Critical Thinking Characteristics Nursing Diagnosis
The goal of nursing staff development programs is safe, competent practice. Comprehensive programs provide the critical resources to support and promote practice. In addition, professional nursing standards of practice, health care laws, regulations, and accreditation requirements focus on the components of competent patient care to protect the health care consumer. The establishment of a staff development program that is linked to clinical practice is key to the success of professional nurse development.
Critical care staff development programs can be designed to educate staff nurses within the competencies of the synergy model.1 The program builds on the nurse’s prior education and professional nursing experience, which facilitates attainment and maintenance of competence. Concepts intrinsic to the educational process and to critical care nursing are used as a framework around which professional development opportunities are organized. Once defined on the basis of a unit’s patient population, the organizing framework serves as the structure within which all critical care nursing staff development programs are designed.
Technical training alone is no longer sufficient to meet the care delivery needs of the nurse in the critical care environment. Critical care nurses require broad knowledge and expertise in areas such as communication, critical thinking, and collaboration.9 They need to attain the diverse skills necessary to meet the complex needs of their patients and families.
The theory and science required to meet the synergy competencies includes topics such as disease processes, nursing procedures, cultural differences, moral and ethical principles and reasoning, research principles, and educational learning theories. This information can be presented through a variety of methods, including lectures, written information, posters, self-studies, or computer-based technology. However, it is essential that the information be related to realistic clinical situations. Clinical scenarios, case studies, and simulations that represent the dynamic and ambiguous clinical situations nurses encounter daily are most effective.25
Bedside teaching is particularly helpful in the development of clinical judgment and caring practice skills. Expert nurses are role models for many of the competencies delineated by the synergy model. Novice nurses learn by watching these expert nurses and emulating their behaviors. Clinical teaching also enables the novice practitioner to gain experience with unfamiliar interventions in a safe and protected environment. Communicating and validating clinical knowledge focuses learning, positively affects patient outcomes, and adds to the total body of nursing knowledge.25
Information about research and research utilization builds clinical inquiry and system thinking skills. Demystifying research, outcome, and quality processes contributes to the development of these key skills. Use of journal club formats and supporting staff involvement in research develop clinical inquiry skills. Building knowledge in the areas of health care trends and political action expand system thinking skills. Development of critical thinking skills and problem solving skills also assists with development of system thinking.
Nurses acquire facilitation of learning skills by incorporating communication development into their professional development plan. Presenting clinical teaching strategies and helping staff to determine learner readiness and assess understanding are included in the development of facilitation of learning. The importance of developing patience, flexibility, and a nonconfrontational style is reinforced.
Negotiation, conflict resolution, time management, communication, and team building are components of collaboration skills. Role playing, role modeling, and clinical narratives are methodologies that have been used to develop collaboration skills.
Nurses learn technical skills and scientific knowledge in many ways, but caring practices and advocacy are developed only through relationships that evolve over time.26 Nurturing professional relationships with experienced staff promotes the novice’s integration into practice. Expert nurses who share their clinical knowledge and coach other nurses have a tremendous impact on novice nurses. Nurses who coach are in their roles because they are able to clinically persuade and guide situations. They demonstrate expert skills and expedite the ongoing clinical development of others.
A variety of staff development programs exist, but most fall into three general categories: orientation, in-service education, and continuing education programs.
Orientation programs help acclimate new staff to unit-based policies, procedures, services, physical facilities, and role expectations in a work setting. A specific type of orientation program that has developed in response to the nursing shortage is the critical care internship program. These programs have been developed as a mechanism to recruit and train entry-level nurses. They are designed to integrate nurses with little or no nursing experience into the complex critical care environment. They provide extended clinical support for novice nurses and introduce new knowledge more deliberately than do traditional orientation programs. Basic information and skill acquisition are the core features of these programs. This foundation builds on the knowledge and skills that these nurses previously acquired in their nursing school programs. Teaching usually is under the direction of a hospital educator and generally involves less senior staff as preceptors. Typically, the novice nurse starts with providing care to the least complex patients. The program establishes a foundation on which the novice can develop into a competent clinician.25
AACN has recently released the Essentials of Pediatric Critical Care Orientation program. This program provides a bridge for the knowledge gap between what nurses learn in their basic education program and what they need to develop clinical competence with critically ill pediatric patients. The program consists of an interactive eight-module course that provides case scenarios and practice activities that augment knowledge and lead to improved job satisfaction. This program provides flexibility because it is a self-paced didactic e-learning course that can be incorporated into a blended learning environment, combining traditional educational activities such as preceptorships, discussion groups, workshops, or simulation experiences.
In-service education programs, which are the most frequent type of staff development activity, involve learning experiences that are provided in the workplace to assist staff in the performance of assigned functions and maintenance of competency.27 These programs usually are informal and narrow in scope. They often are spontaneous sessions resulting from new situations on the unit in settings such as patient rounds or staff meetings. Examples of planned in-service sessions are demonstrations of new equipment, procedure reviews, and patient care conferences.
Legislation, regulations, professional standards, and expectations of health care consumers help determine the need for continuing education. Continuing nursing education includes planned, organized learning experiences designed to expand knowledge and skills beyond the level of basic education.27 The focus is on knowledge and skills that are not specific to one institution and that build upon previously acquired knowledge and skills. Examples of continuing education programs include formal conferences, seminars, workshops, and courses.
To become a professional nurse requires that you learn to think like a nurse. What makes the thinking of a nurse different from a doctor, a dentist or an engineer? It is how we view the client and the type of problems we deal with in practice when we engage in client care. To think like a nurse requires that we learn the content of nursing; the ideas, concepts and theories of nursing and develop our intellectual capacities and skills so that we become disciplined, self-directed, critical thinkers.
Critical thinking is the disciplined, intellectual process of applying skilful 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). Critical thinking when developed in the practitioner includes adherence to intellectual standards, proficiency in using reasoning, a commitment to develop and maintain intellectual traits of the mind and habits of thought and the competent use of thinking skills and abilities for sound clinical judgments and safe decision-making.
Intellectual Standards for Reasoning
Practitioners in nursing who are critical thinkers value and adhere to intellectual standards. Critical thinkers strive to be clear, accurate, precise, logical complete, significant and fair when they listen, speak, read and write. Critical thinkers think deeply and broadly. Their thinking is adequate for their intended purpose (Paul, Scriven, Norris & Ennis). All thinking can be examined in light of these standards and as we reflect on the quality of our thinking we begin to recognize when we are being unclear, imprecise, vague or inaccurate. As nurses, we want to eliminate irrelevant, inconsistent and illogical thoughts as we reason about client care. Nurses use language to clearly communicate in-depth information that is significant to nursing care. Nurses are not focused on the trivial or irrelevant.
Nurses who are critical thinkers hold all their views and reasoning to these standards as well as, the claims of others such that the quality of nurse's thinking improves over time thus eliminating confusion and ambiguity in the presentation and understanding of thoughts and ideas.
Elements of Reasoned Thinking
Reasoning in nursing involves eight elements of thought. Critical thinking involves trying to figure out something; a problem, an issue, the views of another person, a theory or an idea. To figure things out we need to enter into the thinking of the other person and then to comprehend as best we can the structure of their thinking. This also applies to our own thinking as well. When I read an author I'm trying to figure out what the author is saying; what problem or issue the author is addressing, what point of view or frame of reference he is coming from, what the goal or purpose is of this piece of writing, what evidence, data or facts are being used and what theories, concepts, principles or ideas are involved. I want to understand the interpretations and claims the author is making and the assumptions that underlie his thinking. I need to be able to follow the author's lines of formulated thought and the inferences which lead to a particular conclusion. I need to understand the implications and consequences of the author's thinking. As I come to understand the author in-depth I will also begin to recognize the strength and weakness of his reasoning. I will be able to offer my perspective on the subject at hand with a clear understanding of how the author would respond to my ideas on the subject.
The Elements of Thought
All thinking, if it is purposeful, includes the following elements of thought (Paul, 1990).
- The problem, question, concern or issue being discussed or thought about by the thinker. What the thinker is attempting to figure out.
- The purpose or goal of the thinking. Why we are attempting to figure something out and to what end. What do we hope to accomplish.
- The frame of reference, points of view or even world view that we hold about the issue or problem.
- The assumptions that we hold to be true about the issue upon which we base our claims or beliefs.
- The central concepts, ideas, principles and theories that we use in reasoning about the problem.
- The evidence, data or information provided to support the claims we make about the issue or problem.
- The interpretations, inferences, reasoning, and lines of formulated thought that lead to our conclusions.
- The implications and consequences that follow from the positions we hold on the issue or problem.
When nurses reason they use these elements of thought to figure out difficult questions and recognize that their thinking could be flawed or limited by lack of in-depth understanding of the problem at issue therefore, they critically monitor their thinking to ensure that their thinking meets the standards for intellectual thought.
In summary, as a critical thinker, I am able to figure out by reading or listening critically what nurse scholars believe about nursing and on what basis nurses act as they practice nursing. To do this I must clearly comprehend the thinking of another person by figuring out the logic of their thinking. I must comprehend clearly the thinking of myself by figuring out my own thoughts on the subject at hand. Finally, I must use intellectual standards to evaluate my thinking and the thinking of others on a given problem such that I can come to a defensible, well reasoned view of the problem and therefore, know what to believe or do in a given circumstance. To do this I must be committed to developing my mind as a self-directed, independent critical thinker. I must value above all else the intellectual traits and habits of thought that critical thinkers possess.
Intellectual Traits and Habits of Thought
To develop as a critical thinker one must be motivated to develop the attitudes and dispositions of a fair-minded thinker. That is, one must be willing to suspend judgments until one truly understands another point of view and can articulate the position that another person holds on an issue. Nurses come to reasoned judgments so that they can act competently in practice. They continually monitor their thinking; questioning and reflecting on the quality of thinking occurring in how they reason about nursing practice. Sloppy, superficial thinking leads to poor practice.
Critical inquiry is an important quality for safe practice. Nurses must pose questions about practice and be willing to attempt to seek answers about practice. Nurses must be willing to attempt to seek answers to the difficult questions inherent in practice, as well as the obvious. Question posing presupposes intellectual humility and a willingness to admit to one's areas of ignorance as well as, intellectual curiosity and perseverance and willingness to seek answers. Critical thinkers in nursing are truth seekers and demonstrate open-mindedness and tolerance for others' views with constant sensitivity to the possibility of their own bias.
Nurse's who are critical thinkers value intellectually challenging situations and are self-confident in their well reasoned thoughts. To reason effectively, nurses have developed skills and abilities essential for sound reasoning.
Critical Thinking Skills and Abilities
Critical thinkers in nursing are skilful in applying intellectual skills for sound reasoning. These skills have been defined as information gathering, focusing, remembering, organizing, analyzing, generating, integrating and evaluating (Registered Nurse's Association of British Columbia, 1990). The focus of classroom and clinical activities is to develop the nurse's understanding of scholarly, academic work through the effective use of intellectual abilities and skills. As you encounter increasingly more complex practice situations you will be required to think through and reason about nursing in greater depth and draw on deeper, more sophisticated comprehension of what it means to be a nurse in clinical practice. Nursing is never a superficial, meaningless activity. All acts in nursing are deeply significant and require of the nurse a mind fully engaged in the practice of nursing. This is the challenge of nursing; critical, reflective practice based on the sound reasoning of intelligent minds committed to safe, effective client care.
To accomplish this goal, students will be required to reason about nursing by reading, writing, listening and speaking critically. By doing so you will be thinking critically about nursing and ensuring that you gain in-depth knowledge about nursing as a practice profession.
Critical Thinking...a Holistic Approach
Critical Listening: A mode of monitoring how we are listening so as to maximize our accurate understanding of what another person is saying. By understanding the logic of human communication - that everything spoken expresses point of view, uses some ideas and not others, has implications, etc., critical thinkers can listen so as to enter empathetically and analytically into the perspective of others.
Critical Thinking: 1) Disciplined, self-directed thinking which implies the perfection of thinking appropriate to a particular mode or domain of thinking. 2) Thinking that displays master of intellectual skills and abilities. 3) The art of thinking about your thinking while you are thinking in order to make your thinking better: more clear, more accurate, or more defensible.
Critical Writing: To express oneself in languages required that one arrange ideas in some relationships to each other. When accuracy and truth are at issue, then we must understand what our thesis is, how we can support it, how we can elaborate it to make it intelligible to others, what objections can be raised to it from other points of view, what the limitations are to our point of view, and so forth. Disciplined writing requires disciplined thinking; disciplined thinking is achieved through disciplined writing.
Critical Reading: Critical reading is an active, intellectually engaged process in which the reader participates in an inner dialogue with the writer. Most people read uncritically and so miss some part of what is expressed while distorting other parts. A critical reader realizes the way in which reading, by its very nature, means entering into a point of view other than our own, the point of view of the writer. A critical reader actively looks for assumptions, key concepts and ideas, reasons and justifications, supporting examples, parallel experiences, implications and consequences, and any other structural features of the written text to interpret and assess it accurately and fairly. ( Paul, 1990, pp 554 & 545 )
Critical Speaking: Critical speaking is an active process of expressing verbally a point of view, ideas and thoughts such that others attain an in-depth understanding of the speaker's personal perspective on an issue. Monitoring how we express ourselves verbally will ensure that we maximize accurate understanding of what we mean through active dialogue and openness to feedback on our views. (Heaslip, 1993).
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