This Practice Question has been published with the kind permission of the Royal College of Nursing.
The drive for evidenced based practice has increased the need to understand decision making in healthcare (Cader et al 2005). In addition to this, clinical practice has evolved with the expectation that a nurse should have the knowledge and experience to correctly identify patient problems and make appropriate decisions that may affect an older patients’ well-being (Wolf 2013).
Although there is a great deal of attention given to critical thinking in the literature, there is a suggestion that it needs to remain vague as a term to protect its purpose to encourage thinking (Bailin et al 1999). This lack of clarity may be seen as negative by some, but can allow for creative thinking and enable problem solving that is innovative and patient focused.
What influences critical thinking?
Many of us make decisions about patients’ care every day, but do not think too much about the complex processes of reasoning that allows us to reach conclusions. Rutter and Brown (2013) suggest that appraising the situation through standards of analysis are important, but judgement also plays a part and deductive argument says that a premise is only acceptable if the judgement can be adequately defended. In practice, this means reaching a conclusion that has a good argument, can be supported by expert views, and does not contradict the evidence. Many nurses are aware of evidenced-based practice and would consider this the cornerstone of their practice. However, it is the idea that evidenced based practice and critical thinking, being so closely related, is crucial in the assessment process (Bate et al 2012) therefore suggesting that critical thinking is based on sound knowledge and learning gained through education. There are other concepts that influence critical thinking including: socialisation and developed beliefs, as well as unconscious assumptions made about patients (Berman 2001). Berman (2001) suggests that it is not always possible to prevent this from happening, but it is crucial this is recognised to adapt to a situation with a patient and communicate effectively.
A framework of practice
It may be helpful to consider critical thinking in terms of a framework. Coutts (2014) discusses a six-phase model of critical thinking starting with identifying problems, gathering information, conclusion considered, tested, evaluated and then making a clinical decision. Although appearing simple, this in reality is a complex process for the nurse that allows them to make meaningful decisions about care and treatment for the older person. Practically, critical thinking allows decisions to be made even if that decision is to do nothing, as in not attempting resuscitation.
Nurses often use patient norms to quickly identify abnormalities and this can be vital in situations requiring fast thinking, such as a patient collapsing. Nurses will respond quickly to this and follow training and procedural cues to manage this patient’s needs. However, it is also critical thinking that enables nurses not to be misled by simple visual cues at other times, by considering additional and collateral information to form a view of a patient’s condition (Kahneman, 2012). This type of thinking is used when urgency is not required or used to back up earlier ‘fast thinking’ views, for example, establishing a patient’s pre-morbid condition to plan their discharge from hospital. Many would describe this as professional judgement, but this is part of our thinking created by comprehensive knowledge and expertise. This is a fundamental feature of practical reasoning as this creative and critical thinking allows the nurse to deal with uncertainty and unpredictable situations, which many would recognise to be normal in healthcare.
Credible decision making
Decision making in nursing is seen as a fundamental part of clinical care and some regard gut feeling or intuition as an important part of this. However, realising that this inner knowledge aided by evidence and education is part of critical thinking may help nurses to recognise what they do as credible in a scientific world. Furthermore, the practice of critical thinking should be encouraged to provide excellent care and improve patient well-being.
References
Bailin S (2002) Critical thinking and science education. Science and Education. 11 361-375
Bate L, Hutchinson A, Underhoill J et al (2012) How clinical decisions are made. British Journal of Clinical Pharmacology. 74, 4, 614-620.
Berman SI (2001) Words Meanings and People. International Society for General Semantics, Concord, CA.
Cader R, Campbell S, Watson D (2005) Cognitive continuum theory in nursing decision making. Journal of Advanced Nursing. 49, 4, 397-405.
Coutts B (2014) The complex decision making needed in significant event analysis. Primary Healthcare. 24, 2, 26-30.
Kahneman D (2012) Thinking, Fast and Slow. Penguin Random House.
Rutter L, Brown K (2013) Critical thinking and Professional Judgement for Social Work. 3rd edition. Sage Publications.
Wolf L (2013) An integrated, ethically driven environmental model of clinical decision making in emergency settings. International Journal of Nursing Knowledge. 24, 1, 49-53