Critical Thinking Ackley

Critical Thinking in Nursing
Betty Ackley, RN, MSN, EdS
Scenario One
A nursing assistant is taking a blood pressure
on a surgical patient
The BP is 90/60
The assistant is thinking
Ive got to get this recorded and get the rest of

those vital signs taken
Copyright 2008 Mosby, Inc. All rights reserved.
Usual thinking is routine, as in Scenario One,

or aimless, with random thoughts running
through our heads
Usual thinking is not purposeful in nature
Scenario Two
A registered nurse takes a blood pressure on the

same surgical patient
The BP is 90/60
The RN is thinking
Is this patient hypovolemic?

Is he heading into shock?
What more should I assess?
Could he be septic?
What are the other vital signs?
Pulse
Respirations
Temperature
Do they show a pattern?
And much more . . .
This is an example of critical thinking

The nurse is thinking to determine what
is happening to this client
The client may be in serious trouble
Critical thinking is significant thinking
These two scenarios illustrate the difference

between regular thinking
What the nursing assistant is doing
Versus critical thinking
What the nurse is thinking
This ability to think critically is key to excellent

nursing practice
In fact, great nurses are virtual thinking

machinesalways observing,
questioning, analyzing, diagnosing,
evaluating, and so much more
Critical thinking is the use of those cognitive

skills or strategies that increase the
probability of a desirable outcome. It is
purposeful, reasoned, and goal-directed
(Halpern, 1996 [cognitive psychologist]).
Critical thinking is purposeful and

solution-seeking
Critical Thinking Includes
Identifying and challenging assumptions

Challenging the importance of context
Imagining and exploring alternatives
Reflective skepticism
Making good arguments
Creative thinking
10
Critical Thinking
Its more than logical thinking and problem

solving
Ideally nurses should prevent problems from
happening
Example
The nurses goal is not to be in a code on her

client; instead her goal is to prevent the code from
happening by anticipating changes in her clients
condition
11
Whilst problem solving has an important

place in helping to diagnose disorders and
overcome difficulties, nursing needs to move
beyond its borders because the role also
concerns problem-free issues such as health
and well-being. Creativity, imagination, and
focusing on strengths, not problems, are also
important cognitive processes (McAllister,
2003).
12
Critical thinking is a skill that can be taught

and improves with practice
Expert nurses use critical thinking (Benner,

1984)
13
Characteristics of
Critically Thinking People
Truth-seeking
Analytical
Inquisitiveness
Critical thinking selfconfidence
Open-mindedness
Systematic in
thinking
Maturity
Creative
Adapted from: Alfaro-LeFevre,

2004
14
Components of Critical Thinking
Left brain thinking

Logical
Problem solving
Right brain thinking
Creative
Intuitive
Prevents problems
from happening
15
Creative Thinking
Suspending the left logical side of our brain

Allowing the creative right brain to emerge
16
Methods to Gain Input from the

Right Creative Side of the Brain
Exercise
Vacations
Meditation
Daydreaming
Sleep
Routine, repetitive work
17
Methods to Increase
Creative Thinking
Brainstorming
Lateral thinking
Conceptual mapping
18
Brainstorming Rules
Say everything that comes into your head

No discussion of any kind! Just listing
No judgments of any ideas, no evaluations
Adding onto other peoples ideas is OK
19
Lateral Thinking
Lateral thinking is a way of thinking which

seeks the solution to a problem by making
associations with other apparently unrelated
areas, rather than pursuing one logical train
of thought (Macquarie Dictionary)
20
Lateral Thinking (cont)
Looking at issues/problems from the side as

opposed to vertically
21
Lateral Thinking (cont)
Stepping stone method

Random stimulation
Use a random word, object, or situation to
stimulate thinking
A statement that is illogical used to stimulate
thinking. Used to suspend judgment (left
brain function) for a period of time until
explore ideas (DeBono, 1994).
22
Conceptual Map
AKA
Mind Map
23
Value of a Conceptual Map
Brainstorming
Creating a group mind set
Organizing ideas
Decision making
24
Creative Thinking
Keep an open mind

Suspend judgment until you have evaluated
the situation thoroughly
Evaluate the underlying assumptions or
perceptions about the situation or idea
25
Think outside of the box

Watch for and support the What ifs and Ahhah! that come with creative thinking
26
Creative Thinking
Trust your instincts

Use the techniques
Have fun!
27
Problem Solving and

Decision Making
28
Solving Problems and Making Good

Decisions
To have a good outcome
Be creative
Think win-win
And think critically!
29
Methods for Solving Problems
Trial and error

Experimentation*
Purposeful inaction
Problem-solving process*
*Recommended Methods
30
Problem-Solving Process
Define the problem
(WWWWWH)
Gather data
Analyze data
Develop solutions
Select a solution
Implement
Evaluate
31
Use the questions
WWWWWH
Who?
What?
Where?
Why?
When?
How?
32
Think About It
How do you usually make decisions?
33
Assumptions
34
Part of good critical thinking is being

able to differentiate facts from
assumptions, what is true or what is
assumed to be true
35
An assumption is a statement for which

no proof or evidence is offered
(Halpern,1996).
36
Assumptions are built into the human psyche

We make them all the time
These assumptions serve as an underlying
filter that affect all decisions
Like a screen or sieve that we process information

through
37
To be an effective critical thinker, it is helpful

to know your own assumptions, and how they
may color or change any decision you make
38
Clinical Example of an Inappropriate

Assumption
Its 3 AM in the ICU. Im caring for a 56-year-old

women with a GI bleed. There was no apparent
active bleeding. Her vs were 104/60, 118, 24.
She was alert, oriented, and talkative. Her urine
output was down to 10 cc/hour. Her attending
physician was a nephrologist. When her urine
output dropped, I assumed she had renal
impairment and probably did not put out normal
amounts of urine because she was being cared
for by a nephrologist. I WAS WRONG.
39
Clinical Example of an Inappropriate

Assumption (cont)
The nephrologist was also an internist, and this

woman previously had normal urine function.
The dec urine function was an indication of
worsening of her condition, and she was in
early stages of shock. I missed it. I should have
notified the physician of her dec urine output.
She died that morning after I had gone home to
bed. Its possible if I had notified the physician,
with treatment she could have survived. In this
situation, the assumption I made was harmful.
40
Making a Good Argument
41
As nurses, we have to be able to express

ourselves well so that other people will carry
out our decisions that we have arrived at by
critical thinking
42
To be effective as a nurse its not good

enough to just know what needs to be done;
we also need to influence others to carry out
our decisions
43
In order to do this, we need to be able to state

our cases succinctly and effectively
This is an extension of critical thinking, called
making a good argument
44
Now we are not talking about the usual

argument, a dispute or quarrel
45
Two Main Parts of an Argument
Premise
and
Conclusion
46
Conclusion
What you want to have happen, your belief,

or your point of view
For a good conclusion, you have to say it, be
specific, and obvious
To find a conclusion in an argument, you can
look for conclusion markers, which are
words such as therefore, so, and as a result
47
Premise
Why it should happen
The premise should be based on

facts/data/research, which we call evidence
You need evidence to have a good premise
Here you are giving reasons, and preferably more

than one if possible
The better the evidence, the better the argument
To find the premise, you can look for premise

markers, which are words such as because,
since, given that, and as evidenced by
48
Assumptions are also part of arguments

We use assumptions as premises, but they
dont work that well
Its much better to use evidence-based
premises
49
Making a Poor Argument When

Delegating to a UAP
Example
Jane, would you please take Mrs. Jones vital

signs every hour and report them to me?
Conclusion
Jane doesnt know why she should do this

She wont be motivated to do it
There is no premise to this argument
50
Making a Good Argument When

Delegating to a UAP
Example
Jane, would you please check Mrs. Jones vital signs

every hour and report them to me?
She just had major surgery yesterday and Im

concerned about her high pulse rate and the amount
of wound drainage (premise)
Im afraid she may be heading into shock (premise)
51
Additional Methods to
Increase Critical Thinking
52
Reframe the problem in your mind by

paraphrasing it, rewriting it, drawing a
diagram that shows relationships, or
drawing a picture of it
These are techniques to clarify the situation

and gain a different perspective
53
Use PMI
P = Plus or good points

M = Minus or bad points
I = Interesting points
(DeBono, 1994)
54
PMI allows us to suspend judgment until we

have looked at the idea from several
perspectives
55
Seek input from others to look for errors in

thinking, false perceptions
56
Summary Critical Thinking Has

Many Components
Creative thinking
Problem solving
Recognizing assumptions
Making a good argument
Using critical thinking techniques
57
Critical thinking in nursing is where its at

It separates the professional from the
technician
Enjoy using your mind
Its the most fascinating thing in this world
58
References
Alfaro-LeFevre R: Critical thinking in nursing: a practical approach , 3rd

ed, Philadelphia, 2004, WB Saunders.
DeBono E: DeBonos thinking course, New York, 1994, Facts on File.
DeBono E: Lateral thinking: creativity step by step , New York, 1970,
Harper and Row.
Halpern DF: Thought and knowledge: an introduction to critical
thinking, 3rd ed, Mahwah, New Jersey, 1996, Lawrence Erlbaum
Associates.
Maynard CA: Relationship of critical thinking ability to professional
nursing competence, Journal of Nursing Education, 35(1):12-18,
1996.
McAllister M: Doing practice differently: solution-focused nursing,
Journal of Advanced Nursing, 41:6, 528, 2003.
Rubenfeld MG, Scheffer BK: Critical thinking in nursing: an interactive
approach 2nd ed, Philadelphia, 1999, JB Lippincott.
Scheffer BK, Rubenfeld MG: A consensus statement on critical
thinking in nursing, Journal of Nursing Education, 39(8): 352-9, 2000.
59

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Critical Thinking in Nursing

Betty Ackley, RN, MSN, EdS

The assistant is thinking

Ive got to get this recorded and get the rest of

Copyright 2008 Mosby, Inc. All rights reserved.

Usual thinking is routine, as in Scenario One,

Usual thinking is not purposeful in nature

Copyright 2008 Mosby, Inc. All rights reserved.

A registered nurse takes a blood pressure on the

Is this patient hypovolemic?

Do they show a pattern?

And much more . . .

Copyright 2008 Mosby, Inc. All rights reserved.

This is an example of critical thinking

Copyright 2008 Mosby, Inc. All rights reserved.

These two scenarios illustrate the difference

What the nursing assistant is doing

Versus critical thinking

What the nurse is thinking

This ability to think critically is key to excellent

Copyright 2008 Mosby, Inc. All rights reserved.

In fact, great nurses are virtual thinking

Copyright 2008 Mosby, Inc. All rights reserved.

Critical thinking is the use of those cognitive

Copyright 2008 Mosby, Inc. All rights reserved.

Critical thinking is purposeful and

Copyright 2008 Mosby, Inc. All rights reserved.

Critical Thinking Includes

Identifying and challenging assumptions

Copyright 2008 Mosby, Inc. All rights reserved.

Its more than logical thinking and problem

The nurses goal is not to be in a code on her

Copyright 2008 Mosby, Inc. All rights reserved.

Whilst problem solving has an important

Copyright 2008 Mosby, Inc. All rights reserved.

Critical thinking is a skill that can be taught

Expert nurses use critical thinking (Benner,

Copyright 2008 Mosby, Inc. All rights reserved.

Adapted from: Alfaro-LeFevre,

Copyright 2008 Mosby, Inc. All rights reserved.

Components of Critical Thinking

Left brain thinking

Right brain thinking

Copyright 2008 Mosby, Inc. All rights reserved.

Suspending the left logical side of our brain

Copyright 2008 Mosby, Inc. All rights reserved.

Methods to Gain Input from the

Copyright 2008 Mosby, Inc. All rights reserved.

Copyright 2008 Mosby, Inc. All rights reserved.

Say everything that comes into your head

Copyright 2008 Mosby, Inc. All rights reserved.

Lateral thinking is a way of thinking which

Copyright 2008 Mosby, Inc. All rights reserved.

Lateral Thinking (cont)

Looking at issues/problems from the side as

Copyright 2008 Mosby, Inc. All rights reserved.

Lateral Thinking (cont)

Stepping stone method

Copyright 2008 Mosby, Inc. All rights reserved.

Copyright 2008 Mosby, Inc. All rights reserved.

Value of a Conceptual Map

Copyright 2008 Mosby, Inc. All rights reserved.

Keep an open mind

Copyright 2008 Mosby, Inc. All rights reserved.