Critical Thinking

Vickie Fieler, PhD, RN, AOCN

What is Critical Thinking?

Definition of Critical Thinking

• Critical thinking is the disciplined, intellectual process of applying skillful reasoning as a guide to belief or action (Paul, Ennis & Norris).

• In nursing, critical thinking for clinical decision-making is the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care (Heaslip).

• Paul, R.W. (1990). Critical Thinking: What Every Person Needs to Survive in a Rapidly Changing World. Rohnert Park, California: Center for Critical Thinking and Moral Critique

• Norris, S. P. & Ennis, R.H. (1989). Evaluating critical thinking. Pacific Grove, CA: Midwest Publications, Critical Thinking Press

• Heaslip, P. (1993). Critical Thinking and Nursing. http://www.criticalthinking.org/pages/critical-thinking-and-nursing/834

Key Concepts

• Open-minded Inquiry

In times of constant change, we must be open to new ideas and be willing to revise

or abandon earlier ideas

Assumptions

• Beliefs we take for granted

• Man laying in gutter, only bums lay in the gutter, that man is a bum

Or• Man laying in gutter, man in a gutter

needs help, that man needs help

Bias

• Bias distorts inquiry– Factors such as: favoritism, ignorance,

omission, corruption, misplaced loyalty, threats, prejudice, etc., undermines a fair examination.

Dogmatism

• Stubbornly inflexible view point

Expertise

• We are not experts in everything• We must sometimes rely on Experts• Experts are not infallible“When experts are agreed, the opposite opinion cannot be certain. When they are not agreed, no opinion is certain, When experts think the evidence is insufficient, we should suspend judgment.” Hare, W. (2001). Bertrand Russell and the ideal of critical receptiveness. Skeptical Inquirer, 25, 3:40-44.

Fallibility and Gullibility

• Our beliefs are subject to error and change

• The desire to be open-minded floods us with wishful thinking, persuasive advertising, ignorance, and naiveté.

• We need to balance open-mindedness with skepticism.

Humility

• Recognizing one’s one limitations and liability to error.

Uncertainty

• Deeply controversial issues, disagreement among experts, conflicting information

• The world we live in is not settled and finished

• We must have tolerance for ambiguity

Veracity

• A commitment to truth• Basing our views on an honest

assessment of the evidence• A passion to learn• Sabotaged by ulterior motives,

wishful thinking, hasty judgment, and resistance to ideas

A real patient care example by Jennifer Theriault, RN, staff nurse at St.

Joseph Hospital

Learning the Art of Critical Thinking

1. Clarify your thinking2. Stick to the point3. Question the questions4. Be reasonable

When we don’t practice critical thinking….

• Jump to conclusions

• Focus on the trivial• Ask irrelevant

questions• Base conclusions

on inaccurate info• Ignore important

info

• Distort data• Fail to notice

contradictions• Fail to think

through implications

• Poor problem solving

Analyzing our Thinking

• Inferences:An intellectual step in which one concludes something is true based on something else that is true.

• AssumptionsSomething we take for granted or presume and do not question. May be justified, unjustified, sound or not sound.

Stages of Critical Thinking Skills

• The Unreflective Thinker

• The Challenged Thinker

• The Beginning Thinker

• The Practicing Thinker

• The Advanced Thinker

• The Accomplished Thinker

Advantages to Critical Thinking

• Gather & organize information

• Understand concepts

• Identify assumptions

• Deal with complexities

• Express logically

• Test and check for accuracy

• Consider other viewpoints

• Consider implications and consequences

• Improve patient care

The “What – IF” Game

1. What is the most common complication of this patient’s condition?

2. How would I know if this complication is occurring?

3. What would I assess in this patient first?

4. What would I do?

The “What – If” Game

• Patient with Pituitary tumor resection• Most common complication =

hemorrhage• Symptom of hemorrhage = loss of

visual field• Quick patient assessment = assess

visual fields

Knee replacement

• Most common complication?

• Symptoms?

• Assessment?

• Action?

Unstable Diabetic

• Most common complications?

• Most common symptoms?

• Assessment?

• Action?

CT and the Nurse

• Recognizes changes in patient status• Anticipates changes in patient status• Voices concern about unsafe practice• Identifies improvement opportunities

• Explores multiple solutions• Understands rationale for action• Understands clinical implications• Asks for assistance when needed

• Prioritizes most urgent patients• Sequences patient care• Delegates effectively• Demonstrates accountability for

delegation• Establishes & adjusts plan of care• Implements nursing interventions• Communicates plan of care

• Applies knowledge from past experiences

• Reevaluates assumptions• Initiates professional dialogue• Debriefs following errors or near-

misses• Adjusts own practice based on

feedback

Another real patient example By Kimberly Badessa, MSN, NP-C, RN, OCN

Questions?