CHAPTER 9 Problem Solving Process (Critical Thinking in Nursing Practice)

 An intentional higher-level reasoning process.

 Safe, competent, skilled practitioners

Critical Thinking & Clinical Judgement Skills

Skill Nursing Practice Applications

1. Interpretation  Be orderly in collecting data
(Collect and clarify data in an orderly about patients.
fashion)  Apply reasoning while looking
for patterns to emerge.
 Categorize the data (e.g,
nursing diagnoses).
 Gather additional data or
clarify any data about which
you are uncertain.

2. Analysis  Be open-minded as you look at

(Be open-minded and do make information about a patient.
imaginations.  Do not make careless
assumptions. Does the data
reveal a problem or trend that
you believe is true, or are
other options?
3. Inference  Look at the meaning and
(Look for relationships within significance if the findings. Are
information you have collected) there relationships about the
findings? Does the data about
the patient help you see that a
problem exists?
4. Evaluation  Look at all situations
(Be objective in nursing action that objectively.
needed to perform)  Use criteria (e.g., expected
outcomes, pain characteristics,
learning objectives) to
determine results of nursing
actions.
 Reflect on your own behavior.
5. Explanation  Support your findings and
(Make sure you have support in your conclusion.
 conclusions and use experiential  Use knowledge and experience
knowledge and scientific bases). and experience to choose
strategies to use in the care of
patients.
6. Self-regulation  Reflect on your experiences.
(Review your methods and correct  Be responsible for connecting
any problems identified). your actions.
 Identify the ways you can
improve your own performance.
What will make you believe
that you have been successful?

Concepts for a Critical Thinker

Skill Nursing Practice Applications

Truth seeking  Seek the true meaning of a
situation. Be courageous,
honest and objective about
asking questions.
Open-mindedness  Be tolerant of different views;
be sensitive to the possibility
of your own prejudices; respect
the right of others to have
different opinions.
Analyticity  Analyze potential problematic
situations; anticipate possible
result or consequences; value
reason; use evidence-based
knowledge.
Systematicity  Be organized, focused; work
hard in any inquiry.
Self-confidence  Trust in your own reasoning
processes.
Inquisitiveness  Be eager to acquire knowledge
and learn explanations even
when applications of the
knowledge are not immediately
clear. Value learning for
learning’s sake.
 Maturity  Multiple solutions are
acceptable. Reflect on you own
judgements; have cognitive
maturity.

Levels of Critical Thinking

1. Basic Critical thinking

learner trust that experts have

the right answer for every
problem.

Ex. The nursing student uses a

hospital Procedure Manual to confirm
how to change an intravenous (IV)
fluid if the current one is consumed.

 The nurse likely follow a procedure step by step without modifying it to

meet a patient’s unique needs (e.g., positioning to minimize the patient’s
pain or mobility restrictions).
 Nurse do not have enough experience to anticipate how to individualize
the procedure when problem arise.
 Learners trusts that experts have the right answer for every problem.
Thinking is based in a set of rules and principles.

2. Complex Critical Thinking

> Separate themselves from experts.

> Analyze and examine choices more independently. The person’s thinking
abilities and initiative to look beyond expert opinion begin to change. In
complex critical thinking each solution has benefits and risks that decides
before making a final decision.

Example: While giving bed bath to a comatose patient, the nurse modifies the
procedure by washing the front part of the body before going to the back,
instead of the standards step by step procedure in the hospital Procedure
manual.
Commitment

 Person make choices without assistance from others and accepts

accountability for decision making
 Nurse chooses an action or belief that is based on available alternatives
and supports it. The nurse takes accountability for the decisions,
considers that result of the decision and determines whether it was
appropriate.

Critical Thinking Competencies

A cognitive process in which nurse uses to make judgements about the clinical
care.

1. General critical thinking

 Scientific Method
 Problem Solving
 Decision Making
2. Specific Critical Thinking

In clinical Situation

 Diagnostic Reasoning
 Clinical inference
 Clinical decision making
3. Specific Critical Thinking

In nursing

 Nursing Process
1. General Critical Thinking
a. Scientific Method
 It is a methodical way to solve problems using reasoning.
 It is a systematic approach to gathering data and solving problems.

The scientific approach has five steps:

 Identify the problem

 Collect data
 Formulate a question or hypothesis
 Test question or hypothesis
 Evaluate result of the test or study
b. Problem solving
 Involves evaluating a situation and trying a solution over time to make
sure it is effective.
 Having solve a problem in one situation adds to a nurse’s experience in
practice, which allows the nurse to apply knowledge in future patient
situations.
c. Decision Making
 Is a product of critical thinking that focuses on problem resolution.

Example of decision making:

1. Choosing a type of dressing for the patient with surgical wound.

2. Selecting the best teaching approach for an adult patient with
colostomy.
3. Selecting the best nursing strategy to help the patient adhere or follow
her medication schedule.

2. Specific Critical Thinking

a. Diagnostic Reasoning and Inference
 Analytical process for determining a patient’s health problems.
 Accurate recognition of a patient’s problems is necessary before the
nurse decides on solutions and implements action.

Example:

what does the patient’s restlessness, shortness of breath and developing

chest pain indicate?

 Diagnostic Reasoning begins when nurse interacts with a patient or make

physical or behavioral observations.
 Inference is the process of drawing conclusion from related pieces of
evidence and previous experience with the evidence.
 Nurse demonstrate diagnostic reasoning by identifying the nursing
diagnosis.

Example:

The patient had undergone surgery. He is lying in a position to splint

movement ooh his incision, has a tense facial expression and experiences
 tenderness when his wound is palpated. The nurse infers that the patient
has a level of discomfort.

Nursing Diagnosis: Acute Pain

 The nurse used patient data that she gathered and analyzed logically to
recognize a problem.
 Diagnostic conclusion, nurse make will help health care providers identify
the nature of the problem more quickly and select appropriate medical
therapies.

b. Clinical Decision Making

 It is a problem-solving
 Nurse make clinical decision to improve a patient’s health or maintain
wellness.
 Skilled clinical decision making occurs through knowing the patient.

To build ability to make decisions, the nurse fosters knowing his/her

patients through the following actions:

 Spend more time during initial patient assessments to observe patient

behavior and measure physical findings as a way to improve knowledge
about the patients. Determine what is important to them and make an
emotional connection. Patients perceive meaningful time as that involving
personal rather than task-oriented conversation.
 The nurse should always keep a patient as the center of focus in trying
to solve clinical problems.

Examples:

A patient who has surgery is anticipated to experience a certain level of

postoperative pain, which often becomes a priority for care. However, if a
patient is experiencing severe anxiety before pain-relief measures will be
effective.

 Nursing Process As a Competency

 Nurses apply the nursing process as a competency when delivering
patient care. (Kataoka-Yahiro and Saylor 1994).
 Critical thinking is necessary in the application of the five- step nursing
process: assessment, diagnosis, planning, implementation, and evaluation.
 The nursing process requires a nurse to use the general and specific
critical thinking competencies to focus on a particular patient’s unique
needs.

A Critical Thinking Model for Clinical Decision Making

 Thinking critically is at the core of professional nursing competence.
 The ability to think critically, improve clinical practice and decrease
errors in clinical judgements is an aim of nursing practice.

The model defines the outcome of critical thinking: nursing judgement that
is relevant to nursing problems in a variety of settings. According to this
model, there are five components of critical thinking.

1. Knowledge base
2. Experience
3. Critical thinking competencies (with emphasis on the nursing process)
4. Attitudes
5. Standards

 Specific Knowledge Base

 Knowledge prepares the nurse to better anticipate and identify patient’s
problem understanding their origin and nature.
 The depth and extent of knowledge influences the nurse’s ability to
think critically above nursing problems.
 Experience
 Nursing is a practice discipline. Clinical learning experiences are
necessary acquire clinical decision- making skills.
 The Nursing Process Competency
 In the nurse’s practice he/she will apply critical thinking components
during each step of the nursing process. (Nursing Process is discussed
more comprehensively in the succeeding Chapters).
 Attitudes for Critical Thinking
 Eleven attitudes define the central features of critical thinker and how
a successful critical thinker approaches a problem.
 Confidence * Perseverance
 Independence * Creativity
 Fairness * Curiosity
 Responsibility * Integrity
 Risk taking * Humility
 Discipline

 Confidence
 Is the belief in oneself, one’s judgement and psychomotor skills, and
one’s possession of the knowledge and the ability to think critically and
draw appropriate conclusions.
 Thinking Independently
 The nurse learns to consider all the sides of a situation.
 Critical thinker does nor accept another person’s ideas without question.

Examples:

1. Why is one type of colostomy pouch ordered over another?

2. Why do patients fall?
3. What can be done to improve compliance of diabetic patients on their
recommended diet?
 Fairness
 A critical thinker deals with situations justly. This means that bias or
prejudice does not enter into a decision.

Example:
1. Regardless of how the nurse feels about obesity, he/she does not allow
personal attitudes to influence the way he/she takes care of patient who
is overweight.
 Responsibility and Accountability
 The knowledge that one is accountable for his/her decisions, actions, and
critical thinking.
 When the nurse is caring for patients, he/ she is responsible for
correctly performing nursing care activities on the basis of standards of
practice.

Example:

The nurse does not take shortcuts, e.g., failing to check identification of a
patient before administering medications; failing to check written informed
consent before transporting a patient to the operating room for surgery.

 Risk Taking
 When taking a risk, consider all options; follow safety guidelines; analyze
any potential dangerous to a patient; and act in a well-reasoned, logical,
and thoughtful manner.

Example:

Trying different approaches to wound care and pain management.

 Discipline
 A discipline thinker is orderly or systematic when collecting information,
making decision or taking actions and misses few details.

Example:

A patient is in pain. Instead of asking only the patient, “how severe is your
pain on a scale of 0 to 10?” the nurse also ask more specific questions about
the character of pain, like.

 Perseverance
 Keep looking for more resources unit it successful approach is found.

Example:
 A patient is unable to speak clearly after a stroke. Perseverance leads the
to be able to communicate effectively by trying different communication
approaches (e.g., picture board, message board, or alarm bells) until he or
she finds method that the patient is able to use.

 Creativity
 Involves original thinking. This means that nurse finds solutions outside
the standard routines of care while still following standard of practice,

Example:

 Curiosity
 A critical thinker’s favorite question is “Why.” In any clinical situation
the nurse learns a great deal of information about a patient.
 Integrity
 A person of integrity is honest and willing to admit to mistake or
inconsistence in his or own behavior, ideas, and beliefs.
 Humility
 Critical thinkers admit what they do not know and try to find the
knowledge needed to make proper decision.

Critical Thinking Attitudes and Applications in Nursing Practice

Critical Thinking Attitude Application in Practice

Confidence  Learn how to introduce
oneself to a patient; speak
with confidence when
beginning of treatment and
procedure
Thinking Independently  Read nursing literature,
especially when there are
different views on the same
subject.
Fairness  Listen to both sides on any
discussion.
 If a patient or family member
complains about a co-worker,
listen to the story and speak
with the co-worker as well.
 Responsibility and Authority  Ask help if you are uncertain
about how to perform a
nursing skill.
Risk Taking  If one’s knowledge causes
question to a health care
provider’s/physician’s order,
do so.
Discipline  Be thorough in whatever is to
be done.
Perseverance  Be cautious of any answer.
Creativity  Look for different approaches
if interventions are not
working for a patient.
Curiosity  Always ask why. A clinical sign
or symptoms often indicates a
variety of problems.
 Explore and learn more about
the patient so as to make
appropriate clinical
judgement.
Integrity  Recognize when one’s opinions
conflict with those of a
patient; review one’s position
and decide how best to
proceed to reach outcomes
that will satisfy everyone.
Humility  Recognize when one needs
more information to make a
decision.

5. Standard for Critical Thinking

It includes Intellectual Standards and Professional Standards.

a. Intellectual Standard
 Paul (1993) identified 14 intellectual standards universal for critical
thinking.
 A principle for rational though.
 These standards applied by nurse during all steps of the nursing process.
 The intellectual standards are as follows;

Clear- Plain and understandable (e.g., clarity in how communicates)

Precise- Exact and specific (e.g., focusing on one problem and possible
solution).

Specific- To mention, describe, or define in detail.

Accurate- True and free from error; getting to the facts (objective &
subjective)

Relevant- essential and crucial to a situation (e.g., a patient’s changing

clinical status)

Plausible- reasonable or probable.

Consistent- expressing consistent beliefs or values.

Logical- engaging in correct reasoning from what one believes in a given

instance to the conclusion that follows.

Deep- containing complexities and multiple relationships.

Broad-containing multiple viewpoints (e.g., patient and family).

Complete- thoroughly thinking and evaluating.

Significant- focusing on what is important and not trivial.

Adequate (for purpose)- satisfactory in quality or amount.

Fair- being open-minded and impartial.

b. Professional Standards
 Critical thinking refers to ethical criteria for nursing judgements,
evidence- based criteria used for evaluation, and criteria for
professional responsibility.
 Promote the highest level of quality nursing care.
 Being ale to focus on a patient’s values and beliefs help the nurse make
clinical decisions that are just, faithful to a patient’s choices and
beneficial to a patient’s well-being.
 Clinical Thinking System
 Nursing process and critical thinking go hand in hand in making quality
decision about patient care.
Knowledge-underlying disease process, Normal growth and development,
Normal physiology and psychology, Normal assessment findings, health
promotion, Assessment skills, and Communication skills.

Standards- ANA Scope and Standards of Nursing Practice, Specialty

standards of practice, Intellectual standards of measurement.

Attitudes- Perseverance, Fairness, Confidence, & Creativity.

Experience- Previous patient care experience, Validation of assessment

findings, & Observation of assessment techniques.

 Developing Critical Thinking Skills

 The nurse need to learn how to connect knowledge and apply theory with
day-to day practices.
 The ability to make sense of what nurse learns in the classroom.

Reflect Journaling

 It is a tool for developing critical though and reflection by clarifying

concepts. These concepts are embedded in the day-to-day clinical
situations and problems the nurse encounters.

The following are tips that may be used for reflecting on a clinical
experience to explore its meaning:

a. Which experience, situation, or information in your clinical experience is

confusing, difficult, or interesting?
 b. What is the meaning of the experience? What feelings did you have?
What feelings did your patient or family have? What influenced the
experience?
c. Do the feelings, guesses, or questions remind you of any experiences
from the past or something that you think is a desirable future
experience? How does it relate?
d. What are the connections between what is being described and what you
have learned about nursing science and theory?

Meeting with Colleagues

 A way to develop critical thinking skills is regularly meeting with

colleagues such as faculty members or preceptors to discuss and
examine work experience and validate decisions.

Concept Mapping

 Visual representation of patient problems and interventions that shows

their relationship to one another. It is a nonlinear picture of a patient to
be used for comprehensive planning.

Managing Stress

 Automatic control of decision making, error detection, speech, memory

and emotions during stressful situations are disrupted because of
continued sympathetic nervous system stimulation.

According to Scheffer and Rubenfeld (2010)

Critical thinking is a metaphorical bridge between information and action.

Critical thinking in nursing involves habits of the mind and requires the
implementation if cognitive skills.

The seven (7) skills are analyzing, applying, standards, discriminating,

information seeking, logical reasoning, predicting, and transforming knowledge.

 In 2000, Scheffer and Rubenfeld conducted a landmark study in which

internationally diverse expert nurses from nine countries define ten
habits of the mind (affective components) and seven skills (cognitive
components) of critical thinking in nursing.
  The ten affective components are confidence, contextual,
inquisitiveness, intellectual integrity, intuition, open-mindedness,
perseverance, and reflection.
 Cognitive process- (body of knowledge) are the thinking processes
based on the knowledge of aspects of client care.
 Cognitive skills- are learned through reading and applying health-related
literature.
 Cognitive skills- are enhanced trough the use of critical thought to
understand and apply content the nurse has previously learned.
 Metacognitive process (actual experience)- include reflective thinking
and awareness if the skills learned by the nurse in caring for the client.
 The nurse reflects in the client’s status, and through the use of critical
thinking skills determines the most effective plan of care.
 Psychomotor skills in critical thinking
 Psychomotor learning is the relationship between cognitive functions and
physical movement and it involves demonstration of physical skills such
as movement, coordination, dexterity, grace, strength, and speed. These
are actions which demonstrate the fine motor skills such as the use of
precision instruments or those actions which evidence gross motor skills.

Critical Thinking

 Socratic questioning- is a technique one can use to look beneath the

surface, recognize and examine assumptions, search for inconsistencies.
 Inductive reasoning- generalization are formed from set of facts or
observation. (QUALITATIVE)
 Moves from specific to general, from particular instances to a general
statement.

Example: Nurse observe a patient has dry skin, poor skin turgor, sunken
eyes-dehydrated(premise).

 Deductive reason- from generalized premise to specific conclusion.

Example: all kids love peanut butter sandwich, this conclusion may not
always be valid.

 Moves from general to specific or from general premise to a particular

situation or conclusion. (QUANTITATIVE)
 Clinical reasoning- cognitive process that uses thinking strategies
 Assess each client’s condition and identify interventions that improve
client’s physiologic and psychosocial outcomes.

Purpose of Critical Thinking

 Creativity
 Thinking that results in the development of new ideas and products.
 Allow nurse to:
 Generate many ideas rapidly.
 Be generally flexible and natural.
 Create original solutions to problems.
 Be independent and self-confident, even when under pressure.
 Demonstrate individually.

Techniques in Critical Thinking

 Critical Analysis
 Application of a set of questions to a particular situation to discard
unimportant ideas.
 Socratic Questioning
 Techniques to search for inconsistencies, examine multiple points of
view, separate the known from beliefs.
 Inductive reasoning
 Generalization formed from a set of facts, observations.
 Deductive reasoning
 Reasoning from general premise to specific conclusion.
 Making valid inferences.
 Differentiating facts from opinions.
 Evaluating the credibility of information sources.
 Clarifying concepts.
 Recognizing assumptions.

Problem Solving

 Trial and Error

 A number of approaches are tried until a solution is found.
 Can be dangerous because client might suffer harm if approaches is
inappropriate.
 Intuition
 Relies on a nurse’s inner sense.
 Understanding or learning of things without conscious reasoning.
 Mental activity in which a problem is identified that represents an
unsteady state.
 Clarify the nature of a problem and suggest possible solutions.
 Problem solving for one situation contributes to the nurse’s body of
knowledge for problem solving in similar situations.

Components of Clinical Reasoning

 Analysis of a clinical situation as it unfolds or develops.

 Cognitive process
 Thinking processes based on the knowledge of aspects of client care.
 Metacognitive processes
 Reflective thinking and awareness of skills learned by the nurse in caring
for the client.
 Setting priorities
 Need to be dynamic, flexible.
 Difficult for beginning nursing students to determine which data are
most relevant.
 (PRECLINICAL PREPARATION)
 Priorities may change based on current client situation.

Integration of Clinical Thinking & Clinical Reasoning

 Decision-making process
 Prioritizing care when providing care to many clients.
 Deciding whether client’s condition can be managed in the home or
requires hospitalization.
 Consider client’s cultural, religious background.
 Logical reasoning skills.
 Commitment to lifelong learning.

Concept Mapping

 Graphic depiction connections.

 Linear and nonlinear relationships.
 Visual aid to critical thinking process.
  Concept Mapping and Enhancing Critical Thinking and Clinical Reasoning.
 Link between existing nursing knowledge and new information.
 Foster demonstration that nurses have acquired body of knowledge,
understanding of concepts pertinent to delivery of safe and effective
care.
 Interrelationship among client’s problems.
 Care based on complexity.

Nursing Process

Characteristics of the Nursing Process

 The system is open & flexible.

 It is planned
 It is goal-oriented.
 It is client- centered.
 It permits creativity for the nurse & client to solve health problems.
 It is interpersonal & collaborative.
 It is cyclic & dynamic.
 It emphasizes feedback.
 It is universally applicable.

Activities Involved in Assessment

COLLECT DATA ORGANIZE DATA

ASSESSMENT

VALIDATE DATA DOCUMENT RECORD DATE

Nursing Diagnosis

 A clinical judgement about individual, family or community responses to

actual, family or community responses to actual health problems/ life
processes.
 It provides basis for selection of nursing interventions to achieve
outcomes for which the nurse is accountable.
Activities Involved in Diagnosis