no added benefit. For example, our intuition might direct us
towards allowing a patient to rest in bed after surgery,
because rest aids recovery. However, drawing on the evi-
dence base available to us, we become aware that supporting
the patient to get out of bed as soon as possible after surgery
reduces the risk for deep vein thrombosis or pneumonia, and
increases the speed of the person’s recovery. For these
reasons, care should be taken when choosing intuitive
problem solving as the most appropriate approach in any
given situation.
Critical thinking
Thoughtful practice should not become automatic or ritu-
alised, with actions that occur without the processes of
critical thinking.
Critical thinking
is a generic skill that can
be applied to any situation: the skill of critical thinking is
common to all disciplines (De Young, 2008; Scheffer &
Rubenfeld, 2000). People use critical thinking skills when-
ever they need to use clear, focused thinking to achieve a
result. For example, you might think critically about how to
approach the challenges that arise on a clinical placement,
how to solve a puzzle, how to manage your budget or how
to pass your next exam.
There are, however, many different definitions of critical
thinking. For example, Paul (1993, p. 20) defines it as a
‘systematic way to form and shape one’s thinking. It func-
tions purposefully and exactly. It is thought that is
disciplined, comprehensive, based on intellectual standards
and as a result, well reasoned’. Although the definitions
differ, there is general agreement on the constituent charac-
teristics of critical thinking, as outlined in Box 14-4.
Critical thinking is also the basis of decision making in pro-
fessional practice. Applying the definition to nursing, critical
thinking is described as the ‘thought process underlying deci-
sions and judgements made about clients under the nurse’s
care’ (Oermann, 1997, p. 25). When critical thinking is applied
to clinical reasoning and judgement in the practice context,
it entails purposeful, informed, outcome-focused (results-
oriented) thinking that requires careful identification of the key
problems, issues and risks involved (Alfaro-LeFevre, 2012). It
Unit III Thoughtful practice and the process of care
260
is further enhanced by reflective thinking that in turn further
improves critical thought (Yildirim & Ozkahraman, 2011).
Critical thinking can be described according to the steps
involved in the process. Table 14-2 explains the steps used
in a critical thinking activity.
Like problem solving, critical thinking activities are
dynamic, and the thinker can combine steps or move back-
wards or forwards. The final two steps in the critical thinking
activity shown in Table 14-2 are dependent on
reflection
; as
discussed in Chapter 13, there is a strong link between criti-
cal thinking and reflection. Combining critical thinking and
reflection enables you to go beyond a surface approach to
thinking, not only uncovering what knowledge you have (or
do not have) about a given situation, but also challenging the
assumptions and beliefs you hold about the situation. Through
reflective practice, students and clinicians can improve their
critical thinking abilities. The case study outlined in the
Research in practice box on page 262 provides an example of
this nexus between critical thinking and reflection.
A strong foundation in critical thinking enables students
and clinicians who find themselves in a new area of practice
(such as beginning work in a new ward or looking after a
patient with an unfamiliar illness) to employ a variety of
aspects of thinking, including both intuition and logic. This
allows them to develop actions based on their previous expe-
riences. Through reflection, we can draw on a variety of past
experiences (our evidence base) and look for similarities and
differences to aid contemplation about future actions.
Creative thinking
Critical thinking is not purely a cognitive process, but also
draws on the compassion and respect for others held by clini-
cians. A model of thinking based on logical or critical
thinking alone does not allow for the influences of the context
in which the thinking is taking place or of the attributes of the
thinker (Seymour, Kinn & Sutherland, 2003). Critical think-
ing also involves reflection and creative thinking, which
belong to the affective domain.
Creative thinking
involves
imagination, intuition and spontaneity, factors which under-
pin the art of nursing, as discussed in Chapter 9. Seymour,
Kinn and Sutherland (2003) maintain that the skilled
critical thinker who is a nurse or midwife incorporates both
scientific thinking and creative thinking in clinical practice.
Creative thinking is most beneficial when conventional solu-
tions have not resolved a situation, or when a desired change
has not occurred (Simpson & Courtney, 2003).
Clinicians who use the principles of person-centred care
to develop clinical reasoning skills that include both critical
and creative thinking are able to ‘imagine possible conse-
quences, generating original approaches and identifying
alternative perspectives’ (Chabelli, 2006, p. 82). Creative
thinking can lead to new insights, perspective and alternative
approaches (Facione, 2013). It can be simple and practical,
and may be applied to any unresolved patient need. This may
be demonstrated in the example of a patient who needed his
arm to be permanently elevated to reduce swelling. The
BOX 14-4 Critical thinking
•
Has a purpose
•
Is an attempt to figure something out, to settle
some question, to solve some problem
•
Is based on assumptions
•
Is based on data, information and evidence
•
Is done from some point of view expressed through,
and shaped by, concepts and ideas
•
Contains inferences or interpretations by which we
give meaning to data
•
Leads somewhere, or has implications and
consequences
Source: Paul & Elder, 2010.
