More on critical thinking, clinical judgment, and docu- mentation
Dear Editor: Dr. Kidd's recent editorial (J EMERG NURS
1995;21:191-2) regard ing the need for ED nurses to document their importance is admirable, but presents a number of confusing and confounding points. To assume that documentat ion is ev idence of "crit ical th ink ing" does not necessar i ly follow; moreover, what exact ly is crit ical thinking, and how is this related to cl inical judgment? The two terms are often used, but the research on both is in its infancy for both nurs ing and medic ine. Furthermore, it is not farfetched to as- sume that if this process can be identif ied, it can be codif ied as an algorithm and taught to technic ians. (This process is at the heart of EMT, CPR, and ACLS training.)
Using nurs ing d iagnoses as a means of demon- strat ing our worth leaves much to be desired. It often has been reported that it muddles communicat ion among health professionals, and in my own experi- ence with s tudents on both undergraduate and grad- uate levels, it fails to demonstrate advantages in actual pat ient care. At a t ime when we need to col laborate with other health care professionals, we insist on us- ing terminology that is narrowly understood. 1
Perhaps more important is Dr. Kidd's ins istence that we demonstrate our contr ibut ion to the entire health care enterpr ise (patients, physic ians, and soci- ety as a whole). This point has been emphas ized by Sue Hegyvary, 2 who points out that the context of the society in which nurs ing's cost effectiveness, impor- tance, and so on is p laced may make the difference as to whether such facts are accepted and acted on. This is well apprec iated by the wel l -known Knaus study that reported that nurse-phys ic ian relat ionships were an important aspect in determin ing ICU mortality, s -
J EMERG NURS 1995;21:483-8. Copyright 9 1995 by the Emergency Nurses Association. 0099-1767/95 $5.00 + 0 18/64/68495
Joseph P. Zbilut, PhD, DNSc, RNC, Professor, Surgical Nursing, Rush College of Nursing, Associate Professor, Molecular Biophysics and Physiology, Rush Medical College, Chicago, Illinois
1. Editorial. Image 1994;26:2. 2. Hegyvary S. Outcomes research: integrating nursing practice into the world view. Rockville, Maryland: National Institutes of Health. Patient outcomes research: examining the effectiveness of nursing practice; DHHS publication no. 93-3411:17-24. 3. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. An evaluation of outcomes from intensive care in major medi- cal centers. Ann Intern Med 1986;104:410-8.
I would like to thank my col league for his thought- fuI crit ique of my editorial. Dr. Zbilut asks several quest ions in his critique. What is critical thinking? Critical thinking is a process that requires careful judgment. 1 This definit ion helps to answer Dr. Zbi lut 's second question: How are critical thintdng and clini- cal judgment related? Critical th inking is a process that allows the nurse to make a dist inct ion in favor of or against a part icular act ion based on the knowledge ga ined in the performance of nursing. Therefore crit- ical th inking is the process, while cl inical judgment is the content.
Dr. Zbilut expresses concern that if the process of crit ical thinking, "can be identif ied, it can be codif ied as an algorithm and taught to technic ians." He cites as an example the algorithms of the ACLS curriculum. However, the Amer ican Heart Associat ion clearly states that algorithms allow the summary of informa- tion, and provide a broad way of t reat ing the patient. They do not replace clinical understanding. 2 Thus, even if a nonnurse could state a nurs ing diagnosis, the part icular diagnosis, its assoc iated interventions, and the resultant outcomes would reflect a different clin-
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