CRITICAL THINKING AND THE NURSING PROCESSNRS 101Unit IIISession 3

Critical Thinking and Nursing Judgment

How do we make decisions?How do nurses make decisions about patient care?What do we rely on to help us in decision making?

Critical Thinking and Nursing JudgmentNot a linear step by step processProcess acquired through hard work, commitment, and an active curiosity toward learningDecision making is the skill that separates the professional nurse from technical or ancillary staff

Critical Thinking and Nursing JudgmentGood problem solving skillsNot always a clear textbook answerNurse must learn to question, look at alternatives

How do nurse's accomplish this?Learns to be flexible in clinical decision makingReflect on past experiences and previous knowledgeListen to others point of viewIdentify the nature of the problemSelect the best solution for improving clients health

Definition of Critical ThinkingCognitive process during which an individual reviews data and considers potential explanations and outcomes before forming an opinion or making a decisionCritical thinking in nursing practice is a discipline specific, reflective reasoning process that guides the nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns. NLN 2000

Critical Thinking in NursingPurposeful, outcome-directedEssential to safe, competent, skillful nursing practiceBased on principles of nursing process and the scientific methodRequires specific knowledge, skills, and experienceNew nurses must question

Critical Thinking in NursingGuided by professional standards and ethic codesRequires strategies that maximize potential and compensate for problemsConstantly reevaluating, self-correcting, and striving to improve

Formula for Critical ThinkingStart Thinking

Why Ask Why

Ask the Right Questions

Are you an expert?

Aspects of Critical ThinkingReflection

Language

Intuition

Levels of Critical ThinkingBasic

Complex

Commitment

Critical Thinking CompetenciesScientific methodProblem SolvingDecision MakingDiagnostic Reasoning and InferencesClinical Decision MakingNursing Process

Developing Critical Thinking Attitudes/SkillsNot easyNot either orSelf-assessmentTolerating dissonance and ambiguitySeeking situations where good thinking practicedCreating environments that support critical thinking

Nursing ProcessSystematic approach that is used by all nurses to gather data, critically examine and analyze the data, identify client responses, design outcomes, take appropriate action, then evaluate the effectiveness of actionInvolves the use of critical thinking skillsCommon language for nurses to think through clinical problems

Nursing Process

Thinking and LearningLifelong processFlexible, open processLearn to think and to ANTICIPATEWhat, why, how questionsLook beyond the obviousReflect on past experienceNew knowledge challenges the traditional way

Components Of Critical ThinkingScientific Knowledge BaseExperienceCompetenciesAttitudesStandards

Attitudes That Foster Critical ThinkingIndependenceFair-mindednessInsight into ethnocentricityIntellectual humilityIntellectual courage to challenge status quoIntegrityPreserveranceConfidenceCuriosity

Professional StandardsEthical criteria for Nursing judgment- Code of EthicsCriteria for evaluation- Standards of careStandards of professional responsibility that nurses strive to achieve are cited in Nurse Practice Acts, TJC guidelines, institutional policy and procedure, ANA Standards of Nursing Practice

Critical Thinking SynthesisReasoning process by which individuals reflect on and analyze their own thoughts, actions, & decisions and those of others

Not a step by step process

Nursing ProcessTraditional critical thinking competency5 Step circular, ongoing processContinuous until clients health is improved, restored or maintainedMust involve assessment and changes in condition

When using the Nursing ProcessIdentify health care needsDetermine Priorities Establish goals & expected outcomesProvide appropriate interventionsEvaluate effectiveness

Nursing Process

AssessmentDiagnosisPlanningImplementationEvaluation

AssessmentSystemically collects, verifies, analyzes and communicates dataTwo step process- Collection and Verification of data & Analysis of dataEstablishes a data base about client needs, health problems, responses, related experiences, health practices, values. lifestyle, & expectations

Critical Thinking and Assessment Process Brings knowledge from biological, physical, & social sciences as basis for the nurse to ask relevant questions. Need knowledge of communication skillsPrior clinical experience contributes to assessment skillsApply Standards of PracticePersonal Attitudes

Assessment DataSubjective DataObjective DataSources of DataMethods of Data Collection-InterviewInterview initiates nurse-client relationshipUse open-ended questionsNursing health history

Nursing DiagnosisStatement that describes the clients actual or potential response to a health problemFocuses on client-centered problemsFirst introduced in the 1950sNANDA established in 1982Step of the nursing process that allows nurse to individualize care

Planning for Nursing CareClient-centered goals and expected outcomes are establishedPriorities are set relating to unmet needsMaslows Hierarchy of Needs is a useful method for setting prioritiesPriorities are classifies as high, intermediate, or low

Purpose of Goals and OutcomesProvides direction for individualized nursing interventionsSets standards of determining the effectiveness of interventionsIndicates anticipated client behavior or response to nursing careEnd point of nursing care

Goals of Care

Goal: Guideposts to the selection of nursing interventions and criteria in the evaluation of interventionsWhat you want to achieve with your patient and in what time frameShort term vs. Long termOutcome Of Care: What was actually achieved, was goal met or not met

Nursing InterventionsInterventions are selected after goals and outcomes are determinedActions designed to assist client in moving from the present level of health to that which is described in the goal and measured with outcome criteriaUtilizes critical thinking by applying attitudes and standards and synthesizing data

Types of InterventionsNurse-Initiated

Physician-Initiated

Collaborative Interventions

Selection Of InterventionUsing clinical decision making skills, the nurse deliberates 6 factors:

Diagnosis, expected outcomes, research base, feasibility, acceptability to client, competency of nurse

Nursing Care PlansWritten guidelines for client careOrganized so nurse can quickly identify nursing actions to be deliveredCoordinates resources for careEnhances the continuity of careOrganizes information for change of shift report

Nursing Care Plans vs Concept MapsNCPConcept/Mind Map

Implementation of Nursing InterventionsDescribes a category of nursing behaviors in which the actions necessary for achieving the goals and outcomes are initiated and completed

Action taken by nurse

Types of Nursing InterventionsStanding Orders: Document containing orders for the use of routine therapies, monitoring guidelines, and/or diagnostic procedure for specific condition

Protocols: Written plan specifying the procedures to be followed during care of a client with a select clinical condition or situation (Pneumonia, MI, CVA)

Implementation Process involves:Reassessing the client

Reviewing and revising the existing care plan

Organizing resources and care delivery (equipment, personnel, environment)

Evaluation

Step of the nursing process that measures the clients response to nursing actions and the clients progress toward achieving goalsData collected on an on-going basisSupports the basis of the usefulness and effectiveness of nursing practiceInvolves measurement of Quality of Care

Evaluation of Goal AchievementMeasures and Sources: Assessment skills and techniquesAs goals are evaluated, adjustments of the care plan are madeIf the goal was met, that part of the care plan is discontinuedRedefines priorities

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