Chapter 2
Thoughtful practice
17
of experience. Beginning clinicians must use their scientific
problem-solving skills as the basis of the care they give because
intuitive problem solving ability comes only through years of
practice and observation. The use of intuition can often move
problem solving forward quickly, however, it can also result
in a trial-and-error approach and it does not necessarily foster
creative ways of solving problems. For this reason, care should
be taken when choosing the most appropriate problem-solving
approach to be used in any given situation.
Of course problem solving in practice does not always occur
in a linear fashion, as practice is complex and messy. Problem
solving is often cyclical in nature: once you have completed
the process, you often go back to the beginning and repeat
the process until the problem has been resolved. In addition,
problems often overlap in any given situation, so problem
solving may occur in concurrent cycles. The constituent parts
of clinical reasoning are discussed in the following section.
Critical thinking
The cognitive component for clinical reasoning is critical
thinking, which is a mental process or set of procedures that is
purposeful and systematic, rational and outcome-directed. Like
problem solving, it is based on a body of knowledge, as well
as an analysis of all available information and ideas. Critical
thinking leads to the formulation of conclusions and the most
appropriate alternatives for patient care. High-levels of critical
thinking within the
nursing process
are necessity for contem-
porary healthcare environments.
Critical thinking and critical thinkers have distinctive
characteristics. As indicated in the above definition, critical
thinking is a conscious, outcome-oriented activity; it is pur-
poseful and intentional. The critical thinker is an inquisitive,
fair-minded truth-seeker with an open mind to the alternative
solutions that might surface (Alfaro-LeFevre, 2011).
Components of critical thinking
Skills needed in critical thinking include interpretation,
analysis, evaluation, inference, explanation, and self-regulation
(Levett-Jones et al., 2010). The critical thinker uses real-
ity-based deliberation based on knowledge to validate the
accuracy of data and the reliability of sources, being mindful
of and questioning inconsistencies. Interpretation is used
to determine the significance of data that are gathered, and
analysis is used to identify patient problems indicated by
the data and inference to draw conclusions. Explanation is
the justification of actions or interventions used to address
patient problems and to help a patient move towards desired
outcomes. Evaluation is the process of determining whether
outcomes have been or are being met, and self-regulation is
the process of examining the care provided and adjusting the
interventions as needed (Banning, 2008).
Critical thinking also includes metacognition, the exami
nation of one’s own reasoning or thought processes while
thinking (through reflection), to help strengthen and refine
thinking skills (Wilkinson, 2007). The critical thinker consid-
ers the possibility of personal bias when interpreting data and
determining appropriate actions. The critical reflective thinker
must be insightful and have a sense of fairness and integrity,
the courage to question personal ethics, and the perseverance
to strive continuously to minimise the effects of egocentricity,
ethnocentricity, and other biases on the decision-making
process (Alfaro-LeFevre, 2011).
Creative thinking
Critical thinking is not simply a cognitive process, based on
logical thinking alone but also involves reflection and
creative
thinking
, which belongs to the affective domain. Creative
thinking involves imagination, intuition and spontaneity,
and complements scientific thinking for innovative problem
solving in clinical practice (Karadag˘, Saritas & Erginer, 2009).
Creative thinking is most beneficial when conventional solu-
tions have not resolved a situation, or when a desired change
has not occurred.
Intuitive thinking
Critical thinking leading to decision making differs between
various levels of clinicians according to their experience.
Intuitive thinking
, subconsciously drawing on knowledge
gained through experience,
is also sometimes described as a
‘hunch’ or a ‘gut feeling,’ but actually this kind of knowledge
is based on a memory of the cue patterns of the patients
that have previously been cared for (Buckingham & Adams,
2000b). This takes time and explains how expertise is slow to
develop.
Critical thinking in nursing practice
Critical thinking in nursing practice results in a comprehen-
sive patient plan of care with maximised potential for success.
Using critical thinking to develop a plan of nursing care
requires considering the human factors that might influence
the plan. The nurse interacts with the patient, family, and
other healthcare providers in the process of providing appro-
priate, person-centred nursing care. The culture, attitude and
thought processes of the nurse, the patient and others will
affect the critical thinking process from the data-gathering
stage through the decision-making stage; therefore, aspects of
the nurse–patient interaction must be considered (Wilkinson,
2007). Nurses must use critical thinking skills in all practice
settings—acute care, ambulatory care, extended care, and in
the home and community.
In decision making related to the nursing process, nurses
use intellectual skills in critical thinking. These skills include
systematic and comprehensive
assessment
, recognition of
assumptions and inconsistencies, verification of reliability and
accuracy, identification of missing information, distinguishing
relevant from irrelevant information, support of the evidence
with facts and conclusions, priority setting with timely decision
making, determination of patient specific outcomes, and reas-
sessment of responses and outcomes (Alfaro-LeFevre, 2011).
For example, nurses use critical thinking and decision-making
skills in providing genetics-related nursing care when they,
through reflection on practice:
•
Assess and analyse family history data for genetic risk
factors.
•
Identify those individuals and families in need of referral
for genetic testing or counselling.
•
Ensure the privacy and confidentiality of genetic
information.
Throughout this text, there are icons that direct the reader
to the ancillaries where there are Genetics in Nursing Practice
charts that will assist this process.
To depict the process of ‘thinking like a nurse,’ Tanner
(2006) developed a model known as the clinical judgement
model. This model supports the idea that nurses engage in a
complex process of clinical reasoning when caring for patients.
