Critical Thinking at the Bedside

Nurses use research and evidenced-based data to improve patient care.

To view the Course Outline and take the test online, click here.

For a printer-friendly version of the exam you can print out, complete and mail in to ADVANCE, click here.

Learning Scope #345
1 contact hour
Expires Nov. 8, 2012

You can earn 1 contact hour of continuing education credit in three ways: 1) For immediate results and certificate; take the test online; grade and certificate are available immediately after taking the test. 2) Mail your completed exam (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the completed exam to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Matters Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The goal of this CE offering is to review the concept of critical thinking, pointing out how the nursing process and nursing diagnosis are ways that nursing applies critical thinking to the work nurses do. It also supports the use of using nursing research and evidence-based practice in the critical thinking process, and ties critical thinking to the provision of safe, patient-centered care. After reading this article, you will be able to:

1. Explain how to use multidimensional thinking skills.
2. Describe the qualities of a good critical thinker.
3. Describe how critical thinking is interwoven in the nursing process and nursing diagnosis.
4. Apply critical thinking skills to your daily patient care.

From the first day you enter your clinical nursing courses and participate in on-site clinical rotations, you are being taught how to think like a nurse. Penny Heaslip writes that thinking like a nurse "requires that we learn the content of nursing; the ideas, concepts and theories of nursing and develop our intellectual capacities and skills so that we become disciplined, self-directed, critical thinkers."1 As we grow in the profession, we continue to sharpen our thinking skills, grow in our practice and help those with less experience become better nurse thinkers.

What do all of the following scenarios have in common?

• An elderly male becomes acutely confused and refuses to follow directions for his safety.
• A teen comes into an urgent care setting requesting information about STDs.
• A mother visits a school nurse and requests information about how the school handles sex education.
• A team leader needs to rearrange assignments when one team member goes home sick.
• Nursing staff in an ICU need to develop an evacuation plan.

Answer: They all require critical thinking skills.

Thinking Like A Nurse

Just what is critical thinking? Critical thinking is active thinking. Critical thinking requires that we use a systematic and logical process to address the challenges we face during patient care delivery. Critical thinking requires us to continually question our beliefs. Critical thinking necessitates that we take the opportunity to reflect on our reasoning processes.1

Using critical thinking skills requires each nurse has a solid theoretical foundation. Critical thinking in nursing is not a modern concept; it is built upon nursing theory, nursing research and evidence-based practice, and knowledge obtained from the study of the social sciences and life sciences. Nurses need to consistently apply the principles of critical thinking and use the most up-to-date nursing research and evidenced-based data to provide safe, high-quality care.

Critical Thinking: Multidimensional

Critical thinking, sometimes called multi-dimensional thinking, is different from one-dimensional thinking. A one-dimensional thinker thinks from one point of view or frame of reference. And one-dimensional thinking has its place in nursing. Nurses use one-dimensional thinking to solve common everyday problems, such as figuring out medication dosages or learning the list of responsibilities of the evening charge nurse. To problem-solve most patient care issues, however, nurses need to use a broader approach, or multidimensional thinking.

Multidimensional thinking requires that nurses analyze and approach the situation from more than one point of view or frame of reference.2

Qualities of Critical Thinkers

Critical thinkers value and adhere to intellectual standards. They strive to be clear, accurate, precise, logical, complete, significant and fair when they listen, speak, read and write. Critical thinkers think deeply and broadly.3

When thinking like a nurse in patient-care situations, nurses strive to eliminate obstacles to clear critical thinking. They strive to eliminate the irrelevant, inconsistent and illogical from their reasoning process. Doing this eliminates confusion and ambiguity in the understanding of patient care needs. Nurses who are critical thinkers systematically think through problems, and if they talk out their reasoning with others, they role-model good multidimensional thinking skills.

Critical nurse thinkers read or listen critically to what nurse scholars believe about nursing, expanding their theoretical knowledge base, making changes to their practice based on sound nursing reasoning. Critical nurse thinkers continually use nursing research and evidence-based practice to ensure safe practice and quality care. To become a critical thinkers, nurses need to:

• become fair-minded;
• suspend judgment;
• thoroughly investigate the problem or situation;
• question and reflect on one's own thinking processes;
• pose questions and seek answers;
• admit to one's lack of knowledge;
• practice intellectual curiosity and perseverance;
• become truth seekers;
• demonstrate open-mindedness and tolerance for others' views;
• value intellectually challenging situations; and
• be self-confident in one's own reasoned thoughts.1

Need for Critical Thinking

Why do nurses need to be good critical thinkers? Mary Chabeli put it simply. She writes "nurses should be critical thinkers because they deal with the lives of patients."4 She further explains nurses need to use critical thinking skills each day in their work because each day nurses come face to face with challenges that "require the ability to make rational and critical clinical decisions and also make astute clinical judgments that are logical."4

Reasoned Thinking

Reasoned thinking involves eight elements of thought. To reason well we need to:

1) Identify the problem, question, concern or issue.
2) Be clear about what we need to figure out or what we hope to accomplish.
3) Explore our own frame of reference or point of view about the issue or problem.
4) Examine our assumptions or our truths upon which we base our claims or beliefs.
5) List out the concepts, principles and/or theories we are using to problem solve.
6) Collect data or information to support our claims about the issue or problem.
7) Investigate the thought processes we use to come to our conclusions.
8) Discuss the implications and consequences that flow from the positions we hold on the issue or problem.5

If the eight elements of reasoned thinking seem familiar, they are. Nurses readily notice how these eight elements interface with the nursing process. The nursing process guides us through problem identification to problem solving in a systematic and logical manner. The ANA has identified the nursing process as the framework necessary for nursing critical thinking - that is, the process of thinking like a nurse. Nurses who think like nurses appreciate the nursing process as a reliable, critical thinking tool. They apply it consistently, comprehensively and completely.

Cheryl Martin writes that "critical thinking is recognized as vital to nursing practice." She describes how critical thinking has been instrumental in evolving nursing from an occupation to a profession, helping nursing progress from a task-orientation to a skilled profession based on well-developed knowledge. Martin points out that decisions made by nurses require critical thinking or reasoning out "complex problems concerning the physical and psychosocial well-being of clients . as a client's status changes, the nurse must recognize, interpret and integrate new information and make decisions about the course of action to follow."6

Using the Nursing Process 

As nursing students develop intuition and become more familiar with the steps of the nursing process, their critical thinking skills are sharpened. As growth continues, students and then graduates gradually enhance their skills in reasoning, and eventually become consistently reliable professionals. Expert nurses have mastered the art of thinking like a nurse; that is, they use critical thinking through the use of the nursing process.7 As Benner points out, they have become expert nurses.8

Critical thinking skills in nursing require a systemic, logical, reasoned approach to the nursing process. Critical thinking requires each nurse develops a deep commitment to continued growth, and makes decisions based on sound judgments and logical conclusions. Critical thinking results in excellent clinical outcomes and enhanced patient safety.

When using the nursing process, the nurse needs to decide which pieces of information offered by the patient are critical and, after analysis, work with the patient to develop mutually agreed upon care goals. The nurse needs to make decisions based on sound clinical judgments, as gathered from a wide variety of sources, as well as the nurse's own observations. The nurse also needs to incorporate a reflective component to decision-making. The reflective component is a review of those judgments and a validation of their appropriateness.

• When thinking like a nurse, the nurse regards the patient as a whole person and bases care, treatment and recovery goals upon that point of view. Data-gathering from the whole-person point of view requires a synthesis of judgment to prioritize goals. The whole-person approach includes those elements of culture as well as institutional goals.7

• When thinking like a nurse, the nurse listens with empathy; that is, listens compassionately. During the patient assessment, the nurse listens, makes observations and sets priorities based on the patient's worldview. Empathetic listening helps nurses determine priorities for patient care in collaboration with the patient to achieve desired patient goals.7

• When thinking like a nurse, the nurse synthesizes all information about the patient in order to delegate duties and responsibilities to provide for safe and appropriate care of the patient.9

Nursing Diagnoses

Margaret Lunney writes critical thinking is closely tied to a nurse's diagnostic accuracy. She writes the development of critical thinking abilities for diagnostic accuracy is important because "the clinical situations that nurses interpret are complex and diverse, making achievement of accuracy of nurses' diagnoses a challenging task."10

She lists 10 strategies for developing critical thinking skills when applying the nursing process and nursing diagnosis. These strategies encourage nurses to:

1) think about the thinking process itself;
2) connect with others and think things through together, creating a synergy to come up with innovative strategies;
3) earn to recognize personal assumptions, inferences and interpretations;
4) consider alternative diagnostic possibilities;
5) develop a balance of reflective skepticism with trust in self and others;
6) develop sensitivity to the impact such factors as age, culture, family situations, emotional states have on the possible meaning of data collected;
7) evaluate the credibility of evidence gathered and compare it with the classic signs and symptoms for nursing diagnoses;
8) recognize and accept intuitive knowing;
9) become comfortable with ambiguity of clinical judgments because it is essential for growth as a diagnostician; and
10) control your anxiety when you become concerned about being "wrong."10

Let's look at one of the examples from the beginning of the article and apply the critical thinking process. We can look at the situation for a number of views, suspending judgment. Look at the following list of questions generated about the elderly male who became acutely confused and refused to follow directions for his safety. Evaluate the list of questions, add some of your own and think through how you would gather information and what it might mean to this situation.

• Does he have an infection? If so, where?
• Has he had a stroke or a TIA?
• Has he been started on a new medication that is causing confusion?
• How has he been eating? Is there a possibility of fluid and electrolyte imbalances? Could he be hypoglycemic or hyperglycemic?
• Might this be a thyroid, parathyroid and pituitary disturbance?
• Could he be experiencing cardiovascular alterations such as decreased cardiac output or a vascular disorder?
• Does he display any abnormalities in temperature regulation such as hypothermia/hyperthermia?
• Has he recently had a visitor who has caused him upset?
• Is this a significant anniversary date for him? Does this day have any other special meaning? Is this a time of the year that might cause distress?
• Has the unit made any changes to routine? Have there been any structural changes to the unit?
• Has there been recent admission, discharges, or deaths? Has there been a change in staff or staffing patterns?
• Have there been any environmental disturbances, such as bad storms?

Nurses need to develop astute critical thinking skills because we "deal with the lives of patients" who have complex problems both with their physical and psychosocial well-being.4,6 The environment in which we work is ever-changing and nurses need to be able to adapt to the change, at the same time providing for safe, high-quality patient care. Critical thinking is thinking like a nurse; thinking like a nurse is critical thinking. It is:

• patient-driven;
• purposeful, informed and outcome-focused;
• knowledge-based as well as experience-based;
• often group thinking, talked out thinking and reflective thinking;
• oftentimes intuitive;
• the application of standards, policies and procedures in conjunction with the patient's values; and
• the process of constant evaluation and reevaluation, using the nursing process, and developing nursing diagnosis to address the patient's needs.6

References for this article can be accessed here.

Joan M. Lorenz has a background as a clinical specialist in psychiatric and mental health nursing, and is president of Clearly Stated, Story, WY.

To view the Course Outline and take the test online, click here.

For a printer-friendly version of the exam you can print out, complete and mail in to ADVANCE, click here.




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