Ch. 8 ATI: Critical thinking and clinical judgment - Everything made easy

Nursing practice

Requires knowledge from biological, social, and physical sciences, pathophysiology, nursing procedures, and nursing skills.

Critical thinking skills

Include interpretation, analysis, evaluation, inference, and explanation.

Clinical judgment

Leads the nurse to choose actions or interventions through a process called clinical reasoning.

Clinical reasoning

The process used to choose appropriate nursing actions or interventions based on clinical judgments.

Nursing knowledge base

Includes foundational thinking skills such as recall and comprehension. This is necessary before developing critical thinking skills in nursing.

Critical thinking in nursing

An active, orderly, well-thought-out reasoning process used to make nursing judgments.

Critical thinking in nursing

Applies knowledge, experience, problem-solving, logic, reasoning, and decision-making.

Critical thinker

Prioritizes, explores different courses of action, considers ethics, and determines appropriate outcomes.

Goal of critical thinking

To correctly identify problems and devise and implement the best solutions (interventions).

Critical thinking and quick judgments

Critical thinking discourages quick judgments that lead to single-focused solutions.

Critical thinking

Requires lifelong learning and the ability to gain relevant experiences.

Critical thinking and experience

Nurses continuously reflect on experiences to improve nursing judgment.

Components of critical thinking

Knowledge, experience, critical thinking competencies, attitudes, and intellectual and professional standards.

Critical thinking and truth

Seeking truth in an open-minded manner helps facilitate critical thinking.

Critical thinking and curiosity

Nurses should be inquisitive about why something is effective or ineffective.

Critical thinking process

Follows a systematic process or pattern.

Critical thinking and conclusions

Critical thinking does not involve jumping to conclusions. Nurses use reason to guide decisions.

Inferences

Nurses pull pieces of information together to determine a relationship between the data.

Critical thinking and reflection, language, and intuition

Critical thinking incorporates reflection, language, and intuition.

Levels of critical thinking

Critical thinking evolves through three distinct levels as a nurse gains knowledge and experience and matures into a competent nursing professional.

Reflection

Purposefully thinking back or recalling a situation to discover its meaning and gain insight into the event.

Reflection question

“Why did I say that or do this?”

Reflection question

“Did the original plan of care achieve optimal client outcomes?”

Successful interventions

If the original plan of care achieved optimal client outcomes, ask, “Which interventions were successful?”

Unsuccessful interventions

If the original plan of care did not achieve optimal client outcomes, ask, “Which interventions were unsuccessful?”

Language

Precise, clear language that demonstrates focused thinking.

Language

Communicates unambiguous messages and expectations to clients and other health care team members.

Language question

“Did I use language appropriate for the client?”

Language question

“Did I communicate the message clearly to the provider?”

Intuition

An inner sensing that facts do not currently support something.

Intuition and data

Intuition should spark the nurse to search the data to confirm or disprove the feeling.

Intuition question

“Did the vital signs reflect any changes that account for the client’s present status?”

Intuition question

“When the client’s status changed in this way last month, there was a specific reason for it. Is that what is happening here?”

Basic Critical Thinking

A nurse trusts the experts and thinks concretely based on rules.

Basic critical thinking

Results from limited nursing knowledge and experience, as well as inadequate critical thinking experience.

Basic Critical Thinking example

A client reports pain 1 hr after receiving pain medication. Instead of reassessing the client’s pain, the nurse tells the client they must wait two more hours before receiving another dose.

Basic Critical Thinking key idea

Follows rules and relies on experts rather than independently analyzing the situation.

Complex Critical Thinking

The nurse begins to express autonomy by analyzing and examining data to determine the best alternative.

Complex critical thinking

Results from increased nursing knowledge, experience, intuition, and flexible attitudes.

Complex Critical Thinking example

A nurse realizes that a client is not ambulating as often as prescribed because of a fear of missing their daughter’s phone call. The nurse assures the client that the staff will listen for and answer their phone when they are out of their room.

Complex Critical Thinking key idea

Analyzes data, considers different possibilities, and uses creativity to problem solve.

Commitment

The nurse expects to make choices without help from others and fully assumes responsibility for those choices.

Commitment

Results from an expert level of knowledge, experience, developed intuition, and reflective, flexible attitudes.

Commitment example

A nurse increases the rate of an IV fluid infusion when a client’s blood pressure indicates hypovolemic shock 24 hr after surgery.

Commitment key idea

Uses expert knowledge and experience to make decisions independently while accepting responsibility for those decisions.

Critical thinking level — A nurse increases an IV rate on a client who has hypotension

Commitment.

Critical thinking level — A nurse follows a facility’s procedure manual to change an IV dressing

Basic.

Critical thinking level — A nurse repositions a client’s arm to improve the infusion of an IV

Complex.

Basic critical thinking rationale

Nursing interventions that involve concrete thinking based on rules, such as following a facility’s procedure manual to change an IV dressing, are examples of basic critical thinking.

Complex critical thinking rationale

Complex critical thinking involves analyzing data and using creativity to problem solve, such as repositioning a client’s arm to promote IV infusion.

Commitment critical thinking rationale

Commitment critical thinking involves using expert knowledge and experience to problem solve while assuming responsibility, such as increasing an IV rate on a client who has hypotension.

Knowledge

Information that is specific to nursing.

Knowledge sources

Basic nursing education; use of evidence-based practice; continuing education courses; advanced degrees and certifications.

Basic nursing education

Provides nursing-specific knowledge.

Evidence-based practice

Provides nursing-specific knowledge.

Continuing education courses

Provide additional nursing-specific knowledge.

Advanced degrees and certifications

Provide additional nursing-specific knowledge and expertise.

Experience

Decision-making ability developed through opportunities to observe, sense, and interact with clients followed by active reflection.

Experienced nurse

Demonstrates an understanding of clinical situations.

Experienced nurse

Recognizes and analyzes cues for relevance.

Experienced nurse

Incorporates experience into intuition.

Competence

Applying the nursing process to make nursing judgments.

Competence

Proficient ability to perform nursing skills.

Critical thinking component — A nurse has been working with clients who have diabetes mellitus for over 5 years

Experience.

Critical thinking component — A nurse uses the nursing process when caring for a client who has hypoglycemia

Competence.

Critical thinking component — A nurse uses an electronic database to gather information about a medication before administering it to a client

Knowledge.

Knowledge component rationale

Using an electronic database to gather information about a medication demonstrates the knowledge component of critical thinking. The nurse is taking initiative to increase their knowledge base.

Experience component rationale

Working with clients who have diabetes mellitus for over 5 years demonstrates the experience component of critical thinking. An experienced nurse has clinical expertise and can apply intuition to critical thinking in clinical situations.

Competence component rationale

Using the nursing process when caring for a client who has hypoglycemia demonstrates the competence component of critical thinking.

Competence and clinical judgment

Competence involves identifying client problems and making clinical judgments using a systematic, individualized process.

National Council of State Boards of Nursing (NCSBN)

Developed the Clinical Judgment Measurement Model (NCJMM) as a framework to measure clinical judgment.

Clinical Judgment Measurement Model (NCJMM)

Assists the nurse with a systematic approach to decision making in client care.

NCJMM and nursing process

The clinical judgment functions of the NCJMM align with the nursing process.

Clinical judgment functions of the NCJMM

Recognize Cues; Analyze Cues; Prioritize Hypotheses; Generate Solutions; Take Actions; Evaluate Outcomes.

Recognize Cues

Identify important information about the client.

Analyze Cues

Examine the collected information and determine what it means.

Prioritize Hypotheses

Determine which possible problems are most important.

Generate Solutions

Identify appropriate solutions or interventions.

Take Actions

Carry out the appropriate nursing actions.

Evaluate Outcomes

Determine whether the interventions achieved the desired outcomes.

General Critical Thinking

Scientific method.

General Critical Thinking

Problem-solving.

General Critical Thinking

Decision-making.

General Critical Thinking

Diagnostic reasoning and inference.

General Critical Thinking

Clinical decision-making; collaboration.

Priority Setting

General critical thinking.

Specific critical thinking in nursing

The nursing process.

Attitudes

Mindsets that affect how a nurse approaches a problem.

Confidence

Feels sure of abilities.

Independence

Analyzes ideas for logical reasoning.

Fairness

Is objective, nonjudgmental.

Responsibility

Adheres to standards of practice.

Risk-taking

Takes calculated chances in finding better solutions to problems.

Discipline

Develops a systematic approach to thinking.

Perseverance

Continues to work at a problem until there’s a resolution.

Creativity

Uses imagination to find solutions to unique client problems.

Curiosity

Desires to obtain more information about clients and problems.

Integrity

Practices truthfully and ethically.

Humility

Acknowledges weaknesses.

Creativity example

Using imagination to find a unique solution to solve a client’s problem.