nurse learners could be facilitated using theidentified core cognitive critical thinking skills, their re-lated sub-skills and the affective dispositions within theframework of the nursing process. Nurse educators andall those people involved in the education and trainingof nurse learners are invited to take on the recommen-dations and engage in further research around criticalthinking within the context of the nursing profession inorder to produce competent and excellent practitionerswho are able to make rational clinical judgments andsolve problems of culturally diverse patients based oncritical thinking.

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