Chapter 8 ATI : Critical Thinking and Clinical Judgment (everything)

Nursing practice

Nursing practice requires the application of knowledge from biological, social, and physical sciences; knowledge of pathophysiology; and knowledge of nursing procedures and skills.

Critical thinking skills

Nurses also must use multiple thinking skills—including critical thinking skills (interpretation, analysis, evaluation, inference, and explanation)—to make clinical judgments about problems in nursing practice.

Clinical judgments

These judgments lead the nurse to choosing actions or interventions through a process called clinical reasoning.

Nursing knowledge base

A nursing knowledge base with foundational thinking skills, including recall and comprehension, is a prerequisite to critical thinking in nursing.

Critical thinking in nursing

In nursing, critical thinking is an active, orderly, well-thought-out reasoning process that guides a nurse in various approaches to making a nursing judgment by applying knowledge and experience, problem-solving, logic, reasoning, and decision-making.

Critical thinker

A critical thinker prioritizes, explores various courses of action, keeps ethics in mind, and determines appropriate outcomes.

Critical thinking and client health

To have a positive effect on a client’s health status, a nurse must be able to think critically, correctly identify problems, and both 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

Critical thinking requires lifelong learning and the ability to acquire relevant experiences that can be reflected on continuously to improve nursing judgment.

Components of critical thinking

The components of critical thinking include knowledge, experience, critical thinking competencies, attitudes, and intellectual and professional standards.

Critical thinking and truth

Critical thinking is facilitated by seeking truth in an open-minded manner and being inquisitive about why something is effective or ineffective.

Critical thinking process

Critical thinking follows a systematic process or pattern, not jumping to conclusions but using reason to guide decisions.

Inferences

Nurses make inferences when making clinical decisions by pulling 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, and it evolves through three distinct levels as a nurse gains knowledge and experience while maturing into a competent nursing professional.

Reflection

Purposefully thinking back or recalling a situation to discover its meaning and gain insight into the event. A nurse should reflect on the following:

Reflection question

“Why did I say that or do this?”

Reflection question

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

Reflection if the original plan of care achieved optimal client outcomes

If so

Reflection if the original plan of care did not achieve optimal client outcomes

If not

Language

Precise, clear language demonstrating focused thinking and communicating unambiguous messages and expectations to clients and other health care team members. A nurse should ask the following:

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 the rules.

Basic critical thinking

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 a pain medication. Instead of reassessing the client’s pain, the nurse tells the client they must wait two more hours before they can receive another dose.

Complex Critical Thinking

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

Complex critical thinking

Complex critical thinking results from an increase in 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.

Commitment

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

Commitment

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.

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

When analyzing cues, the nurse should identify that nursing interventions that involve concrete thinking, based on rules, such as following a facility’s procedure manual to change an IV dressing, is an example 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 and comes from:

• Basic nursing education

• Use of evidence-based practice

• Continuing education courses

• Advanced degrees and certifications

Experience

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

An experienced nurse

Demonstrates an understanding of clinical situations.

An experienced nurse

Recognizes and analyzes cues for relevance.

An 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

When recognizing cues, the charge nurse should identify that using the 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

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

Competence component rationale

A nurse who uses the nursing process when caring for a client who has hypoglycemia is demonstrating the competence component of critical thinking. Competence involves identifying client problems and making clinical judgments using a systematic, individualized process.

National Council of State Boards of Nursing (NCSBN)

As a framework to measure clinical judgment, the National Council of State Boards of Nursing (NCSBN) developed the Clinical Judgment Measurement Model (NCJMM).

Clinical Judgment Measurement Model (NCJMM)

This framework 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.

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. Attitudes of critical thinkers include:

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.

Critical thinking attitude — Using imagination to find a unique solution to solve a client’s problem

Creativity.

Critical thinking attitude — Taking a calculated chance to find a solution to a client’s problem

Risk-taking.

Critical thinking attitude — Caring for a client in a nonjudgmental manner

Fairness.

Critical thinking attitude — Continuing to work to solve a problem for a client until there is a solution

Perseverance.

Critical thinking attitude — Checking a client’s medical record for allergies before administering a medication

Responsibility.

Fairness rationale

When recognizing cues, the charge nurse should identify that caring for a client in a nonjudgmental manner demonstrates the critical thinking attitude of fairness. Fairness is using a nonjudgmental, objective approach in looking at clients and situations.

Responsibility rationale

Checking a client’s medical record for allergies before administering a medication demonstrates the critical thinking attitude of responsibility. The nurse is responsible for administering medications in a safe manner and according to standards of practice. Checking the medical record for allergies helps ensure safety.

Risk-taking rationale

Taking a calculated chance to find a solution to a client’s problem demonstrates the critical thinking attitude of risk-taking. Risk-taking is a calculated approach to solving a problem that is not responding to traditional methods.

Creativity rationale

Using imagination to find a unique solution to solve a client’s problem demonstrates the critical thinking attitude of creativity.

Perseverance rationale

Continuing to work to solve a problem for a client until there is a solution demonstrates the critical thinking attitude of perseverance.

Critical thinking attitude — Speaking with certainty to a client when instructing them about a new diet

Confidence.

Critical thinking attitude — Showing honesty when caring for clients

Integrity.

Critical thinking attitude — Identifying limitations of oneself when dealing with a clinical situation

Humility.

Critical thinking attitude — Using a head-to-toe approach to conduct a physical examination on a client

Discipline.

Critical thinking attitude — Asking questions to obtain more information about a client’s problem

Curiosity.

Integrity rationale

When recognizing cues, the charge nurse should identify that showing honesty when caring for clients demonstrates the critical thinking attitude of integrity. Integrity is caring for clients truthfully and ethically.

Discipline rationale

Using a head-to-toe approach to conduct a physical examination on a client demonstrates the critical thinking attitude of discipline. Discipline involves using a systematic approach to collecting data and making decisions.

Confidence rationale

Speaking with certainty to a client when instructing them about a new diet demonstrates the critical thinking attitude of confidence. A confident nurse believes in their own abilities.