Which professional standard does the nurse feel is most important for critical thinking?

Critical Thinking Defined

Mr. Jacobs is a 58-year-old patient who had a radical prostatectomy for prostate cancer yesterday. His nurse, Tonya, finds the patient lying supine in bed with arms extended along his sides but tensed. When Tonya checks the patient’s surgical wound and drainage device, she notes that the patient winces when she gently places her hands to palpate around the surgical incision. She asks Mr. Jacobs when he last turned onto his side, and he responds, “Not since last night some time.” Tonya asks Mr. Jacobs if he is having incisional pain, and he nods yes, saying, “It hurts too much to move.” Tonya considers the information she has observed and learned from the patient to determine that he is in pain and has reduced mobility because of it. She decides that she needs to take action to relieve Mr. Jacobs’ pain so she can turn him more frequently and begin to get him out of bed for his recovery.

In the case example the nurse observes the clinical situation, asks questions, considers what she knows about postoperative pain and risk for immobility, and takes action. The nurse applies critical thinking, a continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant (Heffner and Rudy, 2008). Critical thinking involves recognizing that an issue (e.g., patient problem) exists, analyzing information about the issue (e.g., clinical data about a patient), evaluating information (reviewing assumptions and evidence) and making conclusions (Settersten and Lauver, 2004). A critical thinker considers what is important in each clinical situation, imagines and explores alternatives, considers ethical principles, and makes informed decisions about the care of patients.

Critical thinking is a way of thinking about a situation that always asks “Why?”, “What am I missing?”, “What do I really know about this patient’s situation?”, and “What are my options?” (Heffner and Rudy, 2008; Paul and Heaslip, 1995). Tonya knew that pain was likely going to be a problem because the patient had extensive surgery. Her review of her observations and the patient’s report of pain confirmed her knowledge that pain was a problem. Her options include giving Mr. Jacobs an analgesic and waiting until it takes effect so she is able to reposition and make him more comfortable. Once he has less acute pain, Tonya offers to teach Mr. Jacobs some relaxation exercises.

You begin to learn critical thinking early in your practice. For example, as you learn about administering baths and other hygiene measures, take time to read your textbook and the nursing literature about the concept of comfort. What are the criteria for comfort? How do patients from other cultures perceive comfort? What are the many factors that promote comfort? The use of evidence-based knowledge, or knowledge based on research or clinical expertise, makes you an informed critical thinker. Thinking critically and learning about the concept of comfort prepares you to better anticipate your patients’ needs, identify comfort problems more quickly, and offer appropriate care. Critical thinking requires cognitive skills and the habit of asking questions, remaining well informed, being honest in facing personal biases, and always being willing to reconsider and think clearly about issues (Facione, 1990). When core critical thinking skills are applied to nursing, they show the complex nature of clinical decision making (Table 15-1). Being able to apply all of these skills takes practice. You also need to have a sound knowledge base and thoughtfully consider what you learn when caring for patients.

TABLE 15-1

Critical Thinking Skills

Modified from Facione P: Critical thinking: a statement of expert consensus for purposes of educational assessment and instruction. The Delphi report: research findings and recommendations prepared for the American Philosophical Association, ERIC Doc No. ED 315, Washington, DC, 1990, ERIC.

Nurses who apply critical thinking in their work are able to see the big picture from all possible perspectives. They focus clearly on options for solving problems and making decisions rather than quickly and carelessly forming quick solutions (Kataoka-Yahiro and Saylor, 1994). Nurses who work in crisis situations such as the emergency department often act quickly when patient problems develop. However, even these nurses exercise discipline in decision making to avoid premature and inappropriate decisions. Learning to think critically helps you care for patients as their advocate, or supporter, and make better-informed choices about their care. Facione and Facione (1996) identified concepts for thinking critically (Table 15-2). Critical thinking is more than just problem solving. It is a continuous attempt to improve how to apply yourself when faced with problems in patient care.

TABLE 15-2

Concepts for a Critical Thinker

Modified from Facione N, Facione P: Externalizing the critical thinking in knowledge development and clinical judgment, Nurs Outlook 44(3):129, 1996.