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Critical Thinking

1.5 Contact Hours
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN), Respiratory Therapist (RT)
This course will be updated or discontinued on or before Monday, December 20, 2021
Course Description
The role of critical thinking in the practice of nursing and other healthcare disciplines cannot be overemphasized. However, the definition of critical thinking in nursing is less clear. A recent study on critical thinking in nursing demonstrated the inhomogeneity in the definition of critical thinking in nursing literature.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Berthina Coleman (MD, BSN,RN)

Outcomes

90% of participants will apply critical thinking skills and will understand how cultural factors can affect the nurses' ability to think critically.

Objectives

After completing this continuing education course, the participant will be able to meet the following:

  1. List examples of personal factors that can influence the way we perceive and practice critical thinking.
  2. Identify knowledge elements as they pertain to critical thinking in nursing.
  3. Identify the person ultimately responsible for proficiency in critical thinking.
  4. Summarize how increased nursing experience can affect a nurse’s critical thinking skills.

Definition of Critical Thinking

The role of critical thinking in the practice of nursing and other healthcare disciplines cannot be overemphasized. However, the definition of critical thinking in nursing is less clear. A recent study on critical thinking in nursing demonstrated the inhomogeneity in the description of critical thinking in nursing literature.

Critical thinking is frequently and commonly used in nursing research and nursing education in the past decade. However, a definition of critical thinking specific to the field of Nursing remains challenging to establish.

Papp et al. defined critical thinking as "the ability to apply higher-order cognitive skills (such as conceptualization, analysis and evaluation) and the disposition to be deliberate about thinking leading to an appropriate and logical action.1” However, nurses must commit themselves to continued practice of critical thinking skills in order to maintain proficiency in critical thinking.

Critical Thinking versus Creative Thinking

Critical thinking is the cognitive search for one answer to a problem through logical thinking. It is a fundamental principle that underlies the practice of nursing and other healthcare disciplines. On the contrary, creative thinking begins with one problem but instead entertains multiple solutions. Nurses must be both flexible and creative in identifying and addressing clinical issues. A nurse’s ability to practice critical thinking will significantly enhance or hinder his/her ability to make decisions in the healthcare setting. Critical thinking in nursing as an essential component of professional accountability in providing quality nursing care.

Implementing Critical Thinking into the Nursing Curriculum

Applying critical thinking into an already crowded nursing curriculum is particularly challenging for nurse educators. Active participation is required to become a proficient critical thinker. Nurses who decide to become affluent in critical thinking must make a personal commitment to critical thinking. Simulative exercises can be used as a method to teach the tenets of critical thinking.2

Critical thinking could be subdivided into process elements or knowledge elements. Process elements are related to problem-solving, decision making and outcomes, whereas knowledge elements referred to nursing knowledge and nursing experience.

Cultural differences can affect how critical thinking is understood and applied. For example, in the United States, decision making is considered an active component of critical thinking, whereas, in Thailand, there was a strong association between happiness and critical thinking.

Personal factors can influence the way we perceive and practice critical thinking. For example, decreased nursing knowledge and lack of time can negatively impact a nurse's ability to exercise critical thinking.

As newer nurses get trained, it is imperative that critical thinking becomes integrated into their education and training as it becomes more apparent that critical thinking has become essential for their daily work.

To ensure competence in critical thinking, nurses should practice on both simple and complex healthcare scenarios. Given that they are required to make decisions in seconds, that may mean the difference between positive and negative patient outcomes.

The Defining Attributes of Critical Thinking

Attributes of a concept are defining factors that must be present for critical thinking to be present and effective. Von Colln-Appling & Giuliano identified the defining attributes of critical thinking, which include knowledge acquisition, knowledge application, analysis of information, decision making and reflection.2 The authors concluded critical thinking defined as a type of behavioral response that must be present for a successful cascade of events to occur.

Knowledge Acquisition and Knowledge Application

The foundation of any nursing education is knowledge acquisition, as well as the ability to apply that knowledge in clinical scenarios. To gain proficiency in critical thinking, nurses must first demonstrate competence in the expected knowledge base, including disease processes, treatment options, adverse medication reactions, and side effects. A fundamental knowledge base is acquired during nursing training, and it is continuously expanded upon during a nurse's professional career. As new knowledge is gained and applied to complex patients and complex health scenarios, critical thinking skills are enhanced. Ideally, the process of acquiring and applying new knowledge remains continuous throughout a nurse's career. The concept of learning and using new knowledge is the fundamental building block needed for the process of critical thinking to begin.2

Analysis of Information

Nurses are expected to analyze and prioritize clinical information when providing patient care. Examples include but are not limited to interpreting lab values, reviewing test results, accurately identifying patients whose clinical status is declining promptly as well as understanding the expected course of a disease process. The application and improvement of this skill with increasing nursing experience will contribute positively to critical thinking skills.2

Informed Decision Making

Informed decision-making is a skill that must be taught to nursing students before they enter the workforce. The practice and execution of informed consent can have positive and negative consequences on patient outcomes. Nurses and nursing students can become inundated with clinical data daily, which can be irrelevant, relevant, but not urgent, relevant, and urgent or critical. Nurses are expected to analyze this information promptly and make decisions expeditiously. Note that a strong knowledge base and nursing foundation will accurately impact the nurse's ability to practice informed decision making.2

Reflection

Reflection focuses on reviewing the thinking process to identify ways in which improvement ensue. The method of reflection is similar to debriefing after an event or an intense clinical scenario. The process can be performed as an individual or a team. It allows for improvement in future scenarios since it gives team members the chance to review each action to determine if it was appropriate and timely. It can also enable the team to examine the role of team members or adjust systems and processes that are applied in the critical thinking process. It also permits the individual or group to identify gaps in knowledge that need to remediate. Lastly, reflection allows for creative thinking as a means of enhancing cognitive growth.2

Antecedents for Critical Thinking

A precursor or prerequisite for critical thinking could positively affect the student's or nurse's ability to practice critical thinking. A vital requirement for critical thinking is the learner's willingness to remain open-minded. Open-mindedness prepares the learner to consider alternative solutions or courses of action for improved outcomes.

Autonomy has also identified positively as a prerequisite for critical thinking. Independent thinking is paramount for clinicians who want to become critical thinkers. The process must be internalized and automated within the individual.

Critical thinking increases competence in clinical practice, which in turn improves patient outcomes. Clinical competence among nursing graduates is not homogenous and is extremely dependent upon the focus of the nursing school placed on critical thinking. Employers are eager to hire nurses who not only have a great nursing foundation but also have honed their critical thinking skills.

Nationwide nursing shortages increased by the recent and continued retirement of older nurses who opted to stay in the workforce after the 2008 economic recession.

Knowledge is not enough to ensure nursing competence. The ability to apply the acquired knowledge to affect the patient's health outcomes positively is the fundamental skill that critical thinking exercises can assess for and improve.

Empirical Referents

The final part of concept analysis in critical thinking is identifying empirical referents. An empirical referent in critical thinking within the field of nursing is the clinical competence of the nurse. The nurse is duty-bound to maintain clinical competence in their area of practice, and it is considered part of their duty to the patient populations in their charge. One method of evaluating the empirical referent of clinical competence is to measure patient quality care outcomes.

Skillful, safe, and efficient nursing interventions must be applied with nurses who are apt in critical thinking to get positive health outcomes for patients. Critical thinking, defined by Scriven and Paul as, "the active mental process and subtle perception, analysis, synthesis and evaluation of information collected or derived from observation, experience, reflection, reasoning or the communication leading to conviction for action.3

Clinicians are expected to adapt to rapidly changing clinical conditions and use limited resources to care for medically complex patients. Clinical providers have to make decisions in medical scenarios that are unclear, multifaceted, and stressful, and each choice may lead to a cascade of events, which can mean the difference between life and death for patients in their care.

In cases where traditional interventions are not effective, clinicians must use creative thinking combined with critical thinking to come up with patient-specific solutions, quickly implemented and flexible so that it may be adaptable in other patients.

Cognitive Skills Required for Critical Thinking

There are cognitive skills needed for clinical problem solving and critical thinking, which include: introductory and concluding justification, critical analysis, distinguishing, and establishing the validity of information sources and valid conclusions.

Critical Analysis

Critical analysis is applied to a clinical scenario to separate clinically relevant information from unnecessary information. To that end, the Socratic method can be used where the clinician asks questions and seeks answers to distinguish between factual information versus what one believes. It is used to examine the data and consider the consequences of any actions. This method can apply at the end of tasks such as history taking or when finalizing the nursing plan. The technique can also happen at the end of a shift or the end of a procedure.4

Assessment of the reliability of the information a clinician processes is necessary for critical thinking. A clinician’s ability to recognize useful and accurate information versus irrelevant information as it pertains to a clinical question is imperative for critical thinking.4

Independence of thought is necessary for maturity in critical thinking. The critical thinker must remain impartial in their decision-making process. It is essential to hone inductive and deductive reasoning skills.

While providing routine nursing care, clinical providers typically make decisions using minimal critical thinking skills by mostly relying on habit. Critical thinking skills become necessary once an abnormal or unusual occurrence happens that forces the clinician to use higher critical thinking skills.

The Nursing Process

The nursing process is an essential method of systematic and rational planning in providing specialized nursing care in a patient-centric matter. There are five parts of the nursing process; assessment, diagnosis, planning, implementation, and evaluation.

Intuition is the perception and understanding of concepts without the use of conscious reasoning.4 It is typically not considered an appropriate technique for clinical decision making. Some clinicians consider it a form of guessing, while others consider it an essential aspect of clinical knowledge and skill acquisition. Some believe clinical instincts can be developed and honed with experience making clinical instincts with experienced clinicians invaluable. Note, however, that intuition is highly dependent upon clinical experience. The reliance on intuition should be discouraged in new graduates.

Critical thinking is vital for the decision-making process; as such, each clinician should try to improve clinical thinking skills. Critical thinking involves both deep and broad thinking. Clear, concise communication is necessary when caring for patients to ensure proper patient outcomes.

Critical thinking is a necessary part of most curriculums in healthcare disciplines. However, this is a part of the curriculum that nursing education programs struggle with the most.4

Clinical Scenario

You are a nurse working in a dialysis unit. Mr. Ade is a patient who is currently receiving dialysis treatment at your clinic. He was diagnosed with chronic kidney disease five years prior and started dialysis three years ago. You are working as the charge nurse one morning and notice that Mr. Ade starts having a seizure in his dialysis seat. You immediately discontinue dialysis treatment and activate emergency response services. After stabilizing Mr. Ade with the help of paramedics, he directly transfers to the local hospital. Paramedics ask if there have been any recent changes to his medication list.

Upon review of the patient’s current medication list, the following medications come to light: Lisinopril, Metformin, Epogen, and Cialis. Which of the medications listed, if administered as prescribed, could be possibly implicated as a cause for the patient's current hemodynamic instability.

Clinical Discussion

In answering the clinical questions, the nurse needs a fundamental knowledge base about contraindicated medications for dialysis patients. It is essential that they identify medications on the contraindicated as well as why these medications are contraindicated. First, nurses must be able to identify the indication for each drug.

There are some medications that are strongly contraindicated in patients on dialysis. For each drug in question, there is glomerular filtration rate (GFR) below which the drug is contraindicated or below which it should be strongly avoided. Examples include the psychotropic drug Lithium, which is contraindicated or should be strongly avoided below 60, with the reason being the increased risk of convulsions. Cefepime is antibiotic which is contraindicated or should be strongly avoided when the GFR is below 30 with a risk of increased central nervous system toxicity. Spironolactone is contraindicated in patients with a GFR below 30 due to the increased risk of hyperkalemia. Metformin is contraindicated or should be strongly avoided in patients with a GFR below 60 due to the increased risk of lactic acidosis.

A dialysis nurse with the appropriate nursing knowledge base should be able to identify Metformin as inappropriate for dialysis patients within a few minutes, and once that medication identified, the nurse should immediately place a call to the emergency department to report the findings. Ultimately, the nurse identified that the drug was started by a new primary care provider the patient saw a month prior. The medication should be identified as contraindicated medication and brought to the attention of the nephrologist. This action can avoid adverse events. Knowledgebase is a critical part of critical thinking, and it is the foundation upon which nurses build their careers.

Summary

Critical thinking is imperative for nurses, and it remains a highly valued and desired skill in nursing practice for the 21st-century nurse. Nurses are required to work in increasingly complex healthcare systems and are asked to integrate nursing practice with rapidly changing advances in technology. Proficiency in critical thinking is ultimately the responsibility of each nurse.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

References

  1. Papp KK, Huang GC, Clabo LML, et al. Milestones of critical thinking. Academic Medicine. 2014;89(5):15-20. DOI:10.109/acm.0000000000000220.
  2. Von Colln-Appling C, Giuliano D. A concept analysis of critical thinking: A guide for nurse educators. Published November 15, 2016. Accessed September 15, 2019. Visit Source.
  3. Scriven M, Paul R. Accessed November 10, 2019. Visit Source.
  4. Papathanasiou I, Kleisiaris C, Fradelos E, Kakou K, Kourkouta L. Critical Thinking: The Development of an Essential Skill for Nursing Students. Acta Informatica Medica. 2014;22(4):283. DOI:10.5455/aim.2014.22.283-286