Chapter 2 - Lecture notes 2 PDF

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Critical Thinking and the Nursing Process...

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Chapter 2 – Critical Thinking and the Nursing Process What Are Critical-Thinking Skills? Skills in critical thinking refer to the cognitive (intellectual) processes used in complex thinking operations such as problemsolving and decision making. When planning nursing care, nurses gather information about the client (skill) and then draw tentative conclusions about the meaning of the information (complex thinking process) to identify the client’s problems. Then they think of several different actions they might take to help solve or relieve the problem. The following are examples of critical-thinking skills: Objectively gathering information on a problem or issue Recognizing the need for more information Evaluating the credibility and usefulness of sources of information Recognizing gaps in one’s own knowledge Listening carefully; reading thoughtfully Separating relevant from irrelevant data and important from unimportant data Organizing or grouping information in meaningful ways Making inferences (tentative conclusions) about the meaning of the information Visualizing potential solutions to a problem Exploring the advantages, disadvantages, and consequences of each potential action

Evaluating the credibility and usefulness of sources of information Recognizing differences and similarities among things or situations Prioritizing or ranking data as needed What Are Critical-Thinking Attitudes? Attitudes are not the same as intellectual skills. They are more like feelings and states of mind. Your attitudes and character determine whether you will use your thinking skills fairly and with an open mind. Without a critical attitude, people tend to use thinking skills to justify narrow-mindedness and prejudice and to benefit themselves rather than others. The following are some critical-thinking attitudes (Paul, 1990): Independent thinking. Critical thinkers do not believe everything they are told or just go along with the crowd. They listen to what others think and they learn from new ideas. They do not accept or reject an idea before they understand it. Nurses should challenge actions, practices, and policies having little logical support. Intellectual curiosity. Critical thinkers love to learn new things. They are inquisitive, exhibit an attitude of inquiry, and frequently think or ask, “What if …?” “How could we do this differently?” “How does this work?” or “Why did that happen?” Intellectual humility. Critical thinkers are aware that they do not know everything. When they are unsure, they are not too proud or embarrassed to ask for help from mentors with wisdom, knowledge, skill, and ability. They reevaluate their conclusions or actions in light of new information and are willing to admit when they are wrong.

Intellectual empathy. Critical thinkers try to understand the feelings and perceptions of others. They try to see a situation as the other person sees it. Intellectual courage. Critical thinkers consider and examine fairly their own values and beliefs as well as the beliefs of others, even when this is uncomfortable. They are willing to rethink, and even reject, previously held beliefs that are not well justified. Without intellectual courage, people become resistant to change. Intellectual perseverance. Critical thinkers don’t jump to conclusions or settle for the quick, obvious answer. Important questions are usually complex, and critical thinkers give them serious thought and research, even when this takes a great deal of effort and time. Fair-mindedness. Critical thinkers try to make impartial judgments. They treat all viewpoints fairly, realizing that personal biases, customs, and social pressures can influence their thinking. They examine their own biases each time they make a decision. Critical thinking can be used in all aspects of your life. Whenever you are trying to reach an important decision, reasoned action (critical thinking) is called for. Everyday uses of critical thinking might include deciding where you should live, choosing which nursing programs you should apply to, and deciding among several job offers. The rest of this chapter shows you why critical thinking is important to you in your chosen career, nursing. Applying the Model: An Example Let’s apply the model to a familiar situation. Soon you will begin your clinical rotations if you have not already done so. Many students find this exciting yet somewhat intimidating.

How could you use the five points of the critical-thinking star (Fig. 2-1) to approach your first clinical day so you will be well prepared and able to function safely? Contextual Awareness One of the first things you need to consider is your usual response to new experiences. How do you react to change? What other tasks or assignments do you have that will dictate the timing of your preparation? Have you had any previous experiences that will aid or hamper you in your preparation? As you consider these questions, you are addressing the star point of contextual awareness. Using Credible Sources You need to gather accurate information about the clinical experience. Base your inquiry on credible sources. Consider these examples: Ask your instructor for guidance on how to best prepare. Consult a student who has successfully completed the same course. You will also need accurate information about the clients who have been assigned to you. Use only knowledgeable, reliable sources, such as the following: The client’s chart Certain Internet sites Nursing texts and journals (not popular, nonscholarly magazines, such as Parents magazine) After you have more information, reexamine your response to the situation. You may find that you are feeling less anxious already! All of this is a part of inquiry. Exploring Alternatives and Analyzing Assumptions Now that you know something about the clinical experience, you can plan your day. You need to consider alternatives and analyze your assumptions about the experience. What is expected of you?

What do you expect from the experience? How should you approach your client? How will you introduce yourself? What skills do you have? How will you apply your skills to caring for your client? Reflecting and Deciding After you have addressed these concerns, quickly review your preparation (reflective skepticism). Do you have enough information to feel comfortable in the situation? Have you left anything out? Do you need more information? This was a demonstration of how you might apply the criticalthinking model to a real experience. In this example, you also used theoretical, practical, personal (self), and ethical knowledge, which are explained in the next section. WHAT ARE THE DIFFERENT KINDS OF NURSING KNOWLEDGE? Critical thinking does not occur in a vacuum. You must have something to think about—a knowledge base. Theoretical Knowledge Each chapter in your text begins by presenting theoretical knowledge. Theoretical knowledge— knowing why—consists of information, facts, principles, and evidence-based theories in nursing and related disciplines (e.g., physiology and psychology). It includes research findings and rationally constructed explanations of phenomena. You will use it to describe your patients, understand their health status, explain your reasoning for choosing interventions, and predict patient responses to interventions and treatments. Practical Knowledge Each chapter also provides the practical knowledge that enables you to apply your theoretical knowledge

to caring for patients. Practical knowledge—knowing what to do and how to do it—consists of processes (e.g., decision process, nursing process, change process) and procedures (e.g., how to give an injection) and is an aspect of nursing expertise. Self-Knowledge In addition to theoretical and practical knowledge, nurses use self-knowledge, or self-understanding. To think critically, you must be aware of your beliefs, values, and cultural and religious biases. This kind of knowledge helps you find errors in your thinking and enables you to tune in to your patients. You can gain self-knowledge by developing personal awareness— by reflecting (asking yourself), “Why did I do that?” or “How did I come to think that?” Ethical Knowledge Finally, nurses use ethical knowledge, that is, knowledge of obligation, or right and wrong. Ethical knowledge consists of information about moral principles and processes for making moral decisions. Ethical knowledge helps you to fulfill your ethical obligations to patients and colleagues. Chapter 43 will help expand your ethical knowledge. This text is organized using the concepts of practical knowledge and theoretical knowledge, as summarized in the following list: Practical Knowledge: Knowing What (That is, knowing wha Theoretical Knowledge:

Knowing Why (That is, knowing why

WHAT IS NURSING PROCESS? Nursing process is a systematic problem-solving process that guides all nursing actions. It is the type of thinking and doing nurses use in their practice. In fact, the American Nurses Association (ANA) organizes its standards of care around the nursing process (ANA, 2015). What Are the Phases of the Nursing Process? The nursing process consists of six phases (or steps): assessment, diagnosis, planning outcomes, planning interventions, implementation, and evaluation (Wilkinson, 2012). A model

illustrating these phases is shown in Figure 2-2. Various experts organize the phases in different ways. Some have a fourstep process that combines assessment and diagnosis into one phase that they call “assessment.” Many have a five-step process, combining outcomes and interventions into one “planning” phase. There is no “right” way to do it, and experienced nurses do not use the steps separately. Your text presents them as distinct and separate only to make it easier for you to learn how the process works. FIGURE 2–2 The phases of the nursing process. What follows is a summary of each nursing process phase. You will learn about them in more depth in Chapters 3 through 7. Assessment The first phase of the nursing process—the datagathering stage—is assessment. Multiple sources. You will obtain information from many sources: the client via history or physical examination, the client record, other health professionals, the client’s family or support system, and the professional literature. Purpose of assessment. You will use the data that you gather to draw conclusions about the client’s health status. Diagnosis This is the second phase of the nursing process. In this step you will identify the client’s health strengths and needs (usually stated in the form of a problem) based on careful review of your assessment data. The term diagnosis has been thought of as being medical, such as a diagnosis of cancer or diabetes. However, nursing diagnoses reflect the client’s responses to actual or potential health problems and are different from medical diagnoses, as you will discover in Chapter 4. Planning (Outcomes and Interventions) The third and fourth steps both involve planning—planning outcomes and planning interventions. The end result of planning is a holistic nursing care plan, individualized to reflect the client’s problems and strengths. A care plan is a written or electronic document containing detailed instructions for a client’s nursing care. See Chapter 5 for more

about goals and outcomes and Chapter 6 for more about interventions. In the planning outcomes step, you work with the client to decide goals for client care—that is, the client outcomes (or changes) you want to achieve through your nursing activities. These outcomes will drive your choice of interventions. The following is an example of an outcome statement you might find in a care plan: Nutritional status will improve as evidenced by a weight gain of 3 lb (1.4 kg) by July 1. In the planning interventions phase, you develop a list of possible interventions based on your nursing knowledge and then choose those most likely to help the client to achieve the stated goals. The best interventions are evidence-based, that is, supported by sound research. Implementation This is the action phase. During implementation you will carry out or delegate the actions that you previously planned. You may delegate an action to another member of the healthcare team only if it is an action that can be carried out safely and legally by that team member. Delegation is discussed further in Chapters 7 and 41. In the implementation phase you also document your actions and the client’s responses to them. Evaluation In this final phase, you determine whether the desired outcomes have been achieved and judge whether your actions have successfully treated or prevented the identified health problems. You then modify the care plan as needed. For example, if a problem has been resolved, you delete it from the care plan; if outcomes have not been achieved, you determine why. It may be that a new intervention is needed. If so, you add it. WHAT IS FULL-SPECTRUM NURSING? KEY POINT: Full-spectrum nursing is a unique blend of thinking, doing, and caring. Full-spectrum nursing is performed by nurses who fully develop and apply nursing knowledge,

critical thinking, and the nursing process to patient situations. The purpose of full-spectrum nursing is to achieve safe, effective care and promote good patient outcomes.

What Concepts Are Used in the Full-Spectrum Nursing Model? You have learned about the model for critical thinking. You are now prepared to learn about a model to explain the concept of nursing. You’ll learn more about concepts in Chapter 8 ; for now, think of them as ideas. The four main concepts that describe full-spectrum nursing are thinking, doing, caring, and patient situation (or context) (Table 2-3). When nurses think, they use the nursing knowledge that they have stored in their memory. In addition, they think about the patient situation, which they acquire through use of the nursing process. Situation, or context, refers to the context for care, the patient’s environment outside the care setting, relationships, resources available for patient care, and so on. Figure 2-3 is a simple, visual model of full-spectrum nursing. You can see that the concept’s full model involves everything you have learned about in this chapter—critical thinking, nursing knowledge, and nursing process—but organized under the simple concepts of thinking, doing, caring, and patient situation. Let’s see how the model concepts work together for a fullspectrum nurse. They are all interrelated and overlapping, but we divide them into simple categories to help you understand and remember them. You can see that a full-spectrum nurse needs

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How Does the Model Work? The full-spectrum nursing model is used throughout this text, so it is important that you understand how it works. Nurses use critical thinking in all steps of the nursing process. They also apply critical thinking to the four kinds of nursing knowledge. When they are doing for the patient, caring motivates and facilitates the thinking and doing. The goal of all this is to have a positive effect on a patient’s health outcomes. The following patient situation illustrates how the four main dimensions of full-spectrum nursing work together. As you read, notice how the concepts overlap. For example, recall that nursing process and problem-solving are themselves complex criticalthinking skills. Also notice how the nurse uses critical thinking with nursing knowledge and the nursing process. Patient Situation When taking a patient’s oral temperature, a nurse sees a glass of ice water on the overbed table. Realizing that a cold drink can reduce the accuracy of the temperature reading, she asks the patient, “How long has it been since you’ve taken a drink of water?” The patient tells her it was just a minute ago. The nurse is busy and tired, but she returns to take the patient’s temperature again at a later time when it will be accurate. Thinking Theoretical knowledge. The nurse realized that a cold drink can lower the patient’s temperature. The nurse used interviewing principles to get more information from the patient. Critical thinking. The nurse recognized relevant information and identified the need for more data. She used the patient’s answer to decide what to do. Being aware of context is an aspect of critical thinking. The context in this scenario includes the following: (1) The ice water was within the patient’s reach

and (2) the patient was physically capable of reaching it and had just taken a drink. Doing Practical knowledge. The nurse used a psychomotor skill when she measured the patient’s temperature to acquire more patient vital sign data. She used a communication process to question the patient. Nursing process. (Assessment) The nurse observed the glass of ice water on the table. The nurse asked, “How long has it been since you’ve taken a drink of water?” The nurse also observed the environmental data (e.g., ice water at the bedside). (Implementation) The nurse took the patient’s temperature. Caring The scenario does not state this, but a caring nurse, even a very busy one, would not be annoyed with the patient for the inconvenience of having to return to take the temperature. Self-knowledge might include the nurse’s awareness that she is tired and feeling irritable. Ethical knowledge would tell her that she has an obligation to get an accurate temperature from the patient rather than thinking, “Oh, I’ll just estimate the reading a degree or two higher, as it doesn’t matter that much.” As a full-spectrum nurse, you will apply thinking, doing, and caring to patient situations to help benefit patients and bring about good outcomes....