More on critical thinking, clinical judgment, and docu- mentation

Dear Editor: Dr. Kidd ' s r e c e n t edi tor ia l (J EMERG NURS

1995;21:191-2) r e g a r d i n g the n e e d for ED nur ses to d o c u m e n t thei r i m p o r t a n c e is admirable , bu t p r e s e n t s a n u m b e r of confus ing and confound ing points . To a s s u m e tha t d o c u m e n t a t i o n is e v i d e n c e of "cr i t ica l t h ink ing" does no t neces sa r i l y follow; moreover , w h a t exac t ly is cr i t ical th inking, and h o w is th is re la ted to cl inical j u d g m e n t ? The two t e rms are often used , bu t the r e s e a r c h on bo th is in i ts in fancy for bo th nu r s ing and med ic ine . Fur thermore , i t is not fa r fe tched to as- s u m e tha t if th is p roces s can be ident i f ied, it c an be codi f ied as an a lgor i thm and t a u g h t to t echn ic ians . (This p roces s is a t the hea r t of EMT, CPR, and ACLS training.)

Us ing nu r s ing d i a g n o s e s as a m e a n s of d e m o n - s t r a t ing our wor th leaves m u c h to be des i red . It often has b e e n r epor t ed tha t i t m u d d l e s c o m m u n i c a t i o n a m o n g hea l th profess ionals , and in m y own exper i - e n c e wi th s t u d e n t s on bo th u n d e r g r a d u a t e and grad- u a t e levels, it fails to d e m o n s t r a t e a d v a n t a g e s in ac tua l p a t i e n t care. A t a t ime w h e n w e n e e d to col labora te w i th o ther hea l th care profess ionals , w e ins is t on us- ing t e rmino logy tha t is nar rowly unders tood . 1

Pe rhaps more impor t an t is Dr. Kidd ' s i n s i s t ence tha t w e d e m o n s t r a t e our con t r ibu t ion to the ent i re hea l th ca re en te rp r i se (pat ients , phys ic ians , and soci- e ty as a whole). This po in t has b e e n e m p h a s i z e d by Sue Hegyvary , 2 who po in t s out t ha t the con tex t of the soc i e ty in w h i c h n u r s i n g ' s cos t ef fec t iveness , impor- t ance , and so on is p l a c e d m a y m a k e the d i f ference as to w h e t h e r such facts are a c c e p t e d and a c t e d on. This is well a p p r e c i a t e d b y the we l l -known Knaus s t u d y tha t r epo r t ed t ha t n u r s e - p h y s i c i a n re la t ionsh ips we re an impor t an t a s p e c t in d e t e r m i n i n g ICU mortal i ty, 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

References

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.

R~ply

I would like to t hank m y col league for his thought - fuI cr i t ique of m y editorial . Dr. Zbi lu t asks severa l ques t ions in his cr i t ique. What is critical thinking? Crit ical th ink ing is a p roces s tha t requi res careful j udgmen t . 1 This def ini t ion he lps to a n s w e r Dr. Zbi lu t ' s s e c o n d ques t ion: How are critical thintdng and clini- cal judgment related? Crit ical t h ink ing is a p rocess tha t al lows the nurse to m a k e a d i s t inc t ion in favor of or aga in s t a par t icu la r ac t ion b a s e d on the knowledge g a i n e d in the pe r fo rmance of nurs ing. Therefore crit- ical t h ink ing is the process, while cl inical j u d g m e n t is t he content.

Dr. Zbi lut e x p r e s s e s conce rn t ha t if the p rocess of cr i t ical th inking, " c a n be ident i f ied , it can be codif ied as an a lgor i thm and t a u g h t to t e chn i c i ans . " He c i tes as an example the a lgor i thms of the ACLS curriculum. However , t he A m e r i c a n Hear t Assoc i a t i on clearly s t a t e s tha t a lgor i thms allow the s u m m a r y of informa- tion, and provide a b road w a y of t r ea t i ng the pat ient . They do not r ep lace cl inical u n d e r s t a n d i n g . 2 Thus, even if a nonnur se could s t a t e a nu r s ing d iagnos is , the par t i cu la r d iagnos i s , i ts a s s o c i a t e d in tervent ions , and the resu l tan t o u t c o m e s would reflect a different clin-

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