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Course: Oncology Nursing

Topic: Critical Thinking and Clinical Judgment

The Nurses International Community

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Module Goals

Learners will be able to:

Define Critical Thinking, Clinical Reasoning, and Clinical Judgment.
Identify the components of Critical Thinking.
Explain the relationship of Critical Thinking, Critical Reasoning, and Clinical Judgment.

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Difference between ‘Thinking’ and ‘Critical Thinking’?

Alfaro-LeFevre, R (2019)

‘Thinking’ refers to any mental activity that can be ‘mindless’

‘Critical Thinking’ is controlled and purposeful, using well-reasoned strategies to get the results you need.

Image by Clip Art by Vector Toons

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Some Definitions of Critical Thinking

“(1)An attitude of being disposed to consider in a thoughtful way, the problems and subjects that come within the range of one’s experiences, (2) knowledge of the methods of logical inquiry and reasoning, and (3) some skill in applying those methods ”(Glaser, 1941, as cited in Leibold, 2020)

“Recognizing the problem, selecting the pertinent data/information, recognizing assumptions, formulating decisions, and drawing a conclusion related to the situation”(Harding and Snyder, 2016, as cited in Leibold, 2020)

Leibold (2020)- Pgs 18-19

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Disposition of Critical Thinking

Robert H. Ennis (2011, as cited in Leibold, 2020), listed three dispositions of critical thinking as:

Care about the truth or accuracy
Care to grasp and communicate a position honestly
Care for every person

Leibold (2020)- Pgs 22-23

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Qualities of a Critical Thinker

(Robert H. Ennis, 2011, as cited in Leibold, 2020)

Open minded
Mindful of alternatives
Well-informed as much as possible
Evaluates the credibility of sources
Practices the identification of assumptions, conclusions, and reasons
Evaluates the logic and reason of an argument
Can develop/defend a reasonable position
Asks questions to gain knowledge
Develops hypothesis and is able to test
Able to define terms
Reaches conclusions when appropriate

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Components of Critical Thinking

Leibold (2020)- Pg 18

Defining the problem, situation, issue, or dilemma
Performing a systematic search
Planning, Inquiring
Determining assumptions
Exploring alternatives
Independently analyzing
Logical reasoning
Explicating rationales
Reaching a conclusion

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Defining Problems, Situations, Issues, and Dilemmas

Crucial first step that critical thinking is based on

Also most basic attribute to critical thinking commonly missed

Identifying the ‘real’ problem/situation/issue/dilemma
Accurate identification of problem/situation/issue/dilemma determines success of achieving desired outcome
Important to gather information and facts to correctly define the problem/situation/issue/dilemma

Leibold (2020)- page 39 and 44

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Performing Systematic Search

Involve gathering needed assessment information and evidence to help make an informed conclusion
Systematic assessment is to use multiple sources of information

library use, journals, books, interviews, physical assessment of patient/client, or psychosocial assessment of patient

Nurses must practice individualized systematic assessment to define problem/issue/situation/dilemma.
A thorough systematic assessment prevents thinker from jumping to conclusions before knowing the facts

Leibold (2020)- page 39 and 44

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Planning

Leibold (2020)- page 39 and 44

Well thought out plans guard the thinker against impulsive behaviour

which is especially dangerous in the nursing profession when lives of patients depend on appropriate action

Hypothetical thinking is often used in planning to consider alternate outcomes with different choices
Purpose of making a plan is to act methodically and in a manner that will promote reaching the intended goal

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Inquiry

Leibold (2020)- page 39 and 44

Paramount to critical thinking
Used on an ongoing basis throughout the thinking process
Example of inquiry using hypothetical thinking:

“I wonder if….then….will...happen,”

Nurses must be competent in the art of questioning

Short answer questions yield a ‘yes’ or ‘no’ answer
Open ended questions yield an elaborate answer

Important to know situation- specific questions

requires practice over time to develop this skill

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Determining Assumptions

Assumptions are thoughts, statements, or perceptions believed to be true.
Making an assumption is not wrong/bad but it is crucial that they be followed up with checking facts.
Errors in thinking happen when assumptions are not checked
Ask yourself “What are my assumptions?” or “Is my thinking accurate?”
It takes practice to be aware of self assumptions
Being aware of and checking assumptions improve critical thinking skills.

Best practice is to routinely check assumptions for accuracy!

Leibold (2020)- Pg 54 and 58

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What Would a Nurse Do?

Pain medication is ordered for 2 am in the morning for a patient who has had an appendectomy, but nurse finds that patient is sound asleep.

The nurse assumes that since the patient is sound asleep, patient is not in pain. Nurse does not administer pain medication.

Do you agree with the nurse? Why or Why not?

Would you have done differently? Why or Why not?

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Exploring Alternatives

Leibold (2020)- page 83.

Involves making a list of the most viable alternatives and assigning value to the alternatives to select the best choice using a systematic method
Personal experiences and culture may influence one’s ability to explore alternatives without being aware of it
Keeping an open mind is essential
Requirements for exploring alternatives are

Accurate identification of problem/situation/issue/dilemma
Clear and thorough assessment
Awareness and fact checking of assumptions

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Proposed strategies to develop exploring alternatives: (Leibold 2020, page 84-87)

Assessment: Perform thorough systematic assessment to gather information
Brainstorm: Method in which as many ideas as possible are thought of without judgment in the initial phase
Literature searches: Conduct literature search to find evidence based information and ideas
Communication: Communicating with others help discover more information as well as share knowledge; help in exploring alternatives
Check the policy and procedure manual: Policy and procedure manuals often have a wealth of information
Consider ethics: Ethics that relate to the case should be considered when exploring alternatives; helps nurse know what is acceptable and provide direction in situations
Hypothetical thought: Considering what could happen in a certain circumstance or situation; helps explore alternatives to consider the consequences of the possible alternatives in a situation
Consider the intended outcome: thinking about the outcome helps one stay on track and making sure the actions line up with the intended outcomes

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Independently Analyzing

Leibold (2020)- Pg 87

Critical thinker examines a whole issue, broken into parts, to discover a deeper understanding.
Opposite of being told what to think.
Self-directed analysis and judgment of logic, precision, and accuracy of the information.

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Logical Reasoning and Explicating Rationales

Leibold (2020)- Pgs 97-98

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Reaching Conclusions

Conclusion is the final step of the critical thinking process.

Jumping to conclusions through bias or inadequate assessment lead to faulty thinking.

Rationales and reasoning derived from credible evidences help reach accurate conclusion.

Leibold (2020)- Pg 114

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How do you think critical thinking applies in Nursing?

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Why is Critical Thinking Important in Nursing?

Nurses are at the forefront of care provision, practicing independently within their scope of practice.
Nursing involves problem solving and decision making regarding patient care on daily basis.
Nurses must use sound clinical reasoning and clinical judgment to provide safe and quality care.
Critical thinking is vital for clinical reasoning and clinical judgment.

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Clinical Reasoning

Clinical reasoning is “Reflective, concurrent, critical, creative, and systems and complexity thinking process embedded in nursing practice that nurses use to filter, frame, focus, juxtapose, and test the match between a patient’s present stated and the desired outcome state” (Kupier et al, 2017, p.424)
Clinical reasoning is both a cognitive and metacognitive process which involves application of knowledge and experience to the clinical situation.
Nurse uses critical thinking to practice clinical reasoning.

Leibold (2020)- Pg 25

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Clinical Judgment

Clinical Judgment is defined by the skill of recognizing cues about a clinical situation, generating and weighing hypotheses, taking action and evaluating outcomes for the purpose of arriving at a satisfactory clinical outcome. Clinical judgment is the observed outcome of two unobserved underlying mental processes-critical thinking and decision making (NCSBN, 2018)
Clinical judgment is based on nurse’s knowledge and experience in combination with their reasoning, intuition, clinical thinking, and evidence-based practice skills (Tanner, 2006)

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Clinical Judgment

Clinical judgments are decisions nurses make to identify and fulfill the patient’s need.
Nurse’s clinical judgment directly influence the patient health outcomes.
Therefore, sound nursing clinical judgment is vital for provision of safe and quality patient care.

Sound clinical judgment is possible only through appropriate use of critical thinking and the clinical reasoning processes!

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References:

Alfaro-LeFevre, R. (2019). Critical Thinking, Clinical Reasoning, and Clinical Judgment (7th ed.). St. Louis, Missouri: Elsevier. Pages-6.

Kuiper, R., O'Donnell, S. M., Pesut, D. J., & Turrise, S. L. (2017). The essentials of clinical reasoning for nurses: Using the outcome-present state test model for reflective practice. Indianapolis, IN: Sigma Theta Tau International. p: 424

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References:

Leibold, N. (2020). The Praxis of Critical Thinking in Nursing (2nd ed.) St. Paul, Minnesota: Nanza Publications. Under the Creative Commons License for Non-commercial use. Retrieved from: https://www.merlot.org/merlot/viewMaterial.htm?id=1380138

NCSBN (2018). Next Generation: NCLEX News. Retrieved from: https://www.ncsbn.org/NCLEX_Next_Winter18_Eng_05.pdf

Tanner, C.A. (2006). Thinking Like a Nurse: A Research-Based Model of Clinical Judgment in Nursing. Journal of Nursing Education, 45(6):204-11. Retrieved from: https://www.researchgate.net/publication/7003793_Thinking_Like_a_Nurse_A_Research-Based_Model_of_Clinical_Judgment_in_Nursing

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