critical thinking and intuitive nursing practice

• DOI: 10.1046/J.1365-2648.1995.22010040.X
• Corpus ID: 25737521

Critical thinking and intuitive nursing practice.

• Richard W. Paul , Penny Heaslip
• Published in Journal of Advanced Nursing 1 July 1995
• Education, Medicine

138 Citations

Critical thinking in clinical nurse education: application of paul's model of critical thinking..

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Promoting Professional Nursing Practice through Critical Thinking and Attitudinal Change

Improving critical thinking in nursing practice, it is time to move from the nursing process to critical thinking., critical thinking in clinical nurse education : application of paul ’ s model of critical thinking, decision-making in palliative care: a reflective case study, the holism in critical thinking, [critical thinking skills in the nursing diagnosis process]., enabling nursing students’ critical thinking with mindtools, critical thinking as an outcome of nursing education. what is it why is it important to nursing practice, related papers.

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Nurses are critical thinkers

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Margaret McCartney: Nurses must be allowed to exercise professional judgment

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The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice. Nurses’ ability to recognize and respond to signs of patient deterioration in a timely manner plays a pivotal role in patient outcomes (Purling & King 2012). Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events (Tomlinson, 2015). The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement. Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010). At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction.

The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.

As lifelong learners, nurses are constantly accumulating more knowledge, expertise, and experience, and it’s a rare nurse indeed who chooses to not apply his or her mind towards the goal of constant learning and professional growth. Institute of Medicine (IOM) report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice. American Nurses Association (ANA), Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice (p.26)

Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier

The future of nursing: Leading change, advancing health, (2010). https://campaignforaction.org/resource/future-nursing-iom-report

Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today. 30(6), 515-520.

NMC (2010) New Standards for Pre-Registration Nursing. London: Nursing and Midwifery Council.

Purling A. & King L. (2012). A literature review: graduate nurses’ preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23–24), 3451–3465

Thompson, C., Aitken, l., Doran, D., Dowing, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50 (12), 1720 - 1726 Tomlinson, J. (2015). Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Medical Education, 15(103)

Competing interests: No competing interests

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Critical Thinking: The Development of an Essential Skill for Nursing Students

Ioanna v. papathanasiou.

1 Nursing Department, Technological Educational Institute of Thessaly, Greece

Christos F. Kleisiaris

2 Nursing Department, Technological Educational Institute of Crete, Greece

Evangelos C. Fradelos

3 State Mental Hospital of Attica “Daphne”, Greece

Katerina Kakou

Lambrini kourkouta.

4 Nursing Department, Alexander Technological Educational Institute of Thessaloniki, Greece

Critical thinking is defined as the mental process of actively and skillfully perception, analysis, synthesis and evaluation of collected information through observation, experience and communication that leads to a decision for action. In nursing education there is frequent reference to critical thinking and to the significance that it has in daily clinical nursing practice. Nursing clinical instructors know that students face difficulties in making decisions related to clinical practice. The main critical thinking skills in which nursing students should be exercised during their studies are critical analysis, introductory and concluding justification, valid conclusion, distinguish of facts and opinions, evaluation the credibility of information sources, clarification of concepts and recognition of conditions. Specific behaviors are essentials for enhancing critical thinking. Nursing students in order to learn and apply critical thinking should develop independence of thought, fairness, perspicacity in personal and social level, humility, spiritual courage, integrity, perseverance, self-confidence, interest for research and curiosity. Critical thinking is an essential process for the safe, efficient and skillful nursing practice. The nursing education programs should adopt attitudes that promote critical thinking and mobilize the skills of critical reasoning.

1. INTRODUCTION

Critical thinking is applied by nurses in the process of solving problems of patients and decision-making process with creativity to enhance the effect. It is an essential process for a safe, efficient and skillful nursing intervention. Critical thinking according to Scriven and Paul is the mental active process and subtle perception, analysis, synthesis and evaluation of information collected or derived from observation, experience, reflection, reasoning or the communication leading to conviction for action ( 1 ).

So, nurses must adopt positions that promote critical thinking and refine skills of critical reasoning in order a meaningful assessment of both the previous and the new information and decisions taken daily on hospitalization and use of limited resources, forces you to think and act in cases where there are neither clear answers nor specific procedures and where opposing forces transform decision making in a complex process ( 2 ).

Critical thinking applies to nurses as they have diverse multifaceted knowledge to handle the various situations encountered during their shifts still face constant changes in an environment with constant stress of changing conditions and make important decisions using critical thinking to collect and interpret information that are necessary for making a decision ( 3 ).

Critical thinking, combined with creativity, refine the result as nurses can find specific solutions to specific problems with creativity taking place where traditional interventions are not effective. Even with creativity, nurses generate new ideas quickly, get flexible and natural, create original solutions to problems, act independently and with confidence, even under pressure, and demonstrate originality ( 4 ).

The aim of the study is to present the basic skills of critical thinking, to highlight critical thinking as a essential skill for nursing education and a fundamental skill for decision making in nursing practice. Moreover to indicate the positive effect and relation that critical thinking has on professional outcomes.

2. CRITICAL THINKING SKILLS

Nurses in their efforts to implement critical thinking should develop some methods as well as cognitive skills required in analysis, problem solving and decision making ( 5 ). These skills include critical analysis, introductory and concluding justification, valid conclusion, distinguishing facts and opinions to assess the credibility of sources of information, clarification of concepts, and recognition conditions ( 6 , 7 ).

Critical analysis is applied to a set of questions that relate to the event or concept for the determination of important information and ideas and discarding the unnecessary ones. It is, thus, a set of criteria to rationalize an idea where one must know all the questions but to use the appropriate one in this case ( 8 ).

The Socratic Method, where the question and the answer are sought, is a technique in which one can investigate below the surface, recognize and examine the condition, look for the consequences, investigate the multiple data views and distinguish between what one knows and what he simply believes. This method should be implemented by nurses at the end of their shifts, when reviewing patient history and progress, planning the nursing plan or discussing the treatment of a patient with colleagues ( 9 ).

The Inference and Concluding justification are two other critical thinking skills, where the justification for inductive generalizations formed from a set of data and observations, which when considered together, specific pieces of information constitute a special interpretation ( 10 ). In contrast, the justification is deduced from the general to the specific. According to this, nurse starts from a conceptual framework–for example, the prioritization of needs by Maslow or a context–evident and gives descriptive interpretation of the patient’s condition with respect to this framework. So, the nurse who uses drawing needs categorizes information and defines the problem of the patient based on eradication, nutrition or need protection.

In critical thinking, the nurses still distinguish claims based on facts, conclusions, judgments and opinions. The assessment of the reliability of information is an important stage of critical thinking, where the nurse needs to confirm the accuracy of this information by checking other evidence and informants ( 10 ).

The concepts are ideas and opinions that represent objects in the real world and the importance of them. Each person has developed its own concepts, where they are nested by others, either based on personal experience or study or other activities. For a clear understanding of the situation of the patient, the nurse and the patient should be in agreement with the importance of concepts.

People also live under certain assumptions. Many believe that people generally have a generous nature, while others believe that it is a human tendency to act in its own interest. The nurse must believe that life should be considered as invaluable regardless of the condition of the patient, with the patient often believing that quality of life is more important than duration. Nurse and patient, realizing that they can make choices based on these assumptions, can work together for a common acceptable nursing plan ( 11 ).

3. CRITICAL THINKING ENHANCEMENT BEHAVIORS

The person applying critical thinking works to develop the following attitudes and characteristics independence of thought, fairness, insight into the personal and public level, humble intellect and postpone the crisis, spiritual courage, integrity, perseverance, self-confidence, research interest considerations not only behind the feelings and emotions but also behind the thoughts and curiosity ( 12 ).

Independence of Thought

Individuals who apply critical thinking as they mature acquire knowledge and experiences and examine their beliefs under new evidence. The nurses do not remain to what they were taught in school, but are “open-minded” in terms of different intervention methods technical skills.

Impartiality

Those who apply critical thinking are independent in different ways, based on evidence and not panic or personal and group biases. The nurse takes into account the views of both the younger and older family members.

Perspicacity into Personal and Social Factors

Those who are using critical thinking and accept the possibility that their personal prejudices, social pressures and habits could affect their judgment greatly. So, they try to actively interpret their prejudices whenever they think and decide.

Humble Cerebration and Deferral Crisis

Humble intellect means to have someone aware of the limits of his own knowledge. So, those who apply critical thinking are willing to admit they do not know something and believe that what we all consider rectum cannot always be true, because new evidence may emerge.

Spiritual Courage

The values and beliefs are not always obtained by rationality, meaning opinions that have been researched and proven that are supported by reasons and information. The courage should be true to their new ground in situations where social penalties for incompatibility are strict. In many cases the nurses who supported an attitude according to which if investigations are proved wrong, they are canceled.

Use of critical thinking to mentally intact individuals question their knowledge and beliefs quickly and thoroughly and cause the knowledge of others so that they are willing to admit and appreciate inconsistencies of both their own beliefs and the beliefs of the others.

Perseverance

The perseverance shown by nurses in exploring effective solutions for patient problems and nursing each determination helps to clarify concepts and to distinguish related issues despite the difficulties and failures. Using critical thinking they resist the temptation to find a quick and simple answer to avoid uncomfortable situations such as confusion and frustration.

Confidence in the Justification

According to critical thinking through well motivated reasoning leads to reliable conclusions. Using critical thinking nurses develop both the inductive and the deductive reasoning. The nurse gaining more experience of mental process and improvement, does not hesitate to disagree and be troubled thereby acting as a role model to colleagues, inspiring them to develop critical thinking.

Interesting Thoughts and Feelings for Research

Nurses need to recognize, examine and inspect or modify the emotions involved with critical thinking. So, if they feel anger, guilt and frustration for some event in their work, they should follow some steps: To restrict the operations for a while to avoid hasty conclusions and impulsive decisions, discuss negative feelings with a trusted, consume some of the energy produced by emotion, for example, doing calisthenics or walking, ponder over the situation and determine whether the emotional response is appropriate. After intense feelings abate, the nurse will be able to proceed objectively to necessary conclusions and to take the necessary decisions.

The internal debate, that has constantly in mind that the use of critical thinking is full of questions. So, a research nurse calculates traditions but does not hesitate to challenge them if you do not confirm their validity and reliability.

4. IMPLEMENTATION OF CRITICAL THINKING IN NURSING PRACTICE

In their shifts nurses act effectively without using critical thinking as many decisions are mainly based on habit and have a minimum reflection. Thus, higher critical thinking skills are put into operation, when some new ideas or needs are displayed to take a decision beyond routine. The nursing process is a systematic, rational method of planning and providing specialized nursing ( 13 ). The steps of the nursing process are assessment, diagnosis, planning, implementation, evaluation. The health care is setting the priorities of the day to apply critical thinking ( 14 ). Each nurse seeks awareness of reasoning as he/she applies the criteria and considerations and as thinking evolves ( 15 ).

Problem Solving

Problem solving helps to acquire knowledge as nurse obtains information explaining the nature of the problem and recommends possible solutions which evaluate and select the application of the best without rejecting them in a possible appeal of the original. Also, it approaches issues when solving problems that are often used is the empirical method, intuition, research process and the scientific method modified ( 16 ).

Experiential Method

This method is mainly used in home care nursing interventions where they cannot function properly because of the tools and equipment that are incomplete ( 17 ).

Intuition is the perception and understanding of concepts without the conscious use of reasoning. As a problem solving approach, as it is considered by many, is a form of guessing and therefore is characterized as an inappropriate basis for nursing decisions. But others see it as important and legitimate aspect of the crisis gained through knowledge and experience. The clinical experience allows the practitioner to recognize items and standards and approach the right conclusions. Many nurses are sensing the evolution of the patient’s condition which helps them to act sooner although the limited information. Despite the fact that the intuitive method of solving problems is recognized as part of nursing practice, it is not recommended for beginners or students because the cognitive level and the clinical experience is incomplete and does not allow a valid decision ( 16 ).

Research Process / Scientifically Modified Method

The research method is a worded, rational and systematic approach to problem solving. Health professionals working in uncontrolled situations need to implement a modified approach of the scientific method of problem solving. With critical thinking being important in all processes of problem solving, the nurse considers all possible solutions and decides on the choice of the most appropriate solution for each case ( 18 ).

The Decision

The decision is the selection of appropriate actions to fulfill the desired objective through critical thinking. Decisions should be taken when several exclusive options are available or when there is a choice of action or not. The nurse when facing multiple needs of patients, should set priorities and decide the order in which they help their patients. They should therefore: a) examine the advantages and disadvantages of each option, b) implement prioritization needs by Maslow, c) assess what actions can be delegated to others, and d) use any framework implementation priorities. Even nurses make decisions about their personal and professional lives. The successive stages of decision making are the Recognition of Objective or Purpose, Definition of criteria, Calculation Criteria, Exploration of Alternative Solutions, Consideration of Alternative Solutions, Design, Implementation, Evaluation result ( 16 ).

The contribution of critical thinking in decision making

Acquiring critical thinking and opinion is a question of practice. Critical thinking is not a phenomenon and we should all try to achieve some level of critical thinking to solve problems and make decisions successfully ( 19 - 21 ).

It is vital that the alteration of growing research or application of the Socratic Method or other technique since nurses revise the evaluation criteria of thinking and apply their own reasoning. So when they have knowledge of their own reasoning-as they apply critical thinking-they can detect syllogistic errors ( 22 – 26 ).

5. CONCLUSION

In responsible positions nurses should be especially aware of the climate of thought that is implemented and actively create an environment that stimulates and encourages diversity of opinion and research ideas ( 27 ). The nurses will also be applied to investigate the views of people from different cultures, religions, social and economic levels, family structures and different ages. Managing nurses should encourage colleagues to scrutinize the data prior to draw conclusions and to avoid “group thinking” which tends to vary without thinking of the will of the group. Critical thinking is an essential process for the safe, efficient and skillful nursing practice. The nursing education programs should adopt attitudes that promote critical thinking and mobilize the skills of critical reasoning.

CONFLICT OF INTEREST: NONE DECLARED.

The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

Critical Thinking: Beyond the Nursing Process

Critical thinking ability is essential to the practice of nursing.   Numerous definitions exist as to what critical thinking is, and questions surround to what extent nurses are taught to use and practice critical thinking. The article that follows will serve to focus on defining critical thinking and developing answers to the following:

Is the nursing process the basis for nursing decisions?

Is critical thinking beyond the nursing process?  

Is nursing practice based on reasoned thought and not intuition?

Are nurses cognizant of and routinely utilizing the universal elements of thought?

The National League of Nursing has defined critical thinking in nursing practice as a discipline specific, reflective reasoning process that guides a nurse in generating, implementing and evaluating approaches for dealing with client care and professional concerns. ( 6 ) Variations on this definition of critical thinking   include:

a. ìReflective and reasoned thinking about nursing problems without one solution, focused on decisions about what to believe and doî (4)

b. Purposeful, self-regulatory judgment: an interactive, reflective, reasoning process of making a judgment about what to do or believe (4)

c.   The identification and evaluation of evidence to guide decision making.   This involves asking questions, defining problems, researching and examining evidence and understanding the bias that exists. (8)

d. Embodies a search for the best knowledge in a given context and requires openness to new judgment and a willingness to reconsider judgments without bias from multiple perspectives that are supported by reason and evidence. (4)

  The American Nurses Association Standards hold that application of the nursing process is the framework for critical thinking. (9) However The Foundation of Critical Thinking suggests that like any framework, it can unfortunately be executed superficially or substantively. (9) They believe that skilled nursing does depend on a well reasoned philosophy of nursing based on an in depth understanding of critical thinking. However they maintain that the norm in nursing is intuitive nursing practice. This intuitive practice when performed automatically without caution, routine review and vigilance can result in many significant negative implications (9) as illustrated in the following:

Consider the following clinical scenario handled by two nurses (identified as Nurse 1 and Nurse 2) resulting in very different patient outcomes:

Scenario: Nurse on AM shift is assigned to a 38 y.o. WF gr. 2 para 1   ab. 1 who   is 2 days post op abdominal hysterectomy for metrorrhagia. Post op course had been uneventful. Past history revealed: hypertension, anxiety disorder and previous spontaneous abortion. Night shift report indicated patient had a high level of anxiety during the night which was not consistent with a routine hysterectomy. Night shift treated client with PRN anxiolytic based on her current status and past history and patient had been quiet in night with no reported or noted complications.

Nurse enters clientís room and patient states she is so worried about the hysterectomy and questions if it was really necessary. She vocalizes fears if it is healing well and continues to say she feels weak, cannot sleep and has experienced some dizziness. Both nurses utilize the night shift report, past history, patient complaints and patient assessment to plan and implement care.

1. Assesses vaginal drainage with patient supine in bed and noted light drainage on top of pad

2. BP lying was WNL

3. Administered PRN dose of anxiolytic based on her past history and current anxiety   and   no follow up assessment as she had tolerated medication well during the night

1.5 hours later patient found unresponsive and lying in a bed saturated with blood.

1. Assesses vaginal drainage by moving patient on her side —found pt. had soaked through 1 pad in one hour and blood had pooled under patient

2. Review of post op Hgb. was 34 and Nurse 2 rechecked finger stick Hgb. which was now 29

3. Assessment of    BP against admission BP.   BP was taken sitting and standing. BP dropped when standing and was lower than admission BP

4. Asked patient to: 1.)   specifically describe her fears   2.) rate anxiety level on scale of 1-5   3).   asked what measures she uses to control her anxiety and 4.) describe what she means when she says she feels weak.

5. Level of consciousness assessed and noted client unclear about time asked client again to describe specifically how she felt and patient reported weakness   and vision seemed blurry.

MD called stat and pt referred back to OR for post op   hemorrhage

  Two nursesí assessments with very different outcomes. What made the difference? The critical thinking process, pattern and the quality and depth of reasoning.

As the complexity of healthcare escalates and the accountability of nurses increases, the need for critical thinking at every level of nursing and in every setting becomes paramount (4). Application of critical thinking skills and abilities is the methodology for professional nursing practice. Critical thinking is the ìcognitive engine that drives the process of clinical judgment in nursingî (4) However, are we preparing nursing students and practicing nurses to truly think critically by basing the thought process solely on the nursing process?

  Paramount to the development of critical thinking in nursing students is learning the tools of critical thinking and then learning to regularly apply reflective, critical thought in routine nursing situations. Through this deliberate process, facilitation of expertise in reasoning will occur. Critical thinking in nursing involves a search for the best knowledge in a given content. One size does not fit all in the care of individuals. No cookie cutter approach to individuals and their problems exist or should exist. Critical thinking demands an openness to new evidence and a willingness to rethink judgments (4) as well as acknowledging bias.   To effectively think critically one must skillfully utilize the elements or tools    innate in thinking. These elements are identified as the:

A. elements of thought

B. universal intellectual standards

C. intellectual traits

The universal intellectual standards are utilized to check the quality of our reasoning or thinking which is developed by utilizing the elements of thought.   These standards question each of the elements of thought to check the quality of our reasoning or thought. To be a critical thinker one must have command of the standards and internalize them to facilitate better reasoning. These intellectual standards transcend diversity of subject matter   and are applied to the universal elements of thought which are embedded     in all sound reasoning.(5)The elements of thought and the universal intellectual standards   are outlined below and have been developed by Linda Elder and Richard Paul in the Paul-Elder Critical Thinking Framework (5)

According to the Paul-Elder Framework if one consistently utilizes the elements of thought and universal intellectual standards it will result in the development of intellectual traits of:

Intellectual Humility-willingness to seek answers and truth and to admit oneís ignorance

Intellectual Courage-willingness to seek answers in spite of antagonism from others

Intellectual Empathy-suspending judgment and willingness to look at anotherís viewpoint

Intellectual Autonomy-willingness to stand by sound judgment

Intellectual Integrity-recognition of the need to be true to one\'s own thinking and to honestly admit discrepancies and inconsistencies in one\'s own thought and action.

Intellectual Perseverance—constantly truth seeking and continually monitoring of oneís thinking

Intellectual Reason and fair-mindedness---reason not based on self serving purpose (5)

The elements of thought and universal standards must be applied to our thinking to assess the quality of our reasoning about an issue or a problem. When these are consistently applied the quality of our reasoning will improve. (1) Therefore consistent utilization of the elements and standards will facilitate sound clinical judgments and safe decision making (4).

To think through and act appropriately to the myriad problems encountered in nursing requires a command of the elements of thought and universal intellectual standards. It also requires the that the nurse acknowledge the obstacles or barriers to critical thinking which surround   egocentric (centered on self)   and socio-centric (centered on oneís society /culture)   thought and that these barriers are    acknowledged and eliminated from our reasoning.(8)

The National League for Nursing (NLN) has formulated steps to facilitate application of critical thinking specific to nursing practice:

1. Interpret –recognize, then classify and describe data significance

2. Analyze—identify the inferential and intended meaning of relationship s among data

3. Evaluate—judge the credibility of information

4. Infer—derive from the evidence reasonable conclusions

5. Explain –justification of reasoning activity is based on convincing arguments (6)

This definition is however not inclusive of all the elements of thought and universal intellectual standards that could lead to incorrect judgments.

The National Council State Board of Nursing (NCSBN) supports the fact that it is the common knowledge that as the complexity of health care and the accountability of nurses increase the need for critical thinking concepts and application of ability to think critically in all healthcare settings to include the classroom, at the bedside and in the boardroom is critical. (3) NCSBN has developed a list of habits of the mind that are crucial for   critical thinking for a nurse who is using objective scientific, problem solving concepts in a context of cultural and clinical variables. NCSBN habits for critical thinking emphasize the elements of thought and universal intellectual standards but are specific to the nursing and they include:

1. Confidence –conviction to express valid and practical opinions and judgment

2. Contextual perspective –assesses variables that affect the clinical situation such as ethnicity, economics and interpersonal variables

3. Creativity-engages imagination to implement original solutions to prevent or solve problems

4. Flexibility—adapts to plans to varying conditions

5. Inquisitiveness-employs curiosity to devise creative solutions to patient care

6. Intellectual integrity-openness to otherís views

7. Intuition-examines insights for innovative solutions

8. Open-mindedness-does not form prejudices or conclusions before hearing all evidence

9. Perseverance—applies effort to problem solve and does not come to conclusions before all data gathered

10.Reflection-gives total consideration to a situation to gather diverse data and possible outcomes.(9)

The NCSBN reports that the actual skill of critical thinking is seldom taught in the classrooms despite its definitive value in problem solving at all levels underlying the ineffectiveness of traditional teaching methods. (4) Students who have been educated using inquiry based learning and reflective learning based activities make better clinical decisions than those who have merely memorized facts. (3) Students and practicing nurses need to be taught to routinely and reflectively ask, What if? What else? What then? (4)

The theory and application of critical thinking must be ongoing in education and in practice for all nurses. To compound the lack of emphasis on critical thinking in the classroom in is the speed today at which information is produced and disseminated. No longer can we ignore the facts that ìbetween birth of the world and 2003 there were five exabytes   (in decimal terms, an exabyte is a billion gigabytes) of information created. We now create five exabytes every two daysî. (8) Nurses must be able to interpret, utilize and critical think through all the mounds of electronic data that is so quickly available at their fingertips   in order to sift what is clinically sound. (7)

Nursing is a complex, multi -faceted profession that demands expertise in critical thinking to meet the needs of our clients in a complex society. The Department of Labor has a category which describe nurses    entitled ìsymbol analystî and the definition is:

1. someone who can carry out multi step operations,

2. manipulate abstract and complex symbols and ideas,

3. acquire new information efficiently

4. remain flexible enough to recognize the need for continuing change and for new paradigms for lifelong learning. (3)

  Are we educating nurses to meet this definition? Are we functioning like this currently in the multiple healthcare settings in which we practice??  

We must continue to make changes in the way our nurses are educated both in school and in practice to facilitate critical thinking inclusive of the elements of thought and universal intellectual standards which moves us beyond the nursing process. We must help nurses and nursing students ìthink about thinkingî to potentiate exemplary care.

1. Elder, L. and   Paul, R.îUniversal Intellectual Standardsî. Retrieved 5/1/11 from http//www.criticalthinking.org.

2. Hesslip, Penny.îCritical Thinking:To think Like a Nurseîretrieved 3/18/11 from http://www.criticalthinking.org

3. Kerby, Linda. ìCritical thinking in Nursing ì   Leader to Leader.   Spring 2008. Retrieved from http: www.NCSBN.org

4. Khosravani,   Setrach,   Maoochehr, Homan and Memarian,   Robabeh. ìDeveloping Critical Thinking in Nursing Students by Group Dynamicsî. Retrieved 3/24/11from http://www.sspub.com/journal/The_internet_Journal_of_Advanced_Nursing

5. Paul, Richard and Elder, Linda.îideas to Action:using critical Thinking to Foster Student leadership and Community Engagement.îRetrieved 5/10/11 from http://louiosville.edu.ideastoaction/what/c-tframework .

6. National League for Nursing. ìCritical thinking in Nursing Students Practiceî /RN Exam. RN Information Bulletin OTACHI: 880SOIP.

7. Pietrasanta, Kathleen, MSED Newport News Public Schools Staff development. Interview   5/2/11.

8.   Scriven, Michael and Paul, Richard. îDefining Critical Thinkingî.   Retrieved   3/18/11 from http://www.critical thinking.org

9. The Critical thinking Community. ìNursing and Healthcareî. Retrieved 3/31/11 from http:www.criticalthinking.org/Ö/definingCT.cfm

Critical Thinking

High quality, safe patient care is dependent upon the healthcare provider’s ability to reason, think, and make judgments about care. Critical thinking, clinical reasoning and judgment are integral to quality clinical decisions and actions. Today’s healthcare landscape has transitioned towards an environment where patients are more medically complex, an aging population with chronic illness, and increased socioeconomic diversity. In order to provide quality patient-centered care, nurses need to develop CT skills in order to provide patients with expert care (Brunt, 2005).

Developing CT is an ethical responsibility of professional nursing practice, and a component for sound clinical judgments and safe decision-making. Thinking in a logical, systematic way, being open to questioning current practice, and reflecting on one’s practice regularly are some key features that strengthen nurses’ CT skills.

The quality of clinical decision-making is influenced by a number of factors, including experience, level of education, time pressures, and also the culture of the nursing unit (Johansson, Pilhammar, & Willman 2009). Developing critical thinking skills has the potential to improve personal practice and patient outcomes.

Critical thinking (CT) is a process used for problem-solving and decision-making. CT is a broad term that encompasses clinical reasoning and clinical judgment. Clinical reasoning (CR) is a process of analyzing information that is relevant to patient care. When data is analyzed, clinical judgments about care is made. The process of analyzing the data, making decisions is the result of CT—thinking critically throughout the entire patient situation, weighing all relevant options and using CT skills to make the best decision for the patient.

While many definitions have been cited for CT (see below), there is a general agreement that CT is a purposeful action that includes analysis, logical reasoning, intuition, and reflection. Making a concerted effort to critically think during patient care leads to safe, effective decisions. Developing CT skills is key for all nurses, they spend the most time with patients, and are able to recognize subtle changes in their patients and are positioned to make quick, precise decisions, often lifesaving. Using effective CT skills allows nurses to shape the outcome of a patient’s experience with the healthcare system.

The concept of critical thinking has been an integral part of professional frameworks for generations, yet scholars still debate a universal accepted definition. Dozens of CT definitions have been published, with each of them sharing some common features, such as reflection, contemplation, holism, and intuition. The list below shares a variety of CT definitions:

“The rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, ideas, statement beliefs and action” (Bandman & Bandman, 1995, p. 7)

A reflective skepticism; “reflecting on the assumptions underlying our and others’ ideas and actions and contemplative alternative ways of thinking and living” (Brookfield, 1987, p. 18)

“The process of purposeful self-regulatory judgment . . . gives reasoned consideration to evidence, context, conceptualization, methods and criteria: (Facione, 2006, p. 21)

“Reasonable and reflective thinking that is focused upon deciding what to believe or do” (Kennedy, Fisher, & Ennis, 1991, p.46)

“An investigation whose purpose is to explore a situation, phenomenon, question, or problem to arrive at a hypothesis or conclusion about it that integrates all available information and that, therefore, can be convincingly justified” (Kurfiss, 1988, p. 37)

“The propensity and skill to engage in an activity with reflective skepticism” (McPeck, 1961, p. 8)

“The deliberative nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting and evaluating information that is both factual and belief based” (National League for Nursing Accrediting Commission, 2000, p. 8)

“A unique kind of purposeful thinking in which the thinker systematically and habitually imposes criteria and intellectual standards upon the thinking, taking charge of the construction of thinking, guiding the construction of the thinking according to the standard, and assessing the effectiveness of the thinking according to the purpose, the criteria and the standards” (Paul, 1993, p. 21)

“In nursing . . . an essential component of professional accountability and quality nursing care [that exhibits] confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance and reflection.” (Scheffer & Ruberfeld, 2000, p. 357)

Concepts Related to Critical Thinking

Clinical Reasoning

• A process where nurses integrate and analyze patient data to make decisions about patient care (Simmons, Lanuza, Fonteyn, & Hicks, 2003)

Clinical Decision-Making

• A process of choosing between different options or alternatives (Thompson & Stapley, 2011)

Clinical Judgment

• A cognitive process used to make judgments based on patient data and cues. Nurses interpret a patient’s concerns, needs, and health problems for proper decision-making (Tanner, 2006, p. 204)
• Outcome of critical thinking in nursing practice; judgments begin with the end goal in mind; outcomes are met, involves evidence (Pesut, 2001)

Logical Reasoning

• Arriving at a conclusion based on relatively small amounts of knowledge and/or information (Westcott, 1968)
• “Drawing inferences or conclusions that are supported in or justified by evidence (Alfaro-LeFevre, 2015, p. 232)
• A purposeful analysis of one’s current and past actions (Schon, 1987)

Experience and Clinical Reasoning

According to Benner’s (1984) novice to expert model, expert nurses have an intuitive grasp of their patients’ problems, their approach is fluid, flexible, and proficient. Compared to novice nurses, they are more task oriented and require frequent verbal and physical cues to provide care.

Novice nurses are challenged with overcoming a knowledge gap, leading to less effective decisions and actions. Compared to experienced nurses, who are challenged with traditional thinking, leading to less effective clinical judgments and decisions (Cappelletti et al., 2014). Successful CR and decision-making require a balance of intuition and evidence-based thinking to make effective clinical decisions (Simmons et al., 2003).

Andersson et al. (2012) found nurses who were specialized in their setting (more experience) used a more holistic approach to making decisions (p. 876), compared to less experienced nurses who used a “task-and action-oriented approach” (p. 873). Gaining experience and knowledge is one way to improve thinking and decision-making, though improving CT skills can close the gap. Being open-minded, self-aware, and reflective offers nurses important information that can improve CR and decision-making. Clinical judgment (akin to CR) improves over time with nurses who uses reflection as a guide for decisions and actions (Cappelletti et al., 2014).

Critical Thinking and Clinical Decision-Making

Lee et al. (2017) conducted an integrated review on nine studies to determine whether effective CT impacted clinical decision-making. Four studies found CT impacted decision-making, though five studies did not find a correlation. Due to poor study designs, Lee et al. (2017) could not come to a clear decision on whether there was as significant correlation.

CT continues to be an important factor for problem-solving, regardless if studies can confirm a correlation to decision-making. Developing CT skills, such as reflection, intuition, and logical reasoning, are essential behaviors that lead to a patient-centered approach. Nurses who stop and think about what worked for a patient in the past, may consider the same option again, or may choose an alternative. Considering all possibilities with the patient’s best interest in mind is part of CT and making clinical decisions.

Researchers will continue to study the impact of CT on nursing care. Nurse educators will continue emphasize CT in the curriculum and assist students in developing CT skills throughout all levels of education as they offer students tools and methods for problem-solving.

Rubenfeld and Scheffer (2001) explain the essence of CT in nursing practice:

Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge (2001, p. 125).

Standards of Practice

Critical thinking and clinical reasoning are weaved throughout the Nursing Scope and Standards of Practice and Code of Ethics (American Nurses Association [ANA], 2021). The nursing process itself, Standards 1-6, are essentially a tool used for clinical reasoning. The standards require core cognitive competencies and guide nurses to use patient data to make effective clinical decisions.

The  Essentials

Clinical Judgement is one of the eight featured concepts within The Essentials (American Association of Colleges of Nursing [AACN], 2021, p.12). The process of clinical judgement, as earlier in this section, is the outcome of critical thinking.

The Essentials explains how a liberal arts education is critical to exposing nurses to a broad worldview, giving them a holistic perspective that engages them in promoting health equity and social justice, , and “forms the basis for clinical reasoning and subsequent clinical judgments” (AACN, 2021, p. ).

Problem-Solving A pproaches

Reflective thinking.

Reflection is a powerful tool for recognizing errors in judgment, questioning one’s response, and ultimately improving outcomes. Below are two practice examples that illustrate the power of reflective thinking with interprofessional communication and patient care:

Novice and senior nurse communication

• Problem: A novice nurse is struggling with inserting IVs just about every shift. One day, the nurse asks the same more experienced nurse for help again. The nurse listens though does not turn around to face the nurse when questioned, and responds in a swift, aggressive way, “I’m swamped, we have no aides today and I’m falling behind with everything. I’ll help you when I get time, but it’s going to be a while.”
• Impact: The nurse’s patient is at risk for injury without an IV line. The patient may be upset and unsatisfied with care knowing the IV was out for an extended period of time. The nurse feels dejected, does not feel like she is a valued team member, and loses further confidence in her abilities. She considers quitting her job or transferring to another unit.
• Reflection: The experienced nurse realizes she was not empathetic to the nurse’s needs and impatient and aggressive in her response. She realizes the nurse is new and doesn’t have much confidence in her skills yet. She also knows the nurse is probably disappointed in the lack of teamwork and camaraderie. Most of all, she feels bad about disrespecting her coworker.
• Impact of reflection : After reflection of the situation, the nurse apologizes for her poor behavior. She states she will work with her each shift they work together, she will share personal tips and review educational materials. Additionally, she will offer to have her observe her IV insertions until she has mastered the skill. She will also make sure the new nurse feels like she is part of the team, not just the new nurse.

Shift report

• Problem: The oncoming nurse enters his patient room for the first time and finds the foley bag is full and the patient is complaining of abdominal discomfort.
• Impact: The patient is at risk for infection and may be disappointed with the quality of nursing care.
• Reflection: The oncoming nurse realizes there is always one or two problems or inconsistencies when he assesses his patients for the first time. He knows the outgoing nurses are skilled and provide quality care and considers another reason for the errors. After thinking about this for a while, he believes the process for shift report can help reduce change of shift errors. The nurse realizes there needs to be a better way for sharing patient information during change of shift.
• Impact of reflection: The nurse researches evidence-based practices to improve safety and quality during shift change. The nurse shares a copy of the review article on bedside report with his manager. The nurse offers to be a change champion on the unit to implement a new process for shift report.

L ong-term impact of reflection :

• Improved team cohesiveness, nurse retention and job satisfaction
• Improved patient satisfaction experience and quality of care, leading to higher insurance reimbursement

Glynn (2012) states reflective thinking enhances clinical judgment and gives nurses the opportunity to learn from actual or perceived errors. In regard to the communication scenario, it’s through reflection that nurses can think about their behaviors and responses. Reflect on the message for clarity, and whether it was shared in an empathetic and respective way.

As discussed in the communication chapter, poor communication is the number one reason for medication errors and sentinel events. Through reflection, miscommunication can be identified, solutions found, and implemented. In order for this process to come to fruition, nurses must take the initiative to reflect on their practice.

Creative Thinking

Creative thinking helps nurses generate alternative approaches to clinical decision-making. This type of thinking works especially well with medically complex patients, where care needs to be individualized to reach desired outcomes.

Akin to the concept of “thinking outside the box”, finding a novel approach to patient care prevents traditional, stagnant thinking. Choosing alternatives based solely on creative thinking can negatively impact outcomes unless it is paired with the skill of critical thinking. Critical thinking requires the nurse to view the patient holistically,

Nurses access knowledge unconsciously and trust this information as fact. Often referred to as a “gut feeling”, intuition comes naturally. Intuition is not a tool that is sought out at will, instead the knowledge emerges naturally during a care experience, resulting in firm actions and decisions. Intuition is a measure of professional expertise (Smith, Thurkettle, & Cruz, 2004), a type of clinical judgement that develops over time (Benner, 1984). Since this knowledge is considered intangible or irrelevant, some disregard it, though many studies have shown its positive influence in making accurate decisions and improving the quality of care (Robert, Tilley & Petersen, 2014).

• Nurses will recognize something about their patient that they can’t explain, and will make decisions on care without concrete evidence to back up their actions. Such actions can be lifesaving (Billay, Myrick, Luhanga & Yonge 2007). Each clinical experience acts as a learning experience for which lessons are learned and applied to the next experience (McCutcheon & Pincombe, 2001).
• Holtslander (2008) states Carper’s (1978) seminal work on the fundamental ways of knowing was published as a reaction to the overemphasis of empirical (scientific) knowledge in nursing practice. One of the four ways of knowing , called aesthetic knowing , explains the component of art within nursing practice, an, awareness of the patient, viewing the patient as unique. This viewpoint allows nurses to consider more than just empirical knowledge to guide practice.

Critical Thinking Skills

As discussed earlier, CT encompasses a broad range of reasoning skills that lead to effective decision-making. Through the process of clinical reasoning and judgment, nurses make best choice after assembling and analyzing patient data.

White (2003) studied senior baccalaureate nurses and found the following five themes were essential to developing clinical decision-making skills:

• Gaining confidence in clinical skills
• Building relationships with staff
• Connecting with patients
• Gaining comfort in self as a nurse
• Understanding the clinical picture

Scheffer and Rubenfeld (2000) found CT is comprised of affective and cognitive components. Affective components refer to an individual’s feelings and attitudes, and cognitive components refer to thought processes. The CT components include 10 habits of the mind (affective components) and seven skills (cognitive components), as follows:

Habits of the mind

• Confidence : assurance of one’s reasoning abilities
• C ontextual perspective : considerate of the whole situation, including relationships, background and environment relevant to some happening
• C re a tivity : intellectual inventiveness used to generate, discover, or restructure ideas; imagining alternatives
• F lexibility : capacity to adapt, accommodate, modify or change thoughts, ideas, and behaviors
• I nquisitiveness : an eagerness to know by seeking knowledge and understanding through observation and thoughtful questioning in order to explore possibilities and alternatives
• I ntellectual integrity : seeking the truth through sincere, honest processes, even if the results are contrary to one’s assumptions and beliefs
• I ntuition : insightful sense of knowing without conscious use of reason
• O pen-mindedness : a viewpoint characterized by being receptive to divergent views and sensitive to one’s biases
• P erseverance : pursuit of a course with determination to overcome obstacles
• R eflection : contemplation upon a subject, especially one’s assumptions and thinking for the purposes of deeper understanding and self-evaluation (Scheffer & Rubenfeld, 2000, p. 358)
• Analyzing : separating or breaking a whole into parts to discover their nature, function and relationships
• A pplying standards : judging according to established personal, professional or social rules or criteria
• D iscriminating : recognizing differences and similarities among things or situations and distinguishing carefully as to category or rank
• I nformation seeking : searching for evidence, facts or knowledge by identifying relevant sources and gathering objective, subjective, historical, and current data from those sources
• L ogical reasoning : drawing inferences or conclusions that are supported in or justified by evidence
• P redicting : envisioning a plan and its consequences
• T ransforming knowledge : changing or converting the condition, nature, form, or function of concepts among contexts (Scheffer & Rubenfeld, 2000, p. 358)

Development of CT is a lifelong process that requires nurses to be self-aware, and to use knowledge and experience as a tool to become a critical thinker. As nurses move along the continuum from novice to expert, one’s competence and ability to critically think will expand (Brunt, 2005).

• Transitions to Professional Nursing Practice. Authored by : Jamie Murphy. Provided by : SUNY Delhi. Located at : https://courses.lumenlearning.com/suny-delhi-professionalnursing . License : CC BY: Attribution

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Critical thinking: the use of intuition in making clinical nursing judgments

• PMID: 7636606

Making clinical nursing judgements is central to the practice of nursing, and critical thinking skills are essential to making clinical judgments. Qualitative studies have shown that the use of intuition in making clinical nursing judgments is an important part of the critical thinking process. This descriptive correlational study examines the relationships between the use of intuition in clinical judgment-making and characteristics of the nurse, such as level of nursing proficiency and years of clinical experience. Findings support Benner's (1984) model of skill acquisition as well as prior findings of studies on the use of intuition in clinical nursing practice. Thus, as the level of nursing proficiency increases from beginner to expert and as the amount of clinical experience increases, the use of intuition to make clinical nursing judgments increases significantly.

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