Fundamentals of Nursing

(NCM103LC4)
11:00 am - 3:00 pm

CHAPTER 9
Nursing as a Science
PROBLEM SOLVING PROCESS
(Critical Thinking in Nursing Practice)

• Critical Thinking Defined

• Critical Thinking and Clinical Judgment Skills
• Concepts for A Critical Thinker
• Levels of Critical Thinking in Nursing
✓ Basic
✓ Complex
✓ Commitment
• Critical Thinking Competencies
✓ General Critical Thinking
✓ Specific Critical Thinking In Clinical Situation
✓ Specific Critical Thinking In Nursing
• A Critical Thinking Model for Clinical Decision Making
✓ Specific Knowledge Base
✓ Experience
✓ Nursing Process Competency
✓ Attitudes for Critical Thinking
✓ Standards for Critical Thinking
• Developing Critical Thinking Skills
• Managing Stress

Submitted by:
Naluz, Reign Margareth L.
BSN-1A
Critical Thinking
- is process gained through experience, commitment, and an active curiosity toward
learning. This Chapter leads nurses to thinking about and understand the thinking
processes used in clinical judgment towards improved decision to identify patient
problems.

CRITICAL THINKING
- It is the ability to think in a systematic and logical manner with openness to
question and reflect on the reasoning process.
- It involves open-mindedness, continual inquiry, and perseverance, combined with a
willingness to look at each patient situation and determine which identified
assumptions are true and relevant.
- It considers what is important in each clinical situation, imagines and explores
alternatives, considers ethical principles, and makes informed decisions about the
care of patients.
- It involves the use of evidence-based knowledge, or knowledge based on research
or clinical expertise.
- It requires cognitive skills and the habit of asking questions, staying well informed,
being honest in facing personal biases, and always being willing to reconsider and
think clearly about issues (Facione, 1990).
- It requires reflection. Reflection involves purposeful thinking back or recalling a
situation to discover its purpose or meaning. It is like instant replay. Research has
shown that, when nurses reflect on past experiences, they perceive that their
knowledge increase and their critical thinking moves to a higher level (Kaddoura,
2013).

Critical Thinking and Clinical Judgment Skills

1. Interpretation
2. Analyzing
3. Inference
4. Evaluation
5. Explanation
6. Self-regulation

Concepts for a Critical Thinker

1. Truth Seeking
2. Open-mindedness
3. Analyticity
4. Sytematicity
5. Selfconfidence
6. Inquisitiveness
7. Maturity
Levels of Critical Thinking in Nursing
The three levels of critical thinking in Nursing are as follows: (1) Basic, (2) Complex,
(3) Commitment

1. Basic Critical Thinking

- At the basic level of critical thinking a learner trusts that experts have the right
answers for every problem
- Thinking is concrete and based on a set of rules or principles.
- To basic critical thinking level, 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 pon or mobility restrictions).
- At this level, the nurse does not have enough experience to anticipate how to
individualtze the procedure when problems arise.
- At this level answers to complex problems seem to be either right or wrong (e.g.,
when the IV fluid has stopped infusing, the IV needle is out of the vein). Although
there are other explanations, basic critical thinkers tend to think that one right
answer usually exists for each problem.
- A basic critical thinker learns to accept the diverse opinions and values of experts
(eg. instructors and staff nurse preceptors).

2. Complex Critical Thinking

-Complex critical thinkers begin to separate themselves from experts.
- The nurse analyzes the clinical situation and examine choices more independently.
- A person's thinking abilities and initiative to look beyond expert opinion begin to
change.
- The nurse learns that alternatives and perhaps conflicting solutions exist.
- In complex critical thinking, each solution has benefits and risks that should be
weighed before making a final decision. There are options. Thinking becomes more
creative and innovative.
- The complex critical thinker is willing to consider different options from routine
procedures when complex situations develop.
- The nurse learns to gather additional information and take a variety of different
approaches for the same therapy.

3. Commitment
- At this level of critical thinking the nurse anticipates when to make choices without
assistance from others and accepts accountability for decisions made.
- The nurse do more than just consider the complex alternatives that a problems
poses.
- This level of critical thinking, the nurse chooses an action or belief that is based on
available alternatives and supports it. The nurse takes sccountability for the
decisions, considers the results of the decision and determines whether it was
appropriate

CRITICAL THINKING COMPETENCIES

1. General Critical Thinking

a. Scientific Method
- It is a methodical way to solve problems using reasoning.
- It is a systematic ordered approach to gathering data and solving problems.
- This approach looks for the truth and verifies that a set of facts agrees with
reality.
The scientific method has five steps:
1. Identify the problem.
2. Collect data.
3. Formulate a question or hypothesis.
4. Test the question or hypothesis.
5. Evaluate results of the test or study.

b. Problem Solving
- Effective problem solving involves evaluating a situation and trying a solution
over time to make sure it is effective.
- If a problem recurs, it becomes necessary to try different options.
- Having solved a problem in one situation adds to a nurse's experience in
practice, which allows the nurse to apply that knowledge in future patient situations.

c. Decision Making
- Is a product of critical thinking that focuses on problem resolution
- Following a set of criteria helps the nurse make a thorough and thoughtful
decision. The set of criteria may be personal; based on an organizational policy, or in
the mursing, a professional standard.

2. Specific Critical Thinking

a. Diagnostic Reasoning and Inference
- Diagnostic reasoning is the analytical process for determining a patient's
health problems (Harjai and Tiwari, 2009).
- Accurate recognition of a patient's problems is necessary before the nurse
decides on solutions and implements actions.
- It requires that the nurse assigns meaning to the behaviors and physical signs
and symptoms presented by the patient.
- Diagnostic reasoning begins when the nurse interacts with a patient or make
physical or behavioral observations.
 - Part of diagnostic reasoning is clinical inference, the process of drawing
conclusions from related pieces of evidence and previous experience with the
evidence.
- When making an inference, the nurse form patterns of information from
data before making a diagnosis.
- The nurse demonstrates diagnostic reasoning by identifying the nursing
diagnosis.

b. Clinical Decision Making

- It is a problem-solving activity.
- Nurses make clinical decisions to improve a patient's health or maintain
wellness.
- Clinical decision making requires careful reasoning (i.e., choosing the options
for the best patient outcomes on the basis of a patient's condition and the priority of
the problem).
- Skitted clinical decision making occurs through knowing the patient. Knowing
the patient is an in-depth knowledge of a patient's patterns of responses within a
clinical situation and knowing the patient as a person.
- Knowing the patient is central to individualizing nursing care so a patient
feels cared for and cared about.
- To build ability to make decisions, the nurse fosters knowing his/her patients

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 purpose of the nursing process is to diagnose and treat human responses (eg.,
patient symptoms, need for knowledge) to actual or potential health problems.
- Use of the process allows nurses to help patients meet agreed on outcomes for
better health.
- The nursing process requires a nurse to use the general and specific critical thinking
competencies to focus on a particular patient's unique needs.

Components of Critical Thinking

1. Specific Knowledge Base
- Knowledge prepares the nurse to better anticipate and identify patient's problems
by understanding their origin and nature.
- A nurse's broad knowledge base offers a physical, psychological, social, moral,
ethical, and cultural view of patients and their health care needs.
- The depth and extent of knowledge influences the nurse's ability to think critically
about nursing problems.
2. Experience
- Nursing is a practice discipline. Clinical learning experiences are necessary to
acquire clinical decision-making skills.
- Knowledge combined with clinical expertise from experience defines critical
thinking.
- In clinical situation, the nurse learns from observing, sensing, talking with patients
and families, and reflecting actively on all experiences.
- With experience, the nurse begins to understand clinical situations, anticipate and
recognize cues of patient's health patterns, and interpret the cues as relevant or
irrelevant.
- Perhaps, the best lesson a new nursing student can learn is to value all patient
experiences which become stepping-stone for building new knowledge and inspiring
innovative thinking

3. The Nursing Process Competency

- The nursing process competency is the third component of the critical thinking
model.
- 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

4. Attitudes for Critical Thinking

- Eleven attitudes define the central features of a critical thinker and how a
successful critical thinker approaches a problem.
- The following are the essential attitudes for critical thinking:
• Confidence
• Independence
• Fairness
• Responsibility
• Risk Taking
• Discipline
• Perseverance
• Creativity
• Curiosity
• Integrity
• Humility
• Confidence. Is the belief in oneself, one's judgment 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 sides of a situation.
- A critical thinker does not accept another person's ideas without question
- Independent thinking and reasoning are essential to the improvement and
expansion of nursing practice.

• Fairness. A critical thinker deals with situations justly. This means that bias or
prejudice does not enter into a decision.

• Responsibility and Accountability. Responsibility is the knowledge that one is

accountable for his/her decisions, actions and critical thinking.

• Risk Taking. People often associate taking risks with danger. But risk taking does
not always hay negative outcomes. Risk taking is desirable, particularly when the
result is a positive outcome.
- When taking a risk, consider all options; follow safety guidelines; analyze any
potential dange to a patient, and act in a well-reasoned, logical, and thoughtful
manner.

• Discipline. A disciplined thinker is orderly or systematic when collecting

information, makina decisions or taking actions and misses few details.

• Perseverance. A critical thinker is determined to find effective solutions to patient

care problems This is especially important when problems remain unresolved or
recur. Learn as much as possible about a problem and try various approaches to care.
- Persevering means keep looking for more resources until a successful approach is
found.

• Creativity. Creativity involves original thinking. This means that the nurse finds
solutions outside of the standard routines of care while still following standards of
practice.

• Curiosity. A critical thinker's favorite question is "Why." In any clinical situation the
nurse leams a great deal of information about a patient.

• Integrity. Critical thinkers' question and test their own knowledge and beliefs. The
nurse's personal integrity builds trust from co-workers. Nurses face dilemmas or
problems in everyday clinical practice, and everyone makes mistakes at times.
- A person of integrity is honest and willing to admit to mistakes or inconsistencies in
his or her own behavior, ideas, and beliefs.

5. Standards for Critical Thinking

The fifth component of the critical thinking model includes
a. Intellectual Standards
b. Professional Standards

1. Intellectual Standards
- Paul (1993) identified 14 intellectual standards universal for critical thinking.
- An intellectual standard is a principle for rational thought.
- These standards are applied by the nurse during all steps of the nursing
process.
- During planning, the nurse applies standards such as being logical and
significant so that the plan of care is meaningful and relevant to a patient's needs
- A thorough use of intellectual standards in clinical practice prevents the
nurse from performing critical thinking haphazardly.

The intellectual standards are as follows:

1. Clear - Plain and understandable (e.g., clarity in how one communicates).
2. Precise - Exact and specific (e.g., focusing on one problem and possible
solution).
3. Specific - To mention, describe, or define in detail.
4. Accurate True and free from error; getting to the facts (objective and
subjective).
5. Relevant Essential and crucial to a situation (e.g., a patient's changing
clinical status).
6. Plausible - Reasonable or probable.
7. Consistent - Expressing consistent beliefs or values.
8. Logical - Engaging in correct reasoning from what one believes in a given
instance to the conclusion that follows
9. Deep - Containing complexities and multiple relationships
10. Broad - Covering multiple viewpoints (e.g., patient and family).
11. Complete - Thoroughly thinking and evaluating Significant - Focusing on
what is important and not trivial.

2. Professional Standards
 - Professional standards for critical thinking refer to ethical criteria for nursing
judgments evidence-based criteria used for evaluation, and criteria for professional
responsibility (Pa 1993).
- Application of professional standards requires the nurse to use critical
thinking for the go of individuals or groups (Kataoka-Yahiro and Saylor, 1994).
- Professional standards promote the highest level of quality nursing care.
- Excellent nursing practice is a reflection of etirical standards. Patient requires
more than jue the application of scientific knowledge.
- Being able to focus on a patient's values and beliefs helps the nurse make
clinical decision that are just, faithful to a patient's choices and beneficial to a
patient's well-being.
- Critical thinkers maintain a sense of self-awareness through conscious
awareness of their hiefs, values and feelings and the multiple perspectives that
patients, family members, and peers present in clinical situations.
- Critical thinking also requires the use of evidence-based criteria for making
clinical judgments. These criteria are sometimes scientifically based on research
findings or practice based on standards developed by conical experts and
performance improvement initiatives of an institution

• Developing Critical Thinking Skills

To develop critical thinking skills the nurse needs to learn how to connect knowledge
and theory with day-to-day practices. The ability to make sense of what the nurse
learns in the classroom, from reading or from having dialogue with other students
and nurses and then to apply it during patient care is challenging.

1. Reflective Journaling
2. Meeting with the Colleagues
3. Concept Mapping
4. Managing Stress