Critical Thinking and the Nursing Process

In today’s health care arena, the nurse is faced with increasingly complex issues and situations resulting from advanced technology, greater acuity of patients in hospital and community settings,
an aging population, and complex disease processes, as well as ethical and cultural factors.  Traditionally, nurses have used a problem-solving approach in planning and providing nursing care. Today the decision-making part of problem solving has become increasingly complex and requires critical thinking.

Definition of Critical thinking

Critical thinking is a multidimensional skill, a cognitive or mental process or set of procedures. It involves reasoning and purposeful, systematic, reflective, rational, outcome-directed thinking based on a body of knowledge, as well as examination and analysis of all available information and ideas. Critical thinking leads to the formulation of conclusions and the most appropriate, often creative, decisions, options, or alternatives. Critical thinking includes metacognition, the examination of one’s own reasoning or thought processes while thinking, to help strengthen and refine thinking skills. Independent judgments and decisions evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Nursing practice in today’s society mandates the use of high-level critical thinking skills within the nursing process. Critical thinking enhances clinical decision making, helping to identify patient needs and to determine the best nursing actions that will assist the patient in meeting those needs. Critical thinking and critical thinkers have distinctive characteristics. As indicated in the above definition, critical thinking is a conscious, outcome-oriented activity; it is purposeful and intentional. The critical thinker is an inquisitive, fair-minded truth seeker with an open-mindedness to the alternative solutions that might surface.

Critical thinking Process: Rationality and Insight
Critical thinking is systematic and organized. The skills involved in critical thinking are developed over time through effort, practice, and experience. Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Critical thinking requires background knowledge and knowledge of key concepts as well as standards of good thinking. The critical thinker uses reality-based deliberation to validate the accuracy of data and the reliability of sources, being mindful of and questioning inconsistencies. Interpretation is used to determine the significance of data that are gathered, and analysis is used to identify patient problems indicated by the data. The nurse uses inference to draw conclusions. Explanation is the justification of actions or interventions used to address patient problems and to help a patient move toward desired outcomes. Evaluation is the process of determining whether outcomes have been or are being met, and self-regulation is the process of examining the care provided and adjusting the interventions as needed. Critical thinking is also reflective, involving metacognition, active evaluation, and refinement of the thinking process. The critical thinker considers the possibility of personal bias when interpreting data and determining appropriate actions. The critical thinker must be insightful and have a sense of fairness and integrity, the courage to question personal ethics, and the perseverance to strive continuously to minimize the effects of egocentricity, ethnocentricity, and other biases on the decision making process.

Components of Critical thinking
Certain cognitive or mental activities can be identified as key components of critical thinking. When thinking critically, a person will do the following:
1 Ask questions to determine the reason why certain developments have occurred and to see whether more information is needed to understand the situation accurately.
2 Gather as much relevant information as possible to consider as many factors as possible.
3 Validate the information presented to make sure that it is accurate (not just supposition or opinion), that it makes sense, and that it is based on fact and evidence.
4 Analyze the information to determine what it means and to see whether it forms clusters or patterns that point to certain conclusions.
5 Draw on past clinical experience and knowledge to explain what is happening and to anticipate what might happen next, acknowledging personal bias and cultural influences.
6 Maintain a flexible attitude that allows the facts to guide thinking and takes into account all possibilities.
7 Consider available options and examine each in terms of its advantages and disadvantages.
8 Formulate decisions that reflect creativity and independent decision making.

Critical thinking requires going beyond basic problem solving into a realm of inquisitive exploration, looking for all relevant factors that affect the issue, and being an “out-of-the-box” thinker. It includes questioning all findings until a comprehensive picture emerges that explains the phenomenon, possible solutions, and creative methods for proceeding. Critical thinking in nursing practice results in a comprehensive patient plan of care with maximized potential for success.

Critical thinking In Nursing Practice
Using critical thinking to develop a plan of nursing care requires considering the human factors that might influence the plan. The nurse interacts with the patient, family, and other health care providers in the process of providing appropriate, individualized nursing care. The culture, attitude, and thought processes of the nurse, the patient, and others will affect the critical thinking process from the data-gathering stage through the decision-making stage; therefore, aspects of the nurse-patient interaction must be considered. Nurses must use critical thinking skills in all practice settings—acute care, ambulatory care, extended care, and in the home and community. Regardless of the setting, each patient situation is viewed as unique and dynamic. The unique factors that the patient and nurse bring to the health care situation are considered, studied, analyzed, and interpreted. Interpretation of the information presented then allows the nurse to focus on those factors that are most relevant and mostsignificant to the clinical situation. Decisions about what to do and how to do it are then developed into a plan of action.

Fonteyn (1998) identified 12 predominant thinking strategies used by nurses, regardless of their area of clinical practice:
Recognizing a pattern
1 Setting priorities
2 Searching for information
3 Generating hypotheses
4 Making predictions
5 Forming relationships
6 Stating a proposition (“if–then”)
7 Asserting a practice rule
8 Making choices (alternative actions)
9 Judging the value
10 Drawing conclusions
11 Providing explanations

Fonteyn further identified other, less prominent thinking strategies the nurse might use:
1 Pondering
2 Posing a question
3 Making assumptions (supposing)
4 Qualifying
5 Making generalizations

These thought processes are consistent with the characteristics of critical thinking and cognitive activities discussed earlier. Fonteyn asserted that exploring how these thinking strategies are used in various clinical situations, and practicing using the strategies, might assist the nurse–learner in examining and refining his or her own thinking skills.

Throughout the critical thinking process, a continuous flow of questions evolves in the thinker’s mind. Although the questions will vary according to the particular clinical situation, certain general inquiries can serve as a basis for reaching conclusions and determining a course of action. When faced with a patient situation, it is often helpful to seek answers to some or all of the following questions in an attempt to determine those actions that are most appropriate:
1 What relevant assessment information do I need, and how do I interpret this information? What does this information tell me?
2 To what problems does this information point? Have I identified the most important ones? Does the information point to any other problems that I should consider?
3 Have I gathered all the information I need (signs/symptoms, laboratory values, medication history, emotional factors, mental status)? Is anything missing?
4 Is there anything that needs to be reported immediately? Do I need to seek additional assistance?
5 Does this patient have any special risk factors? Which ones are most significant? What must I do to minimize these risks?
6 What possible complications must I anticipate?
7 What are the most important problems in this situation? Do the patient and the patient’s family recognize the same problems?
8 What are the desired outcomes for this patient? Which have the highest priority? Does the patient see eye to eye with me on these points?
9 What is going to be my first action in this situation? How can I construct a plan of care to achieve the goals?
10 Are there any age-related factors involved, and will they require some special approach? Will I need to make some change in the plan of care to take these factors into account?
11 How do the family dynamics affect this situation, and will this have an affect on my actions or the plan of care?
12 Are there cultural factors that I must address and consider?
13Am I dealing with an ethical problem here? If so, how am I going to resolve it?
14 Has any nursing research been conducted on this subject?


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