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Critical Thinking Skills in Nursing
PREPARED BYSAMEER ABDULMALIK ALKUBATI
SUPERVISED BYPROF. DR. NAGWA A. IBRAHIM
2011
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Alexandria UniversityFaculty of NursingDoctorate Program
Foundation of Nurs-ing Science
2011
Outline
1. Introduction
2. Definition of critical thinking
3. Components of Critical Thinking
4. Critical Thinking Competencies
5. Standards for Critical Thinking
6. Importance of critical thinking in nursing education and practice
7. Aspects of Critical Thinking
8. Levels of critical thinking in nursing
9. Dimensions of critical thinking
a. Critical thinking skills
b. Critical thinking dispositions
10.The relationship between Critical Thinking and Problem Solving, De-
cision making, Creative thinking
11.Development of critical thinking in nursing
12.Concepts in Critical Thinking
13.The Nursing Process and Critical Thinking
14.References
2
Goal
At the end of this seminar the doctoral students will be able to understand
the concept of critical thinking in nursing
Intended learning outcomes of course (ILOS)
I- knowledge and understanding:
1. Define critical thinking
2. Differentiate between critical thinking, problem solving, decision
making, nursing process and creative thinking
3. Enumerate 10 importance of critical thinking in nursing education
and practice
4. Identify 4 measures for assessment of critical thinking
II- Intellectual skills:
1. Distinguish between critical thinking skills and dispositions
2. Develop strategies for promoting critical thinking in nursing
III- General and transferable skills:
1. Apply critical thinking strategies in nursing practice and education
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Introduction
In clinical settings, it is common for nurses to deal with a group of
complicated and high-risk patient-care situations that require decisions to
be made quickly. As an integral part of the health care system, nurses and
nursing are impacted by all the challenges and changes in the health care
system. These include (a) quality, cost, and access issues; (b) continuous
technological growth; (c) new knowledge and treatments emerging on an
ongoing basis; and (d) continuous expansion as the population ages, with
the associated increase in disease processes. These changes have been asso-
ciated with current ethical and moral dilemmas that are borne out in the
daily practice of nurses.
Thus, nurses should be skilled in critical thinking, in order to deal effec-
tively with complex change, and provide the best nursing care. Conse-
quently, a major paradigm change in nursing education from focusing on
curricular content to curricular outcomes, with a major emphasis on helping
students learn to think critically; they must be taught how to think, not what
to think.
Definition of critical thinking
American Philosophical Association (APA, 1990) who did use a Delphi re-
search project on critical thinking. "purposeful, self-regulatory judgment
which results in interpretation, analysis, evaluation and inference as well
as explanation of the evidential conceptual, methodological, criteriological
or contextual considerations upon which that judgment was based".
• Chaffee (2002) Active, organized, cognitive process used to exam-
ine one’s thinking and that of others.
• Profetto-McGrath and others (2003) Critical thinking is both a
process and set of skills.
• Settersten and Lauver (2004) Recognize, analyze, evaluate, and draw
conclusions.
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Components of Critical Thinking
When a nurse enters into any clinical experience there are five compo-
nents of critical thinking that lead the nurse to make the clinical judg-
ments that are necessary for safe, effective nursing care:
1- Scientific Knowledge Base
The depth and extent of knowledge influence the nurse’s ability to think
critically about nursing problems.
2- Experience
-Unless a nurse has the opportunity to practice and make decisions about
client care, critical thinking in clinical decision making will not develop.
3- Critical Thinking Competencies
a. General critical thinking which include the scientific method,
problem solving, and decision making.
b. Specific critical thinking competencies in clinical situations
which include diagnostic reasoning, clinical inferences, and clinical de-
cision making. These competencies are used by physicians, social
workers, nurses and other health care professionals in deciding about
the clinical care and support of clients.
c. The specific critical thinking competency in nursing which is
the nursing process. The format for the nursing process is unique to
nursing and offers one approach to critical thinking in clinical decision
making.
4. Attitudes for Critical Thinking
These attitudes are the values that an individual must practice or show to
be successful critical thinker. (Confidence, Independence, fairness, Re-
sponsibility, Risk taking, Discipline, Perseverance, Creativity, Curiosity,
Integrity, Humility).
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Critical thinking attitudes and applications in nursing practice
Critical thinking atti-
tude
application in practice
ConfidenceIntroduce yourself to client…etc
IndependenceRead the nursing literature
fairnessListen to both sides in any problem
ResponsibilityAsk for help if you are uncertain about an
aspect of client care
Risk takingIf your knowledge causes you question a
physician’s order, do so
DisciplineBe thorough in whatever you do
PerseveranceBe wary of an easy answer
CreativityLook for different approaches if interven-
tions are not working
CuriosityAlways ask ”why”
IntegrityDecide how best to proceed to reach mutu-
ally beneficial outcomes
HumilityRecognize when you need more informa-
tion to make a decision
4. Standards for Critical Thinking
These standards are the criteria for determining the soundness, justness,
and appropriateness of critical decisions and judgments.
a. Intellectual standards
Paul(1993) identified 14 intellectual standards that are universal for criti-
cal thinking, (Clear, Precise, Specific, Accurate, Relevant, Plausible,
Consistent, Logical, Deep, Broad, Complete, Significant, Adequate, Fair)
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b. Professional standards: that refer to;
1. Ethical criteria for nursing judgment. Client care requires more
than just the application of scientific knowledge.
2. Criteria for evaluation. Critical thinking requires the use of cri-
teria for evaluation when clinical judgments are made.
3. Professional responsibility. The standards of professional re-
sponsibility that a nurse strives to achieve are those standards cited in
nurse practice acts, national regulatory and treatment, and institutional
practice guidelines.
Importance of critical thinking
A. In nursing education
1. Improve student understanding of their own thought process
2. Improve student ability to transfer learned content and skills to
new applications
3. Improve student motivation
4. Facilitate students' autonomy and self-confidence
5. Students are able to raise vital questions and problems, as well
as formulate and present them clearly
6. Students can gather and assess information and interpret it ef-
fectively
7. Students can reach well-reasoned conclusions and solutions to
problems while testing them against relevant criteria and standards
8. Students can be open-minded
9. Students can clearly communicate ideas, positions, and solu-
tions to others
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B. In nursing practice
1. It is an essential component of communication, problem-solving
ability, theoretical and conceptual understanding of nursing concerns
and research that advance the knowledge base of nursing
2. Improve nurses clinical competence
3. Critical thinking skills aid in the “delivery of safe, comprehen-
sive, individualized, effective and innovative care which stems from
the competent clinical judgment of thinking professionals”
In conclusion, critical thinking is a cornerstone of nursing education and
practice and it is one of the essential keys of nursing education outcomes.
The importance of critical thinking to nursing emerged as the National
League for Nursing (NLN, 1989), an accrediting agency for nursing ed-
ucation programs, recognized this need for critical thinking skills and
mandated the integration of teaching and assessment of critical thinking
skills into the nursing curriculum. The NLN (2000, 2002), Pew Health
Professions Commission (1998), and the American Association of
Colleges of Nursing (2002) have cited critical thinking skills as one of
the core competencies and essential cognitive abilities needed by health
care workers of the 21st century.
Aspects of Critical Thinking
1. Reflection
Review what you did and ways to improve
Did you follow the standards?
2. Language
Always communicate clearly to the patient and staff
To become a critical thinker, a nurse must be able to use lan-
guage, precisely and clearly.
3. Intuition
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Develop a “gut feeling” based on your experience and knowl-
edge
Realize what you do not know and then find out.
e.g: An experienced neurosurgical nurse may enter the room of a head in-
jury client and know immediately if the client behavior change suggests
an increase in ICP.
Levels of critical thinking in nursing
a. Basic critical thinking: Basic – learner believes that the experts are
correct and do thing according to the book. E.g, a nurse uses an institu-
tion’s procedure manual to confirm how to insert a foley catheter.
b. Complex critical thinking: Complex – the critical thinker begins to
develop their own way of thinking. E.g, physician orders state the patient
must walk four times per day but he is vomiting and is unable to do as or-
dered
c. Commitment: Commitment – person accepts responsibility of mak-
ing own decisions or is accountable for actions
The Dimensions of Critical Thinking
The dimensions of critical thinking comprise both cognitive skills and af-
fective dispositions. Facione and Sanchez state that having the requisite
cognitive critical thinking skills is essential to being a good critical
thinker. The concept of critical thinking is also associated with a set of
personal attitudes or dispositions that can be used to describe an individ-
ual who is inclined to use critical thinking.
A. Critical thinking skills
Critical thinking skills are Interpretation, Analysis, Evaluation, Inference,
Explanation, and Self-regulation.
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1. Interpretation involves
- Clarifying meaning about a wide variety of experiences, beliefs,
procedures, rules, etc.
- Understanding the meaning of a patient's behavior or state-
ments.
- Interpreting problems as well as objective and subjective data
from common information sources, related to the care of the patient.
For example, determining the significance of laboratory values, vital
signs, and physical assessment data.
2. Analysis involves:
- Identifying the intended & actual inferential relationships
among statements, questions, concepts, descriptions, or other forms of
representation intended to express belief, judgment, experiences, rea-
sons, information, or opinion.
- Examining ideas, identifying arguments, analyzing arguments.
3. Evaluation includes
- Assessing the logical strength of statements, descriptions or
questions.
- Evaluating information to ascertain its probable trustworthiness
as well as its relevance to particular patient care situations.
- For example, identifying expected patient outcomes and assess-
ing whether or not they are met. If not met, the nurse ascertains why.
4. Inference includes
- Querying claims
- Assessing arguments (recognizes faulty reasoning)
- Reaching conclusions that are appropriate to the care of the pa-
tient
- For example, the nurse determines when a patient's health status
improves or declines through careful monitoring.
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5. Explanation includes:
- Stating results of one’s reasoning
- justifying that reasoning
- Presenting one’s reasoning in the form of strong arguments
- For example, nurse implements interventions based on research
or other sources of evidence.
6. Self-regulation includes:
- Self examination
- Self correction
B. Critical thinking dispositions (CTDs)
Critical thinking dispositions are the affective components of critical
thinking. These affective dispositions are coupled with cognitive skills as
essential components of ideal critical thinker. They are Consistent will-
ingness, motivation, inclination and force to be engaged in critical think-
ing while making decisions and solving problems. Facione (1992) identi-
fied a specific seven attributes for critical thinking dispositions which are
analyticity, open-mindedness, truth-seeking, systematicity, critical think-
ing self-confidence, inquisitiveness and cognitive maturity.
1. Truth-seeking is a tendency to seek the best knowledge in a
given situation, be courageous about asking questions and be honest and
objective about pursuing inquiry even if the finding do not support one's
self interests.
2. Open-mindedness: having an appreciation of alternate perspec-
tives and willingness to respect the right of others to hold different opin-
ions. Understanding other cultural traditions in order to gain perspectives
on self and for others.
3. Analyticity targets the disposition of being alert to problem sit-
uations, anticipating potential outcomes or consequences of situations,
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choices, idea or plans and prizing the use of reason and evidence to solve
problems.
4. Systematicity measures one's inclination to be organized and
focused in inquiry.
5. Critical thinking self-confidence measures the trust of indi-
viduals placed in their reasoning and reflective process and their ability to
guide others to resolution of problems.
6. Inquisitiveness measures intellectual curiosity and the desire to
learn new things even if their immediate application is not apparent.
7. Cognitive maturity represents the attribute of being judicious
in the individual's decision making and the habit of making a judgment in
a timely way, not prematurely based on standards, ethics and evidences.
The relationship between Critical Thinking and Problem Solving,
Decision making, Creative thinking
Critical thinking in nursing has also been used interchangeably with other
terms such as problem solving, clinical decision making, and creative
thinking. Simpson and Courtney (2002) indicated that these terms have
different meanings and there is a need to understand the differences.
Critical Thinking versus Problem Solving
Problem solving is used to seek solutions, whereas critical thinking con-
siders all aspects and judges the solutions rather than focusing solely on
finding an answer.
Critical Thinking versus Clinical Decision Making
- Decision making, is a systematic process of assessment of actions, eval-
uation and judgment making that will contribute to the achievement of a
desired outcome.
- Incorporating critical thinking skills during the clinical de-
cision making process will provide clarification, a range of
potential solutions appropriate to the circumstances or
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setting and reasoning to support the clinical decision
made.
- Lipman and Deatrick(1997) affirm that requisite to clini-
cal decision making is the use of critical thinking.
Critical Thinking and Creative Thinking
Creative thinking is a combination of knowledge and imagination. A cre-
ative thinker typically has an attitude of interest in every thing, continu-
ously exploring of new ideas, options, alternatives and approaches and
then trying to manipulate the understanding into new knowledge or mean-
ing. Creative thinking is ultimately stimulated through posing Socratic
questions, such as “What else” and “Why” or “What if?”
Paul(1990) emphasizes that critical and creative thinking
“have an intimate relationship to figuring things out.
So, Critical Thinking is considering a broad umbrella under which
several forms of thinking occur.
Development of critical thinking in nursing
It is a gradual process of enhancing one’s ability to use critical thinking in
his/her personal and professional life. This can be occurred through the
following:-
1. Nursing programs play an important role to prepare well-qual-
ified students to become well-prepared nurses who are able to use critical
thinking. Thus, critical thinking should fit within all nursing programs
parts include objectives, teaching-learning strategies and evaluation
methods.
a. Learning objectives: should be based on the developing of crit-
ical thinking skills and dispositions rather than the lower level of cog-
nitive domain
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b. Curriculum there is a need to teach critical thinking as a sub-
ject, even before it can be integrated into the program content and
linked it to every lesson given.
c. Teaching-learning strategies:
Nurse educators realize the importance of teaching critical-thinking skills
to students and are aware that these skills can be developed by devising
teaching methods that stimulate higher-level thinking in theory and prac-
tice. Therefore, how can nurse educators stimulate these skills or abili-
ties in themselves and in their students?
Various strategies are offered to enhance critical-thinking abilities.
1. Questioning
2. Small-group activities
3. Role-playing
4. Debate
5. Case studies
6. Journals
7. Simulations
8. Problem solving
9. Cooperative learning
10. Computer assisted instruction
11. Concept mapping
Although these strategies are very important to apply in nursing program,
there are many several barriers to teaching for critical thinking in bac-
calaureate programs, including student resistance to active learning, inad-
equate class time, insufficient time to prepare critical thinking activities,
and the need to cover content.
d. Evaluation tool: tool to measure critical thinking skills and dis-
positions involved in the course report or specification.
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2. Nurse educators
- Nurse educators play an important role in the facilitation of critical
thinking dispositions of their graduates. In fact, the external measure of
nurse educators' effectiveness is their graduates' abilities to think criti-
cally. Hence, they should demonstrate competence related to critical
thinking in order to be role model, open doors to new perspectives of the
world for their students, as well as foster self-confidence and encourage
lifelong learning.
- Nurse educators should grasp the knowledge about the dimensions of
critical thinking by reading research articles, participating in seminars,
workshops and conferences on critical thinking and introducing these
competencies to colleagues and students.
- They should continuously reflect on their teaching practice, skills and
beliefs to enhance their critical thinking skills and dispositions
- They should work under an umbrella of peer cognitive coaching through
collaboration and reflection in an effort to become better decision-makers
- Use of research evidence in practice supports the cultivation of critical
thinking disposition in nurse educators
3. Educational institution
- It should provide support to critical thinkers' efforts, listening attentively
to them, and motivating them to think critically because the process of
dispositions development requires intrinsic motivation, rewards, re-
sources and reinforcement to those who are able and willing to think criti-
cally
Concepts in Critical Thinking
Critical thinking involves the use of several concepts, including: explor-
ing, analyzing, prioritizing, explaining, deciding, and evaluating to iden-
15
tify solutions and determine a course of action to solve patient care prob-
lems.
Exploring encourages you to identify all the variables within a situation.
Analyzing is the process of studying each variable to understand its
meaning and its relationship to the other variables.
Prioritizing requires you to weigh the relative importance of each vari-
able to the others, at a given point in time.
Explaining the variables involves the exercise of amplifying each vari-
able to understand its meaning in the situation and to the involved parties.
Deciding means to choose a specific course of action.
Evaluating requires the thinker to assess how correct the thinking
process was, and if further action is needed.
The Nursing Process and Critical Thinking
The nursing process and critical thinking are complementary processes.
And, it may be useful for nurses to correlate these tools to improve criti-
cal thinking skills, while at the same time, improve the level of care de-
livered to patients.
Nurses use critical thinking skills in each step of the nursing process. Ev-
erything nurses do requires high level thinking, Rubenfeld & Scheffer
1999 cited that "no action is performed without critical thinking”
The following table is designed to help you correlate the nursing process
with critical thinking steps.
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NURSING
PROCESSCRITICAL THINKING
AssessmentOrganized process, based on knowledge, contains
subjective and objective data. Exploring
DiagnosisRequires inference, hypotheses, analysis, synthesis,
and problem solving. Analyzing
Planning
Involves prioritizing, decision making and setting
goals for care outcomes
Implementation
Use of nursing interventions and skills, family and
other staff involved, includes medial interventions.
Prioritizing and deciding .
EvaluationInvolves analyzing results, reassessing, revisiting
goals and projected outcomes. Evaluating.
References
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1 -Potter P, Perry A. Fundamentals of nursing. 6th ed, St. Louis. Mosby
Company, 2005; 262-275.
2 -Simpson E, Courtney M. Critical thinking in nursing
education: A literature review. Available on
http://eprints.qut.edu.au/263/1/SIMPSON_CRITICAL_
THINKING.PDF.
3- Lipman TH, Deatrick JA. Preparing advanced practice
nurses for clinical decision making in speciality practice.
Nurse Educator 1997; 22(2): 47-50.
4 -Taylor C, LeMone P, Lillis C, Lynn P. Fundamentals of nursing: the
art and science of nursing care. 6th ed, Philadelphia. Lippincott
Company, 2008; 218-23.
5 -Kuckyt C. nursing process & critical thinking, 2008. Available at:
http://home.cogeco.ca/~nursingprocess/think.htm
6 -Daniels R. Nursing fundamentals: caring & clinical decision making.
2nd edition. Delmar Cengage Learning, 2008.
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