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Critical Thinking and Clinical Decision Making
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OBJECTIVES
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Define Critical Thinking.
List ways in which nurses can develop critical thinking
skills.
Identify how nurses apply critical thinking to clinical
decision making in nursing practice.
Define Nursing Process.
Identify the steps and characteristics of the Nursing
Process.
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Critical Thinking
• Definition:
• “…in nursing practice is a discipline
specific, reflective reasoning process
that guides a nurse in generating,
implementing, & evaluating
approaches for dealing with client care
& professional concerns”.
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Critical Thinking
• A thinking process that allows the nurse to
make better decisions based on
organization, purpose, discipline and data
collection rather than on random, undirected
data collection
• Used by nurses to solve client problems
and make better decisions
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Critical Thinking
• Higher level reasoning process
• Delineated by:
• Individual’s world view
• Knowledge
• Experiences and skills
• Attitudes
• Rational judgment and action
• Component of accountability and quality nursing care
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How Do Nurses Use Critical Thinking?
1.
Nurses use knowledge from other
subject areas, to enhance skills and
patient care knowledge, e.g.:
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Anatomy
Nutrition
Microbiology
Human Growth & Development
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How Do Nurses Use Critical Thinking?
2.
Nurses cope with constant change in
stressful environments
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Advances in Technology
New Medication
Changes in Clinical Procedures
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How Do Nurses Use Critical Thinking?
3.
Nurses make significant decisions that can
have a profound impact on the patient
• When do I & When don’t I call the
physician?
• When do I report findings to my
supervisor?
• Is this task within my scope of practice
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Creativity in Critical Thinking
• Creativity is a major component of critical
thinking
• Creativity is needed for the development of
new ideas & products
• Creativity is required when new situations
arise & traditional interventions are
ineffective
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Critical Thinking
• Involves the use of:
• Clinical reasoning
• Clinical decision making
• Results in:
• Safe and effective nursing practice
• Decreased errors in clinical judgment
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Critical Thinking Skills
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Critical analysis
Inductive reasoning
Deductive reasoning
Making valid inferences
Differentiating facts from opinions
Evaluating the credibility of information sources
Clarifying concepts
Recognizing assumptions
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How Can Nurses Develop Critical
Thinking Skills?
Critical Analysis:
• apply a set of questions to a particular
situation
• determine essential information and
discard the rest
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How Can Nurses Develop Critical
Thinking Skills?
Inductive Reasoning:
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Generalizations are formed from a set of
facts or observations.
Observations:
• Dry Skin
• Sunken eyes
• Dark urine
What is the problem?
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How Can Nurses Develop Critical
Thinking Skills?
Deductive Reasoning:
• Reasoning from the general to the specific.
• Use critical thinking to determine which premise
is valid.
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How Can Nurses Develop Critical
Thinking Skills?
Always:
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Differentiate fact from fiction
Clarify information
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Alfaro-LeFevre’s 4 Circle Critical
Thinking Model.
CT
Characteristics
Attitudes and
Behaviors
Technical Skills
Critical
Thinking
Ability
Theoretical & Experiential
Knowledge, Technical
skills
And competencies
Interpersonal Skills
and Competencies
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Critical Thinking Attitudes
It is not enough to simply know the patient’s
problem:
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What are it’s complications?
What pathophysiology is involved?
What are the reasons behind the
medications given / diagnostic studies done /
or interventions carried out?
What is the purpose of policies / procedures
that may apply?
What ethical / legal principles may apply?
What are the spiritual / cultural concerns?
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Critical Thinking Attitudes
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Independence
Fair-mindedness
Insight
Intellectual humility
Intellectual courage
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Integrity
Perseverance
Confidence
Curiosity
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Attitudes of Critical Thinkers
1.
2.
3.
Independence of thought:
• Considers a wide range of ideas
• Makes own judgments
• Open-minded
Fair-mindedness:
• Considers opposing viewpoints
• Listens to opinions of others
Intellectual courage:
• Recognizes that beliefs are sometimes false
and misleading
• True to newly acquired beliefs
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Attitudes of Critical Thinkers
4.
5.
6.
Integrity:
• Applies the same standards of proof to their
own knowledge and beliefs as they do with
others
• Maintaining double standards is unfair and
potentially illegal
Perseverance:
• Persistently seeks effective solutions
• Realizes that there are often no quick and
easy answers
Insight into Egocentricity:
• Examines own biases
• Assess client’s background & beliefs
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Attitudes of Critical Thinkers
7.
8.
9.
Confidence:
• Skill in both inductive reasoning & deductive
reasoning
• Not afraid of disagreement. Serve as role
model to others.
Curiosity:
• Seeks out reasons and explanations
• WANTS to learn more
Intellectual Humility:
• Admit when they don’t know
• Explores new information & rethink their
conclusions.
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Critical Thinking Intellectual Skills
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Assesses systematically and
comprehensively (What am I seeing and
what else could it be?)
Recognizes assumptions and
inconsistencies
Checks accuracy and reliability
Identifies missing information
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Critical Thinking Intellectual Skills
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Distinguishes between what is relevant and what
is not
Supports conclusions with facts
Sets priorities and makes decisions in a timely
manner
Determines outcomes specific to each patient
Re-assesses to determine patient responses to
nursing actions
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Appling Critical Thinking to Nursing
Practice
• Critical thinking underlies each step of the nursing
process – a systematic plan for providing
individualized care.
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Decision-Making Process
• Choosing the best actions to meet a desired goal
• Identify purpose
• Set and weigh criteria
• Seek and examine alternatives
• Project, implement, and evaluate outcome
• Use Maslow’s hierarchy of needs
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Nursing Process
• Nurses are responsible for a unique dimension of health
care:
“the diagnosis and treatment of human
responses” to actual or potential health
problems”
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Nursing Process
• Maslow’s Hierarchy of needs:
Self-Actualization
Self-esteem
Loved and belonging
Safety and security
Physiologic
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Maslow’s Hierarchy of Needs
• Physiological:
• Respiration
• Circulation
• Hydration
• Nutrition
• Elimination
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Maslow’s Hierarchy of Needs
• Safety and Security:
• Hazard free environment
• Social rules and laws
• Clothing
• Protection
• Love and Belonging:
• Affection
• Relationships with friends/family/peers
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Maslow’s Hierarchy of Needs
• Self-esteem:
• Respect from peers
• Feeling competent
• Self-worth and self-approval
• Self-actualization:
• Lower level needs have been met
• Content with self and environment
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Characteristics of the Nursing
Process
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The Nursing Process
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Question
A client with diarrhea also has a physician’s
order for a bulk laxative daily. The nurse, not
realizing that bulk laxatives can help solidify
certain types of diarrhea, concludes “The
physician does not know the client has
diarrhea.” This statement is an example of:
1.
2.
3.
4.
A fact.
An inference.
A judgment.
An opinion.
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Answer & Rationale
1.
2.
3.
4.
Incorrect. The prescription and the diarrhea are facts.
Correct. The nurse has inferred and concluded
something that is beyond the available information (and
in this case may not be accurate).
Incorrect. It would be judgment and opinion if the nurse
stated that the laxative would make the diarrhea worse
and should not be given.
Incorrect. It would be judgment and opinion if the nurse
stated that the laxative would make the diarrhea worse
and should not be given.
(Note: Critical thinking will cause this nurse to examine
the assumptions made and gather more data before
acting.)
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Question
1.
2.
3.
4.
A client reports feeling hungry, but does not eat
when food is served. Using critical-thinking
skills, the nurse should perform which of the
following?
Assess why the client is not ingesting the food
provided.
Continue to leave the food at the beside until the
client is hungry enough to eat.
Notify the primary care provider that tube
feeding may be indicated soon.
Believe the client is not really hungry.
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Answer & Rationale
1.
2.
3.
4.
Correct. The nurse recognizes that many
assumptions (beliefs) could interfere with the client
eating—such as that the food presented is not
culturally appropriate. These assumptions must be
clarified.
Incorrect. Option 2 reaches conclusions not supported
by the facts.
Incorrect. Option 3 reaches conclusions not supported
by the facts.
Incorrect. In option 4, the nurse has made a judgment
or has an opinion that may not be accurate. Also, the
nurse is acting without assessment. Implementation
should be preceded by assessment.
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Question
1.
2.
3.
4.
In the diagnostic statement “Excess fluid volume
related to decreased venous return as
manifested by lower extremity edema
(swelling),” the etiology of the problem is which
of the following?
Excess fluid volume.
Decreased venous return.
Edema.
Unknown.
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Answer & Rationale
1. Incorrect. Excess Fluid Volume is the nursing
diagnosis.
2. Correct. Because the venous return is
impaired, fluid is static, resulting in swelling.
Therefore, decreased venous return is the
cause (etiology) of the problem.
3. Incorrect. Edema of the lower extremity is the
sign/symptom or critical attribute.
4. Incorrect. The cause is known.
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Question
Under what circumstances is it considered acceptable
practice for the nurse to document a nursing activity
before it is carried out?
1.
2.
3.
4.
When the activity is routine (e.g., raising the bed rails)
When the activity occurs at regular intervals (e.g.,
turning the client in bed)
When the activity is to be carried out immediately (e.g., a
stat medication)
It is never acceptable
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Answer & Rationale
1.
2.
3.
4.
Incorrect.
Incorrect.
Incorrect.
Correct. It is never acceptable practice for the nurse to
document a nursing activity before it is carried out.
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