Chapter 8: Critical Thinking, the Nursing Process, and Clinical Judgment

1. Chapter 8: Critical Thinking, the Nursing Process, and Clinical Judgment Bonnie M. Wivell, MS, RN, CNS

2. Defining Critical Thinking • Facione and others (1990) • Purposeful, self-regulatory judgment that results in interpretation, analysis, evaluation, and inference • Is essential as a tool of inquiry • A pervasive and self-rectifying human phenomenon • Ideal critical thinker is inquisitive, well-informed, trustful of reason, open-minded, flexible, fair-minded in evaluation, honest in facing personal biases, prudent in making judgments, willing to reconsider, clear about issues, orderly in complex matters, diligent in seeking relevant info., reasonable in selection of criteria, focused in inquiry, and persistent in seeking results

3. Paul and Elder (2005) • “Critical thinking is a process by which the thinker improves the quality of his or her thinking by skillfully taking charge of the structures inherent in thinking and imposing intellectual standards upon them.” • A “well-cultivated critical thinker” • Raises questions and problems • Gathers and assesses relevant info. • Arrives at conclusions and solutions that are well-reasoned • Is open-minded and recognizes alternative ways of seeing problems • Communicates effectively with others as solutions to complex problems are formulated

4. Critical Thinking in Nursing • A nurse exercising critical thinking asks the following questions: • What assumptions have I made about this pt? • How do I know my assumptions are accurate? • Do I need any additional information? • How might I look at this situation differently? • Reflective thinking: an active process valuable in learning and changing behaviors, perspectives, or practices; occurs after nurse-patient interactions have ended

5. Critical Thinking in Nursing • “Think on your feet”: Examining your thinking process during an interaction • As you move from novice to expert your ability to critically think will improve with practice • Driven by the needs of the pt. and family • Is more than your opinion • You must be able to describe how you came to a conclusion and support your conclusions with explicit rationales.

6. The Nursing Process • A universal intellectual standard by which problems are addressed and solved • “A designated series of actions intended to fulfill the purposes of nursing – to maintain the pt’s wellness – and, if this state changes, to provide the amount and quality of nursing care the situation demands to direct the pt. back to wellness.” • The cornerstone of nursing standards, legal definitions, and practice, hence it needs to be understood by all nurses

7. Phases of the Nursing Process • Assessment – information gathered • Subjective/Objective • Primary source = the pt. • Secondary source = nurse observations or reports of family/friends • Tertiary sources = medical records or reports from other healthcare providers • Collect, organize and protect confidentiality of data

8. Phases of the Nursing Process • Analysis and Diagnosis • 1973 NANDA published its first list of nursing diagnosis • 6th edition published in 2006, includes 167 approved diagnoses • “actual or potential health problems which nurses, by virtue of their education and experience, are capable and licensed to treat” • www.evolve.elsevier.com/Chitty/professional/

9. Analysis and Diagnosis (Cont’d) • 5 components • Label • Definition • Defining characteristics • Risk factors • Related factors • P = Problem (NANDA diagnostic label) • E = Etiology (causal factors) • S = s/s (defining characteristics) • Prioritize!!

10. Phases of the Nursing Process • Planning • Goals: short/long term • S = Specific • M = Measurable • A = Attainable • R = Realistic • T = Time bound

11. Phases of the Nursing Process • Nursing Interventions • Independent = no supervision required • Dependent = require instructions, orders or supervision, usually by a physician • Interdependent = nurse must collaborate or consult with another health professional

12. Phases of the Nursing Process • Critical paths = multidisciplinary plans of care • Implementation: nursing orders or interventions are carried out • Evaluation: nurse examines the pt’s progress in relation to the goals and outcome criteria to determine whether a problem is resoled, is in the process of being resolved, or is unresolved • The nursing process is a dynamic, nonlinear tool for critical thinking about human responses

13. Developing Clinical Judgment • Clinical judgment consists of informed opinions and decisions based on empirical knowledge and experience • Sound clinical judgment is created by using critical thinking, applying the nursing process, staying current with developments in practice and research, understanding your scope of practice, and acquiring substantial clinical experience.

14. Chapter 11: The Science of Nursing and Evidence-Based Practice Bonnie M. Wivell, MS, RN, CNS

15. Background • Nursing could achieve a high level of professional status only to the extent that the discipline was based on a scientific body of knowledge unique to nursing • Nurse researchers began developing knowledge unique to nursing and theorists began developing theories and testing them • Hence theory and research are the foundations of scientifically based nursing practice

16. Background • EBP began to emerge which required nurses to base their care and activities on research-based knowledge • The nursing process became a means of adapting a scientific framework to the management of patient care

17. Science and the Scientific Method • Scientific Method: an orderly, systematic way of thinking about and solving problems • Quantitative research: “doing science” that requires standardized experimental designs, measurable variables and outcomes, and statistical analyses • Qualitative research: explore human responses in health and illness • Ethnography • Unstructured interviews • Participant observation

18. Pure and Applied Science and Research • Pure science: summarizes and explains the universe without regard for whether the information is immediately useful; information gathered solely for the sake of obtaining new knowledge • Joseph Priestly discovered oxygen in 1774 but didn’t have an immediate use for the info • Applied science: seeks to use scientific theory and laws in some practical way • How oxygen is best used in the care of premature infants with respiratory distress syndrome

19. Inductive and Deductive Reasoning • Inductive reasoning: begins with a particular experience and proceeds to generalizations • Deductive reasoning: proceeds from the general case to the specific; the premises used must be correct or the conclusions will not be • Valid = soundly founded • True = in accordance with the fact or reality

20. Limitations • Traditional scientific approach used by quantitative researchers; has been used productively by nurse researchers studying a wide range of nursing problems; however this approach cannot solve all nursing problems • Health care settings are not comparable to labs • Human beings are far more than collections of parts that can be dissected and subjected to examination or experimentation • The scientific method fails to consider the meaning of patients’ own experiences – the subjective view of reality

21. What is Nursing Research? • “Seeking to understand and ease the symptoms of acute and chronic illness, to prevent or delay the onset of disease or disability or slow its progression, to find effective approaches to achieving and sustaining good health, and to improve the clinical settings in which care is provided.”

22. Nursing Research • Phenomena: events or circumstances related to improving patient care • A problem may be amenable to research if: • The researcher’s ideas about the problem fit logically and dovetail with what is already known about the topic • The proposed research project is based on related research findings or is supported by similar ongoing research in other settings; building nursing knowledge • The proposed research is carefully designed so that the results will be applicable in similar situations or will generate hypotheses for further research

23. Problem Solving vs Research • Problem solving: specific to a given situation and is designed for immediate action practical knowledge, common sense, and experience • Research: generalizable to other situations and deals with long-term solutions rather than immediate ones; extensive review of lit to determine latest thinking and research

24. Evidence-Based Practice • Using the best available research findings to make clinical decisions that are most effective and beneficial for patients • Created in the 1980s by a Canadian university as an approach to clinical learning • The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients • Integrating individual clinical expertise with the best available external clinical evidence from systematic research

25. The Research Process • Identification of a research problem • May replicate or design a similar study • Review of the literature (ROL) • Locate similar studies that have been completed or on which you can build to create a conceptual framework (organization of supporting ideas, on which to base the study) • Formulation of the research question or hypothesis

26. The Research Process Cont’d. • Design the study • Experimental design: will researcher manipulate, influence or change participants in any way • Data collection instruments • Must be reliable (accurate) and valid (measures what it is supposed to be measuring) • Implementation • Data collection and analysis

27. The Research Process Cont’d. • Drawing conclusions based on findings • Facts must speak for themselves • Answer the question, “What do these findings mean?” • Discussion of implications • Suggestions of things that should be done in the future • Every good study raises more questions than it answers

28. The Research Process Cont’d. • Dissemination of findings • Publication and presentation of findings • Peer reviewed journals • Presentation at conference • Participants = subjects • For safety and ethical reasons, there are limitations on the use of the scientific method with human beings • Informed consent • Institutional Review Board (IRB) • HIPPA

29. Relationship of Nursing Research to Nursing Theory and Practice • Research ideas are generated from 3 sources • Clinical practice • Literature • Theory • Examples of changes in nursing practice stimulated by research • Improved care of pts with skin breakdown from pressure ulcer • Decreasing light and noise in ICU to prevent sleep deprivation • Using caps on newborns to decrease heat loss and stabilize body temp • Positioning patients following chest surgery to facilitate respiration

30. Summary • Nurse researchers have made significant contributions to improvements in nursing care practices • Nursing research is related to and informed by nursing theory and nursing practice and in turn influences them • Nurses of all education backgrounds have a role in research • EBP is the goal of nursing research