Fundamentals of Nursing and Midwifery 2e

Unit III Thoughtful practice and the process of care

260

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 • 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 BOX 14-4 Critical thinking

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

Source: Paul & Elder, 2010.