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Nursing Critical Thinking and Clinical Reasoning, Exercises of Nursing

Personal Critical Thinking Indicators:Behaviors,Attitude,Characteristics and Components of Clinica Reasoning. The exercise on critical thinking is given in end.

Typology: Exercises

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# 153613 Cust: Pearson Au: Berman Pg. No. 144
Title: Kozier & Erb’s Fundamentals of Nursing 10e C/M/Y/K
Short / Normal
DESIGN SERVICES OF
S4CARLISLE
Publishing Services
144
10 Critical Thinking and Clinical Reasoning
INTRODUCTION
The term “thinking like a nurse” was introduced by Dr. Christine
Tanner in 2006. To think like a nurse, critical thinking and clinical
reasoning must be defined and understood. This chapter examines
the influence of critical thinking and clinical reasoning on the care of
clients. Both these terms describe the mental processes nurses use to
ensure that they are doing their best thinking and decision making.
The practice of nursing requires critical thinking and clinical
reasoning. Critical thinking is the process of intentional higher level
thinking to define a client’s problem, examine the evidence-based
practice in caring for the client, and make choices in the delivery of
care. Clinical reasoning is the cognitive process that uses thinking
strategies to gather and analyze client information, evaluate the rel-
evance of the information, and decide on possible nursing actions to
improve the clients physiological and psychosocial outcomes. Clini-
cal reasoning requires the integration of critical thinking in the iden-
tification of the most appropriate interventions that will improve the
client’s condition. The concept of clinical reasoning “evolved from
the application of decision-making to the health care professions
(Simmons, 2010, p. 1153). “Clinical reasoning also guides nurses in
assessing, assimilating, retrieving, and/or discarding components of
information that affect patient care” (p. 1151). Clinical reasoning is
often defined in practice-based disciplines, such as nursing and med-
icine, as the “application of critical thinking to the clinical situation”
(Victor-Chmil, 2013, p. 35).
PURPOSE OF CRITICAL THINKING
Critical thinking involves the differentiation of statements of fact,
judgment, and opinion. The process of critical thinking requires
the nurse to think creatively, use reflection, and engage in analytical
thinking (Alfaro-LeFevre, 2013). Alfaro-LeFevres 4-Circle Critical
Thinking Model provides a visual representation of critical think-
ing abilities and promotes making meaningful connections between
nursing research and critical thinking and practice (Figure 10–1 ).
Critical thinking is an essential skill needed for the identification of
client problems and the implementation of interventions to promote
effective care outcomes (Bittencourt & Crossetti, 2012). The process
of providing feedback and reflection is vital to the improvement of
nursing practice. A study by Asselin (2011) revealed that students
who reflected on new knowledge developed new insights regarding
practice. The insights nurses acquired led to changes in their ap-
proach to practice.
According to Scheffer and Rubenfeld (2010), critical thinking
is a metaphorical bridge between information and action. Criti-
cal thinking in nursing involves habits of the mind and requires the
implementation of cognitive skills. In 2000, Scheffer and Ruben-
feld conducted a landmark study in which internationally diverse
expert nurses from nine countries defined ten habits of the mind
(affective components) and seven skills (cognitive components) of
critical thinking in nursing. The ten affective components are con-
fidence, contextual perspective, creativity, flexibility, inquisitiveness,
intellectual integrity, intuition, open-mindedness, perseverance, and
reflection. The seven skills are analyzing, applying standards, dis-
criminating, information seeking, logical reasoning, predicting, and
transforming knowledge. Lunney (2010) used the affective and cog-
nitive components to demonstrate the use of critical thinking in the
diagnostic process and the identification of an accurate nursing di-
agnosis. The study indicated that nurses need to utilize all 17 critical
thinking concepts in the identification of nursing diagnoses.
Nurses use critical thinking skills in a variety of ways:
Nurses use knowledge from other subjects and fields. Nurses use
critical thinking skills when they reflect on knowledge derived
LEARNING OUTCOMES
After completing this chapter, you will be able to:
1. Describe the significance of developing critical thinking abili-
ties in order to practice safe, effective, and professional nurs-
ing care.
2. Describe the actions of clinical reasoning in the implementa-
tion of the nursing process.
3. Discuss the attitudes and skills needed to develop critical
thinking and clinical reasoning.
KEY TERMS
clinical judgment, 147
clinical reasoning, 144
cognitive processes, 149
concept mapping, 151
creativity, 145
critical analysis, 145
critical thinking, 144
deductive reasoning, 146
inductive reasoning, 146
intuition, 147
metacognitive processes, 149
nursing process, 147
problem solving, 147
Socratic questioning, 146
trial and error, 147
4. Describe the components of clinical reasoning.
5. Integrate strategies to enhance critical thinking and clinical
reasoning as the provider of nursing care.
6. Describe the process of concept mapping to enhance
critical thinking and clinical reasoning for the provision of
nursing care.
M10B_BERM4362_10_SE_CH10.indd 144 25/11/14 1:09 PM
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10 Critical Thinking and Clinical Reasoning

INTRODUCTION

The term “thinking like a nurse” was introduced by Dr. Christine Tanner in 2006. To think like a nurse, critical thinking and clinical reasoning must be defined and understood. This chapter examines the influence of critical thinking and clinical reasoning on the care of clients. Both these terms describe the mental processes nurses use to ensure that they are doing their best thinking and decision making. The practice of nursing requires critical thinking and clinical reasoning. Critical thinking is the process of intentional higher level thinking to define a client’s problem, examine the evidence-based practice in caring for the client, and make choices in the delivery of care. Clinical reasoning is the cognitive process that uses thinking strategies to gather and analyze client information, evaluate the rel- evance of the information, and decide on possible nursing actions to improve the client’s physiological and psychosocial outcomes. Clini- cal reasoning requires the integration of critical thinking in the iden- tification of the most appropriate interventions that will improve the client’s condition. The concept of clinical reasoning “evolved from the application of decision-making to the health care professions” (Simmons, 2010, p. 1153). “Clinical reasoning also guides nurses in assessing, assimilating, retrieving, and/or discarding components of information that affect patient care” (p. 1151). Clinical reasoning is often defined in practice-based disciplines, such as nursing and med- icine, as the “application of critical thinking to the clinical situation” (Victor-Chmil, 2013, p. 35).

PURPOSE OF CRITICAL THINKING

Critical thinking involves the differentiation of statements of fact, judgment, and opinion. The process of critical thinking requires the nurse to think creatively, use reflection, and engage in analytical thinking (Alfaro-LeFevre, 2013). Alfaro-LeFevre’s 4-Circle Critical

Thinking Model provides a visual representation of critical think- ing abilities and promotes making meaningful connections between nursing research and critical thinking and practice (Figure 10–1 • ). Critical thinking is an essential skill needed for the identification of client problems and the implementation of interventions to promote effective care outcomes (Bittencourt & Crossetti, 2012). The process of providing feedback and reflection is vital to the improvement of nursing practice. A study by Asselin (2011) revealed that students who reflected on new knowledge developed new insights regarding practice. The insights nurses acquired led to changes in their ap- proach to practice. According to Scheffer and Rubenfeld (2010), critical thinking is a metaphorical bridge between information and action. Criti- cal thinking in nursing involves habits of the mind and requires the implementation of cognitive skills. In 2000, Scheffer and Ruben- feld conducted a landmark study in which internationally diverse expert nurses from nine countries defined ten habits of the mind (affective components) and seven skills (cognitive components) of critical thinking in nursing. The ten affective components are con- fidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. The seven skills are analyzing, applying standards, dis- criminating, information seeking, logical reasoning, predicting, and transforming knowledge. Lunney (2010) used the affective and cog- nitive components to demonstrate the use of critical thinking in the diagnostic process and the identification of an accurate nursing di- agnosis. The study indicated that nurses need to utilize all 17 critical thinking concepts in the identification of nursing diagnoses. Nurses use critical thinking skills in a variety of ways:

  • (^) Nurses use knowledge from other subjects and fields. Nurses use critical thinking skills when they reflect on knowledge derived
LEARNING OUTCOMES

After completing this chapter, you will be able to:

  1. Describe the significance of developing critical thinking abili- ties in order to practice safe, effective, and professional nurs- ing care.
  2. Describe the actions of clinical reasoning in the implementa- tion of the nursing process.
  3. Discuss the attitudes and skills needed to develop critical thinking and clinical reasoning.
KEY TERMS

clinical judgment, 147 clinical reasoning, 144 cognitive processes, 149 concept mapping, 151

creativity, 145 critical analysis, 145 critical thinking, 144 deductive reasoning, 146

inductive reasoning, 146 intuition, 147 metacognitive processes, 149 nursing process, 147

problem solving, 147 Socratic questioning, 146 trial and error, 147

  1. Describe the components of clinical reasoning.
  2. Integrate strategies to enhance critical thinking and clinical reasoning as the provider of nursing care.
  3. Describe the process of concept mapping to enhance critical thinking and clinical reasoning for the provision of nursing care.

Chapter 10 •^ Critical Thinking and Clinical Reasoning 145

Figure 10–1 •^ Alfaro-LeFevre’s 4-Circle Critical Thinking Model. Adapted with permission from Critical Thinking Indicators (CTIs): 2014 Evidence-Based Version, by R. Alfaro-LeFevre, 2014. Retrieved from http://www.alfaroteachsmart.com/2014CTIrichJan.pdf.

Theoretical & Experiential Knowledge Intellectual Skills / Competencies

CT Characteristics (Attitudes / Behaviors)

Technical Skills / Competencies

Starting at the top and going clockwise around the circles above, here’s what you need to do to develop your ability to think critically.

  1. Develop a critical thinking character. Hold yourself to high standards. Make a commitment to developing critical thinking characteristics such as; honesty, fair-mindedness, creativity, patience, and confidence.
  2. Take responsibility and seek out learning experiences to help you get the theoretical and experiential knowledge to think critically. Practice intellectual skills such as assessing systematically and comprehensively. Just as practicing physical skills improves your ability to perform physically, practicing thinking skills improves your ability to perform intellectually.
  3. Gain interpersonal skills such as teamwork, resolving conflict, and being an advocate. Keep in mind that “being too nice” problems (e.g., not giving constructive criticism because of concerns of not offending someone) can be as bad as “not being very nice” problems (e.g., demonstrating arrogance, sarcasm, and or intolerance of other ways of doing things). Learn how to give and take feedback. To improve you must get through the negative aspects of criticism.
  4. Practice related technical skills (e.g., using computers, managing IV’s). Until these skills become like second natures, they create a “brain drain” making it difficult to focus on other important things such as monitoring patient responses to care.

Interpersonal Skills / Competencies

Critical Thinking Ability

from other interdisciplinary subject areas such as the biophysi- cal and behavioral sciences and the humanities in order to pro- vide holistic nursing care. For example, when providing care to a client at the end of life, it is important to have knowledge of culture and religion to enhance the delivery of culturally sensi- tive care and enhance the client’s spiritual well-being to promote a good death.

  • (^) Nurses deal with change in stressful environments. A client’s condition may rapidly change and routine protocol may not be adequate to cover every unexpected situation. Critical thinking enables the nurse to recognize important cues, re- spond quickly, and adapt interventions to meet specific client needs at the right time. Box 10–1 lists some personal critical thinking indicators.
  • (^) Nurses make important decisions. Every day, and every moment during the day, nurses use critical thinking skills and clinical rea- soning to make judgments about a client’s care. For example, de- termining which observations must be reported to the primary

care provider immediately and which can be noted in the electronic medical record for later consulta- tion with the primary care provider requires critical thinking. Also clients have different health needs simultaneously. For example, a client who is experi- encing an acute asthma attack with air hunger will also experience anxiety. The nurse must administer a medication to improve breathing before addressing the client’s anxiety. Critical thinking cognitively fuels the intellectual artistic activity of creativity. When nurses incorporate creativity, they are able to find unique solutions to unique problems. Creativity is thinking that results in the de- velopment of new ideas and products. Creativity in prob- lem solving and decision making is the ability to develop and implement new and better solutions for health care outcomes. Creativity is required when the nurse encounters a new situation or a client situation in which traditional interventions are not effective. Creative thinkers must assess a problem and be knowledgeable about the un- derlying facts and principles that apply. An example would be a 4-year-old child who has sustained a severe burn and has been discharged from the hospital. The home care nurse has orders to soak and cleanse the wound in the bathtub. After arriving at the child’s home, the nurse determines the family does not have hot water service due to an inability to pay the gas bill. The nurse warms water on the electric stove so the wound can be cleansed in the bathtub as ordered by the primary care provider. Next the nurse contacts the social worker to help the family obtain financial assistance so the gas bill can be paid and the hot water restored. In this clinical scenario the nurse has utilized cre- ativity by warming the water on the stove. The nurse has also utilized knowledge of the role the social worker plays in providing care to the child and family. The use of creativity provides the nurse with the ability to:

  • Generate many ideas rapidly.
  • Be generally flexible and natural; that is, able to change viewpoints or directions in thinking rapidly and easily.
  • Create original solutions to problems.
  • Be independent and self confident, even when under pressure.
  • Demonstrate individuality.

TECHNIQUES IN

CRITICAL THINKING

In addition to the ten affective and seven cognitive components of critical thinking, the nurse uses other techniques to ensure effective problem solving and decision making. These techniques include critical analysis, inductive and deductive reasoning, making valid inferences, differentiating facts from opinions, evaluating the cred- ibility of information sources, clarifying concepts, and recognizing assumptions. Critical analysis is the application of a set of questions to a particular situation or idea to determine essential information and

Chapter 10 •^ Critical Thinking and Clinical Reasoning 147

that the sum of the angles in any triangle is always 180 degrees, you can conclude that the sum of the angles in the triangle you happen to have is also 180 degrees. A nurse might start with a premise that all children love peanut butter sandwiches. Thus, if the nurse is try- ing to encourage a child to eat, then the nurse should offer the child a peanut butter sandwich. This is an example in which the premise is not always valid and, thus, the conclusion also may not be valid. Nurses use critical thinking to help analyze situations and establish which premises are valid. In critical thinking, the nurse also differentiates statements of fact, inference, judgment, and opinion. Table 10–1 shows how these statements may be applied to nursing care. Evaluating the credibil- ity of information sources is an important step in critical thinking. Unfortunately, we cannot always believe what we read or are told. The nurse must ascertain the accuracy of information by checking other documents or with other informants. Hence, the expanding need for evidence-based nursing practice. To comprehend a client situation clearly, the nurse and the client must agree on the mean- ing of terms. For example, if the clients says to the nurse “I think I have a tumor,” the nurse needs to clarify what the word means to the client—the medical definition of a tumor (a solid mass) or the common lay meaning of cancer—before responding. People also live their lives under certain assumptions. Some people view humans as having a basically generous nature, whereas others believe that the human tendency is to act in their own best interest. The nurse may believe that life should be considered worth living no matter what the condition, whereas the client may believe that quality of life is more important than quantity of life. If the nurse and client recog- nize that they make choices based on these assumptions, they can still work together toward an acceptable plan of care. Difficulty arises when people do not take the time to consider what assumptions un- derlie their beliefs and actions.

APPLYING CRITICAL THINKING

TO NURSING PRACTICE

When a nurse uses intentional thinking, a relationship develops among the knowledge, skills, and attitudes that are ascribed to criti- cal thinking and clinical reasoning, the nursing process, and the problem-solving process. Implementation of the nursing process provides nurses with a creative approach to thinking and doing to obtain, categorize, and analyze client data and plan actions that will meet the client’s needs. The nursing process is a systematic, rational method of planning and providing individualized nursing care. It begins with assessment

Statement Description Example Facts Can be verified through investigation Blood pressure is affected by blood volume. Inferences Conclusions drawn from the facts; going beyond facts to make a statement about something not currently known

If blood volume is decreased (e.g., in hemorrhagic shock), the blood pressure will drop. Judgments Evaluation of facts or information that reflects values or other criteria; a type of opinion

It is harmful to the client’s health if the blood pressure drops too low. Opinions Beliefs formed over time; include judgments that may fit facts or be erroneous

Nursing interventions can assist in maintaining the client’s blood pressure within normal limits.

TABLE 10–1 Differentiating Types of Statements

of the client and use of clinical reasoning to identify client problems. The phases of the nursing process are assessing, diagnosing, plan- ning, implementing, and evaluating. These phases are described in detail in Chapters 11 through 14.

Problem Solving

Problem solving is a mental activity in which a problem is identified that represents an unsteady state. It requires the nurse to obtain infor- mation that clarifies the nature of the problem and suggests possible solutions. Throughout the problem-solving process the implementa- tion of critical thought may or may not be required in working toward a solution (Wilkinson, 2012). The nurse carefully evaluates the pos- sible solutions and chooses the best one to implement. The situation is carefully monitored over time to ensure that its initial and continued effectiveness returns the client to a steady state. The nurse does not discard the other solutions, but holds them in reserve in the event that the first solution is not effective. Therefore, problem solving for one situation contributes to the nurse’s body of knowledge for problem solving in similar situations. Commonly used approaches to problem solving include trial and error, intuition, and the research process.

TRIAL AND ERROR

One way to solve problems is through trial and error, in which a number of approaches are tried until a solution is found. However, without considering alternatives systematically, one cannot know why the solution works. The use of trial-and-error methods in nurs- ing care can be dangerous because the client might suffer harm if an approach is inappropriate. However, nurses often use trial and error in the home setting due to logistics, equipment, and client lifestyle. For example, when teaching a client to perform a colostomy irriga- tion, a bent coat hanger hung on the shower curtain rod provides an appropriate height to perform the irrigation. In the hospital setting a lowered intravenous (IV) pole is more likely utilized.

INTUITION

Intuition is a problem-solving approach that relies on a nurse’s in- ner sense. It is a legitimate aspect of a nursing judgment in the imple- mentation of care (Wilkinson, 2012). Intuition is the understanding or learning of things without the conscious use of reasoning. It is also known as sixth sense, hunch, instinct, feeling, or suspicion. As a problem-solving approach, intuition is viewed by some people as a form of guessing and, as such, an inappropriate basis for nursing de- cisions. However, others view intuition as an essential and legitimate aspect of clinical judgment acquired through knowledge and experi- ence. Clinical judgment in nursing is a decision-making process to

148 Unit 3 •^ The Nursing Process

2012). Fair-mindedness helps one to consider opposing points of view and to try to understand new ideas fully before rejecting or ac- cepting them. Critical thinkers strive to be open to the possibility that new evidence could change their minds. The nurse listens to the opinions of all members of a family, young and old. Sometimes the traditional approach will emerge as the most effective strategy, whereas at other times a new and possibly unproven approach should be tried. In every case, the nurse must be able to provide the rationale for any action taken.

Insight into Egocentricity

Critical thinkers are open to the possibility that their personal biases or social pressures and customs could unduly affect their think- ing. They actively try to examine their own biases and bring them to awareness each time they think or make a decision. By failing to reflect on personal biases, the nurse may reach inappropriate conclu- sions for the individual client. For example, a nurse spends extensive time teaching a client who is obese about nutrition and weight loss to prevent recurrence of back pain, but is mystified when the client ap- pears uninterested and does not follow the nurse’s advice. The nurse’s bias of assuming that all clients will incorporate preventive care (just because the nurse would do this) resulted in an inaccurate assess- ment of the client’s motivation; both the nurse’s and the client’s time was wasted. Possibly, the client’s cultural views of weight are differ- ent from those of the nurse. Had the nurse assessed the client’s back- ground and beliefs about weight and collected sufficient evidence, the nurse might have identified a problem more relevant to the client’s priorities and, thus, developed a better care plan.

Intellectual Humility

Intellectual humility means having an awareness of the limits of one’s own knowledge. Critical thinkers are willing to admit what they do not know; they are willing to seek new information and to rethink their conclusions in light of new knowledge. They never assume that what everybody believes to be right will always be right, because new evidence may emerge. A hospital nurse might be unable to imagine how an older adult’s wife will care for her husband who has recently had a stroke. However, the nurse also recognizes that it is not really possible to know what the couple can achieve.

Intellectual Courage to Challenge

the Status Quo and Rituals

With an attitude of courage, a nurse is willing to consider and exam- ine fairly his or her own ideas or views, especially those to which the nurse may have a strongly negative reaction. This type of courage comes from recognizing that beliefs are sometimes false or mislead- ing. Values and beliefs are not always acquired rationally. Rational beliefs are those that have been examined and found to be supported by solid reasons and data. After such examination, it is inevitable that some beliefs previously held to be true will be found to contain questionable elements and that some truth will emerge from ideas considered dangerous or false. Courage is needed to be true to new thinking in such cases, especially if social penalties for nonconfor- mity are severe. For example, many nurses previously believed that allowing family members to observe emergency procedures (such as cardiopulmonary resuscitation) would be psychologically harmful to the family and that members would get in the health care team’s

ascertain the right nursing action to be implemented at the appro- priate time in the client’s care. The nurse must first have the knowl- edge base necessary to practice in the clinical area and then use that knowledge in clinical practice. Clinical experience allows the nurse to recognize cues and patterns and begin to reach correct conclusions. Experience is important in improving intuition because the ra- pidity of the judgment depends on the nurse having seen similar cli- ent situations many times before. Sometimes nurses use the words “I had a feeling” to describe the critical thinking element of considering evidence. These nurses are able to judge quickly which evidence is most important and to act on that limited evidence. Nurses in critical care often pay closer attention than usual to a client when they sense that the client’s condition could change suddenly. Although the intuitive method of problem solving is gaining recognition as part of nursing practice, it is not recommended for novices or students, because they usually lack the knowledge base and clinical experience on which to make a valid judgment.

RESEARCH PROCESS

The research process, discussed in Chapter 2 , is a formalized, logi- cal, systematic approach to problem solving. The classic quantitative research process is most useful when the researcher is working in a controlled situation. Health professionals, often working with people in uncontrolled situations, require a modified approach for solving problems. For example, unlike many experiments with animals in which the environment can be strictly regulated, the effects of diet on health in humans are complicated by a person’s genetic variations, lifestyle, and personal preferences. However, it is becoming increas- ingly important for nurses to identify evidence that supports effective nursing care. One critical source of this evidence is research.

ATTITUDES THAT FOSTER

CRITICAL THINKING

Certain attitudes are crucial to critical thinking. These attitudes are based on the assumption that a rational person is motivated to de- velop, learn, grow, and be concerned with what to do or believe. A critical thinker works to develop the following nine attitudes or traits: independence, fair-mindedness, insight, intellectual humility, intellectual courage, integrity, perseverance, confidence, and curiosity.

Independence

Critical thinking requires that individuals think for themselves. People acquire many beliefs as children, not necessarily based on reason but in order to have an explanation they comprehend. As they mature and acquire knowledge and experience, critical thinkers examine their be- liefs in the light of new evidence. Critical thinkers consider seriously a wide range of ideas, learn from them, and then make their own judg- ments about them. Nurses are open-minded about considering different methods of performing technical skills—not just the single way they may have been taught in school. Nurses should not ignore what other people think, but they should consider a wide range of ideas, learn from them, and then take the time to build their own judgments (Wilkinson, 2012).

Fair-Mindedness

Critical thinkers are fair-minded and make impartial judgments. They assess all viewpoints with the same standards and do not base their judgments on personal or group bias or prejudice (Wilkinson,

150 Unit 3 •^ The Nursing Process

Responding to Changes

in the Client’s Condition

Nurses spend more time with clients than do other health care pro- viders. As a result, an important aspect of nursing practice and the nurse’s responsibility is to detect changes in the client’s condition, recognize a change in priorities, adjust nursing care, and alert the pri- mary care provider when appropriate. Clinical reasoning involves an understanding and assessment of the client’s relevant history and current condition and how it may be changing. By closely monitoring and comparing any changes from previous assessment data, the nurse is able to recognize a change in status that may prevent an adverse outcome.

Reflection

Reflection is a key to the success of clinical reasoning. Through re- flection the nurse identifies factors that improved client care and those that required changing or elimination. It is important to reflect on whether the client was assessed accurately and in a timely man- ner. The nurse thinks back on the interventions implemented and whether they were effective. Most importantly, reflection includes in- formation on the outcome of care. The nurse also reflects on previous clinical experiences similar to this one to determine if the outcomes of care improved the clients’ conditions.

INTEGRATION OF

CRITICAL THINKING

AND CLINICAL REASONING

Nurses use critical thinking and clinical reasoning skills when mak- ing decisions about client care. The decision-making process includes prioritizing care not only with one client but when providing care to many clients. Nurses must make decisions and also assist clients to

Developing Rationales

After assessing the data and determining what is relevant to the client’s condition and concerns, the nurse identifies interventions and sets pri- orities for the most urgent needs (Benner et al., 2010). This is when the nurse transfers nursing knowledge to the clinical situation to justify the plan of care. Nursing students are often asked to explain the “why” of their priority setting and subsequent interventions. Being able to state the rationale, based on nursing knowledge, acts as a check for potential errors, justifies the nurse’s actions, contributes to client safety, and helps the beginning nursing student learn how a nurse thinks in practice.

Learning How to Act

The nurse must know how and when to respond in a clinical situation by recognizing what is most urgent or significant. To take action, the nurse needs to understand the relevant medical and nursing informa- tion and translate this knowledge into a plan of care (Benner et al., 2010). An example is thinking about potential complications given the client’s current problems. Applying this knowledge increases the nurse’s ability to quickly identify assessment data that indicate a po- tential complication. Thus, the nurse can initiate nursing interven- tions or actions quickly because he or she prepared for the possibility. Avoiding potential complications promotes client safety.

Clinical Reasoning-in-Transition

It is important to realize that clinical situations are complex and al- ways changing, especially given the acuity level of clients in today’s hospital settings. Clinical reasoning-in-transition is the ability to recognize subtle changes in a client’s condition over time. It includes the evaluation of nursing interventions and the trending of relevant assessment data. Nurses need to develop a sense of what is most im- portant in each changing clinical situation and remember that the primary focus is on the client’s well-being.

BOX 10–3 Questions to Develop Clinical Reasoning

QUESTIONS TO ASK BEFORE PROVIDING CLIENT CARE

  1. What clinical data from the client’s chart is relevant and must be recognized as significant to the nurse?
  2. What nursing priority will guide the plan of care?
  3. What is the desired client outcome?
  4. What nursing interventions will be initiated based on this priority and desired outcome?
  5. How will the effectiveness of the nursing interventions be evaluated?
  6. What assessment(s) will be focused on based on the client’s primary problem or nursing care priority?

QUESTIONS TO ASK WHILE PROVIDING CLIENT CARE

  1. What recently collected clinical assessment data are relevant and must be recognized as significant?
  2. What relevant clinical assessment data need to be closely watched to detect a possible change in status?
  3. What is the worst possible/most likely complication(s) to anticipate today with this client?
  4. What nursing assessments need to be initiated to identify if this complication develops? © 2014 Keith Rischer, RN, MA, CEN, CCRN/http://www.keithrn.com/downloads/ clinical-reasoning.questions-develop-nurse-thinking/

Home Care Considerations Communication and Clinical Reasoning

  • (^) Interview the client in a nonthreatening, relaxing setting.
  • (^) Utilize the client’s words when describing the chief complaint.
  • (^) Communicate with the family to gain insight into the changes in the client’s condition.
  • (^) Inform the primary care provider of the client’s physiological and psychosocial status.
  • (^) Consult with other health care team members to deter- mine if they have experience with clients who have had

similar health problems whose conditions changed. Ask them what interventions were implemented and the outcome of care.

  • (^) If the client’s status has not improved, consult with the health care team and continue to implement critical thinking strategies to address the client’s health-related outcomes.

TEAMWORK AND COLLABORATION

Chapter 10 •^ Critical Thinking and Clinical Reasoning 151

(Alfaro-LeFevre, 2014). The concept map allows the nurse to map words on a page and focus on concepts and relationships. A gen- eral benefit of these maps is that they are quicker than note taking and highlight key ideas (Alfaro-LeFevre, 2014). This text contains more than a dozen concept maps that demonstrate care planning and physiological processes.

Concept Mapping and Enhancing

Critical Thinking and Clinical Reasoning

Concept mapping provides nurses with a link between existing nurs- ing knowledge and new information. This learning strategy enhances the critical thinking process and can assist the nursing student in understanding complex concepts (Chabeli, 2010). Concept maps foster the demonstration that nurses and health care providers have acquired the body of knowledge and understanding of concepts per- tinent to the delivery of safe and effective care (Daley & Torre, 2010). Rather than address one single client problem, the concept map can incorporate multiple problems. This allows the nurse to demon- strate interrelationships among a client’s problems and determine care based on the complexity of those problems (Billings & Halstead, 2012). Thus, concept mapping may be a valuable tool to improve critical thinking. Four basic types of maps are described in Box 10– and Figure 10–2 •.

make decisions. When faced with several client needs at the same time, the nurse must prioritize and decide which client to assist first. In the home care setting, the nurse must decide if the client’s condition can be managed in the home or requires hospitalization. The nurse must assess the ability of the caregiver and client to under- stand and follow all aspects of the health care teaching the nurse has provided. The nurse must consider the client’s cultural and religious back- ground because both influence the outcomes of care. For example, in the Muslim religion, it is traditional for female relatives to care for a new baby, thus allowing the new mother time to rest. If the nurse fails to review cultural practices and insists that the new mother provide the parenting, then the nurse has not utilized critical thought in the process of clinical reasoning during the implementation of care. Logical reasoning is a critical thinking skill that closely aligns with clinical reasoning. In the planning of care, nurses must question whether knowledge they possess about the care of the client is consis- tent with the most current evidence-based practice. The nurse must review the most current nursing and health-related literature prior to implementing care. A nurse’s ability to accurately implement and integrate critical thinking, clinical judgment, and clinical reasoning is enhanced with a commitment to lifelong learning. Andersson, Klang, and Petersson (2012) conducted a study of clinical reasoning in a pediatric facility. They found that experience and increased education or training were important in the development of professional competence and also enhanced clinical reasoning.

CONCEPT MAPPING

Concept mapping is a technique that uses a graphic depiction of nonlinear and linear relationships to represent critical thinking. Also known as mind mapping, concept maps are context dependent and can be used to develop analytical skills. The attributes of the concept are linked, making meaning of the concept they represent. Concept maps provide an opportunity to visualize things in your own way

BOX 10–4 Types of Concept Maps

  • (^) Hierarchical maps—concept and attributes arranged in a hierarchical pattern and typically constructed in a descending order of importance. Relationships are identified between and among a concept and its attributes (see Figure 10–2A)
  • (^) Spider maps—depict the interrelatedness of the concept and its attributes in the map (see Figure 10–2B)
  • (^) Flowchart maps—linear diagrams demonstrating sequence or cause-and-effect relations (see Figure 10–2C)
  • (^) Systems maps—inputs and outputs illustrate relationships among the concept and its attributes (see Figure 10–2D)

Figure 10–2 •^ Types of concept maps: A, hierarchical; B, spider; C, flowchart; D, systems.

A. B.

C. D.

INPUT

OUTPUT

  • Nurses need critical thinking skills and attitudes to be safe, compe- tent, skillful practitioners.
  • Nurses use clinical reasoning skills to assess each client’s condi- tion and identify interventions that improve clients’ physiological and psychosocial outcomes.
  • Creativity enhances critical thinking. Creative nurses generate many ideas rapidly, are flexible and natural, create original solu- tions to problems, tend to be independent and self-confident, and demonstrate individuality.
  • Critical thinking skills include the ability to do critical analysis, per- form inductive and deductive reasoning, make valid inferences, dif- ferentiate facts and opinions, evaluate the credibility of information sources, clarify concepts, and recognize assumptions. - Critical thinkers have certain attitudes: independence, fair- mindedness, insight, intellectual humility, intellectual courage to challenge the status quo and rituals, integrity, perseverance, con- fidence, and curiosity. - Nurses utilize cognitive processes in clinical reasoning, and their thinking is based on the knowledge of the aspects of client care. - Nurses also utilize metacognitive processes in clinical reasoning through the knowledge they gain in the care of clients. - Clinical reasoning-in-transition is the ability to recognize subtle changes in a client’s condition over time. - Reflection is the identification of factors that improve client’s care.

CHAPTER HIGHLIGHTS

  1. A client with diarrhea also has a primary care provider’s order for a bulk laxative daily. The nurse, not realizing that bulk laxatives can help solidify certain types of diarrhea, concludes, “The pri- mary care provider does not know the client has diarrhea.” What type of statement is this? 1. A fact 2. An inference 3. A judgment 4. An opinion
  2. A client reports feeling hungry, but does not eat when food is served. Using clinical reasoning skills, the nurse should perform which of the following? 1. Assess why the client is not ingesting the food provided. 2. Continue to leave the food at the bedside until the client is hungry enough to eat. 3. Notify the primary care provider that tube feeding may be indicated soon. 4. Believe the client is not really hungry.
  3. A client complains of shortness of breath. During assessment the nurse observes that the client has edema of the left leg only. The nurse reviews evidence-based practice literature and re- flects on a previous client with the same clinical manifestations. What do these actions represent? 1. Clinical judgment 2. Clinical reasoning 3. Reflection 4. Intuition
  4. The client who is short of breath benefits from the head of the bed being elevated. Because this position can result in skin breakdown in the sacral area, the nurse decides to study the amount of sacral pressure occurring in other positions. What decision making is the nurse engaging in? 1. The research method 2. The trial-and-error method 3. Intuition 4. The nursing process 5. In the clinical reasoning process, the nurse sets and weighs the criteria, examines alternatives, and performs which of the follow- ing before implementing a plan? 1. Reexamines the purpose for making the decision. 2. Consults the client and family members to determine their view of the criteria. 3. Identifies and considers various means for reaching the outcomes. 4. Determines the logical course of action should intervening problems arise. 6. The nurse is concerned about a client who begins to breathe very rapidly. Which action by the nurse reflects clinical reasoning? 1. Notify the primary care provider. 2. Obtain vital signs and oxygen saturation. 3. Request a chest x-ray. 4. Call the rapid response team. 7. The nurse is teaching a client about wound care during a follow- up visit in the client’s home. Which critical thinking attitude causes the nurse to reconsider the plan and supports evidence- based practice when the client states, “I just don’t know how I can afford these dressings”? 1. Integrity 2. Intellectual humility 3. Confidence 4. Independence
  5. When the nurse considers that a client is from a developing country and may have a positive tuberculosis test due to a prior vaccination, which critical thinking attitude and skill is the nurse practicing?
  6. Creating environments that support critical thinking
  7. Tolerating dissonance and ambiguity
  8. Self-assessment
  9. Seeking situations where good thinking is practiced

TEST YOUR KNOWLEDGE

Chapter 10 Review

154 Unit 3 •^ The Nursing Process

  1. A client in a cardiac rehabilitation program says to the nurse, “I have to eat a low-sodium diet for the rest of my life, and I hate it!” Which is the most appropriate response by the nurse? 1. “I will get a dietary consult to talk to you before next week.” 2. “What do you think is so difficult about following a low-sodium diet?” 3. “At least you survived a heart attack and are able to return to work.” 4. “You may not need to follow a low-sodium diet for as long as you think.” 10. Which reasoning process describes the nurse’s actions when the nurse evaluates possible solutions for care of an infected wound for optimal client outcomes? 1. Intuition 2. Research process 3. Trial and error 4. Problem solving See Answers to Test Your Knowledge in Appendix A.

Suggested Reading Deschenes, M., Charlin, B. Gagnon, R., & Goudreau, J. (2011). Use of a script concordance test to assess development of clinical reasoning in nursing stu- dents. Journal of Nursing Education, 50 (7), 381–387. doi:10.3928/0148434-10110331- In response to the lack of evidence for assessing and measuring the clinical reasoning skills of nurses, the au- thors developed a script concordance test. This test is an examination of prototypical clinical practice situations that possess ambiguous, complex, and incomplete information. The scoring of the instrument is based on the responses of 15 expert panelists. Thirty first-year nursing students com- pleted the test. The students’ responses are compared to the responses of the expert panel. The study revealed that script concordance tests allow educators to assess the quality of students’ organization of knowledge. They also evaluate students’ ability to make appropriate decisions related to nursing interventions and professional practice.

Related Research Fossum, M., Alexander, G. L., Goransson, K. E., Ehnfors, M., & Ehrenberg, A. (2011). Registered nurses’ thinking strategies on malnutrition and pressure ul- cers in nursing homes: A scenario-based think-aloud study. Journal of Clinical Nursing, 20 , 2425–2435. doi:10.1111/j.1365-2702.2010.03578.x Lapkin, S., & Levett-Jones, T. (2011). A cost-utility analysis of medium versus high-fidelity human patient simulation mani- kins in nursing education. Journal of Clinical Nursing, 20, 3543–3552. doi:10.1111/j.1365-2702.2011.03843.x

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READINGS AND REFERENCES