Textbook of Medical-Surgical Nursing 3e

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Chapter 2   Thoughtful practice

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 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. has not occurred. Intuitive thinking

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).