CRITICAL

THINKING IN
NURSING
Ns.Sri Yuliana.,M.Sc
 BACKGROUND
● Memprioritaskan pelayanan pasien harus didasarkan pada konsep
“berpikir kritis” dari pada hanya fokus pada menyelesaikan tindakan
perawatan.
● Critical thinking adalah konsep umum yang di gunakan dalam
keperawatan, yaitu pemikiran tentang isu klinis seperti kerjasama,
kolaborasi, dan alur dalam bekerja.
● Critical thinking is applied by nurses in the process of solving problems
of patients and decision-making process with creativity to enhance the
effect.
How do we make
decisions?
How do nurses make
decisions about patient
care?
What do we rely on to
help us in decision
making?
In critical thinking, the nurses still distinguish
claims based on facts, conclusions, judgments
and opinions. The assessment of the reliability of
information is an important stage of critical
thinking, where the nurse needs to confirm the
accuracy of this information by checking other
evidence and informants.
• Ada banyak tindakan keperawatan yang harus dilakukan oleh perawat
selama mereka shift, tetapi perawat perlu beradaptasi dan fleksibel untuk
memenuhi kebutuhan pasien.
• Hal ini akan terlihat sulit bagi perawat pemula untuk mengubah pola
pikir dalam membangun “rencana” yang akan dilakukan pada hari itu.
tetapi semakin cepat seorang perawat menyadari prioritas ditentukan oleh
kebutuhan pasien mereka, semakin sedikit frustrasi/beban kerja yang
dialami perawat.
• Strategi prioritas meliputi pengumpulan informasi dan membangun
penalaran klinis/clinical reasoning untuk menentukan tindakan terbaik
saat itu.
The practice of nursing requires critical thinking and clinical
reasoning.
 Critical thinking
Is the process of intentional higher level thinking of define a
clients’ problem examine the evidence –based practice in
caring for the client, and make choices in the delivery of care.
 Clinical reasoning:
Is the cognitive process that uses thinking strategies to
gather and analyze clients information ,evaluate the
relevance of the information , and decide on possible nursing
to improve the clients physiological and psychosocial
outcomes clinical reasoning requires the integration of critical
thinking in the identification of the most appropriate
interventions that will improve the clients condition.
● Berfikir kritis adalah suatu proses dimana
seseorang atau individu dituntut untuk
menginterferensikan atau mengevaluasi informasi
untuk membuat sebuah penilaian atau keputusan
berdasarkan kemampuan, berdasarkan ilmu
pengetahuan dan pengalaman, (Perry dan Potter
2005)
BERFIKIR KRITIS

 Menyelesaikan
masalah,
 Mencari solusi terbaik
masalah pasien u/
 Mempertahankan/
mendapatkan kembali
atau meningkatkan
kesehatannya
ASPEK DALAM BERPIKIR KRITIS
Berpikir kritis adalah proses, suatu disiplin
intelektual untuk menerapkan keterampilan
penalaran sebagai panduan untuk kepercayaan
atau tindakan

Perlu Keterampilan kognitif dengan kualitas

tinggimemerlukan disiplin intelektual, evaluasi
diri, berpikir ulang, oposisi, tantangan dan
dukungan
Mengapa perlu berpikir kritis?
● Dalam keperawatan, berpikir kritis untuk membuat keputusan klinis 
kemampuan untuk berpikir secara sistematis dan logis dengan keterbukaan
terhadap pertanyaan dan merefleksikan penalaran proses yang digunakan
untuk memastikan praktek keperawatan yang aman dan perawatan kualitas
(Heaslip).
● Berpikir kritis yang dikembangkan di praktek Keperawatan meliputi
kepatuhan terhadap standar intelektual, kemahiran dalam penggunaan
alasan, komitmen untuk mengembangkan dan memelihara ciri-ciri
intelektual dari pikiran dan kebiasaan berpikir dan menggunakan
keterampilan berpikir yang kompeten dan kemampuan untuk mengambil
keputusan dan pengambilan keputusan yang aman.
BERPIKIR KRITIS  PERLU MEMAHAMI
ELEMEN BERPIKIR KRITIS
• Menentukan tujuan
• Menyusun pertanyaan atau membuat
kerangka masalah
• Menunjukan bukti
• Menganalisis konsep
• Asumsi

Kejelasan, ketepatan, ketelitian

dan keterkaitan
STANDAR DALAM BERPIKIR KRITIS
KLASIFIKASI BERPIKIR DI KENAL DALAM “THE
SIX RS”
 TEKHNIK DALAM BERPIKIR
KRITIS
1. CRITHICAL ANALYSIS

Pengaplikasian beberapa pertanyaan terhadap keadaan ataupun ide

untuk mendapatkan informasi yang penting dan ide dan untuk
mengeliminasi informasi dan ide yang tidak penting dan relevant
QUESTIONS ABOUT THE DECISION (OR PROBLEM)
Is this question clear, understandable, and correctly
identified?
Is this question important?
Could this question be broken down into smaller parts?
How might _____________ state this question?
QUESTIONS ABOUT ASSUMPTIONS
You seem to be assuming _____________; is that so?
What could you assume instead? Why?
Does this assumption always hold true?
QUESTIONS ABOUT POINT OF VIEW
● You seem to be using the perspective of _____________.
● Why?
● What would someone who disagrees with your
● perspective say?
● Can you see this any other way?
QUESTIONS ABOUT EVIDENCE AND REASONS
● • What evidence do you have for that?
● • Is there any reason to doubt the evidence?
● • How do you know?
● • What would change your mind?
QUESTIONS ABOUT IMPLICATIONS AND CONSEQUENCES
● • What effect would that have?
● • What is the probability that will actually happen?
● • What are the alternatives?
2-Inductive and deductive reasoning:
 Inductive reasoning= generalizations are
formed from a set of facts or observations.
 Deductive reasoning= reasoning from
the general to the specific.
 3-Statements differentiation:
Example Statement Description
Blood pressure is affected by blood Facts: Can be verified through investigation
.volume
If blood volume is decreased Inferences: Conclusions drawn from
(e.g., in hemorrhagic shock), the facts; going beyond facts to
.the blood pressure will drop
make a statement about something
not currently known
It is harmful to the client’s health if the Judgments Evaluation of facts or information that
.blood pressure drops too low
reflects values or other criteria; a type of opinion
Nursing interventions can assist in Opinions Beliefs formed over time; include judgments
maintaining the client’s that may fit
blood pressure within normal facts or be erroneous
limits.
4-Evaluating the credibility of information sources:
is an important step in critical thinking. We cannot always
believe what we read or are told.
● The nurse must ascertain the accuracy of information by
checking
other documents or with other informants. Hence, the
expanding need for evidence-based nursing practice.
5-Clarifying concepts:To comprehend a client situation clearly,
the nurse and the client must agree on the meaning of terms.
For example, if the clients says to the nurse “I think I have a
tumor,” the nurse needs to clarify what the word means to the
client—the medical definition of a tumor (a solid mass) or the
common lay meaning of cancer—before responding.
6-Recognizing assumptions:
People also live their lives under certain assumptions. Some people
view humans as having a basically generous nature, whereas others
believe that the human tendency is to act in their own best interest.
The nurse may believe that life should be considered worth living no
matter what the condition, whereas the client may believe that quality
of life is more important than quantity of life.
 If the nurse and client recognize that they make choices based on
these assumptions, they can still work together toward an acceptable
plan of care.
Difficulty arises when people do not take the time to consider what
assumptions underlie their beliefs actions
.
 Applying critical thinking to nursing practice

Implementation of the nursing process provides nurses with a creative approach

to thinking and doing to obtain, categorize, and analyze client data and plan
actions that will meet the client’s needs.
Nursing process: is a systematic, rational method of planning
and providing individualized nursing care.
The phases of the nursing process are assessing, diagnosing, planning,
implementing, and evaluating
Applying critical thinking to nursing
practice
1. Problem Solving
Problem solving: Process used when a gap is perceived between an existing state (what
is occurring)& a desired state of what should be occurring.
Throughout the problem-solving process the implementation of critical thought may or
may not be required in working toward a solution (Wilkinson, 2012). The nurse
carefully evaluates the possible solutions and chooses the best one to implement.
Commonly used approaches to problem solving include trial and error, intuition, and
the research process
 Applying critical thinking to nursing practice

trial and error:

In trial and error, a number of approaches are tried until a solution is
found.
The use of trial- and-error methods in nursing care can be dangerous
because the client might suffer harm if an approach is
inappropriate.
However, nurses often use trial and error in the home setting due to
logistics, equipment, and client lifestyle .
For example, when teaching a client to perform a colostomy
irrigation, bent coat hanger hung on the shower curtain rod
pervades an appropriate height to perform the irrigation .
 Applying critical thinking to nursing practice
● Intuition
● Is a problem-solving approach that relies on a
nurse’s inner sense. It is a legitimate aspect of a
nursing judgment in the implementation of care.
● Intuition is the understanding or learning of things
without the conscious use of the reasoning. It I also
known as sixth sense, hunch, instinct, feeling, or
suspicion.
 Applying critical thinking to nursing practice

RESEARCH PROCESS:
● is a formalized, logical, systematic approach to problem solving. The classic
quantitative research process is most useful when the researcher is working in a
controlled situation. Health professionals, often working with people.
● For example, unlike many experiments with animals in which the environment
can be strictly regulated, the effects of diet on health in humans are complicated
by a person’s genetic variations, lifestyle, and personal preferences. However, it
is becoming increasingly important for nurses to identify evidence that supports
effective nursing care. One critical source of this evidence is research.
 Applying critical thinking to nursing practice

Clinical judgment:
• in nursing is a decision-making process to ascertain the right
nursing action to be implemented at the appropriate time in the
client’s care.
• The nurse must first have the knowledge base necessary to practice
in the clinical area and then use that knowledge in clinical practice.
• Clinical experience allows the nurse to recognize cues and patterns
and begin to reach correct conclusions.
Integration of critical thinking and clinical reasoning

● Nurses use critical thinking and clinical reasoning skills when

making
decisions about client care. The decision-making process includes
prioritizing care not only with one client but when providing care to many
clients.
 When faced with several client needs at the same time, the nurse
must prioritize and decide which client to assist first.
 Example,In the home care setting, the nurse must decide if the
client’s
 condition can be managed in the home or requires hospitalization.
Integration of critical thinking and clinical reasoning
● Logical reasoning is a critical thinking skill that closely aligns with
clinical reasoning. In the planning of care, nurses must question
whether knowledge they possess about the care of the client is
consistent with the most current evidence-based practice. The nurse
must review the most current nursing and health-related literature
prior to implementing care.
SKENARIO 1
● Saya memiliki pasien yang di jadwalkan operasi pemasangan pacemaker
pada jam 09.00. Dokter menginginkan saya untuk memasang 2 unit darah
sebelum turun kelantai bawah untuk memulai prosedur. Saya melakukan
protocol tersebut. 30 menit setelah unit darah kedua di mulai, saya
menyadari bahwa SPO2 menurun, dari 95% menjadi 92% dan turun lagi
menjadi 90%. Saya memasang 2L oksigen pada pasien dan saturasi oksigen
menjadi 91%. Tetapi itu hanya berlangsung sementara oksigen menurun
kembali menjadi 90%.
● Saya berhenti dan berpikir apa yang sedang terjadi pada pasien?
● Saya melihat riwayat penyakit pasien yaitu gagal jantung
● Saya melihat intake dan output dari pasien, yaitu 1,5 liter
● Saya berpikir bgaimana pasien mendapatkan cairan berlebih dan itu
disebakan oleh CHF/gagal jantung. he can’t really pump out the fluid he
already has, let alone this additional fluid. Maybe I should listen to his lungs
● His lungs were clear earlier. I heard crackles throughout both lungs
Lanjut
● OK, so he’s got extra fluid that he can’t get out of his body. What do
I know that will get rid of extra fluid and make him pee? Maybe
some Lasix?
● I ran over my thought process with a coworker before calling the
doc. They agreed. I called the doc and before I could suggest
anything, he said “Give him 20 mg IV Lasix one time, and I’ll put
the order in.” CLICK.
● I gave the Lasix. He peed like a racehorse (and was NOT happy with
me for making that happen!). And he was off of oxygen before he
went down to get his pacemaker.
Skenario 2
● My patient just had her right leg amputated above her knee. She was on a Dilaudid
PCA and still complaining of awful pain. She maxed it out every time, still saying she
was in horrible pain. She told the doctor when he rounded that morning that the meds
weren’t doing anything. He added some oral opioids as well and wrote an order that it
was okay for me to give both the oral and PCA dosings, with the goal of weaning off
PCA.
● “How am I going to do that?” I thought. She kept requiring more and more meds and
I’m supposed to someone wean her off?
●  asked her to describe her pain. She said it felt like nerve pain. Deep burning and
tingling. She said the pain meds would just knock her out and she’d sleep for a little
while but wake up in even worse pain. She was at the end of her rope.
● I thought about nerve pain. I thought about other patients that report similar pain. 
Diabetics with neuropathy would talk about similar pain… “What did they do for it?
” I thought. Then I remembered that many of my patients with diabetic neuropathy
were taking gabapentin daily for pain.
● “So if this works for their nerve pain, could it work for a patient who has had
an amputation?” I thought.
● I called the PA for the surgeon and asked them what they thought about
trying something like gabapentin for her pain after I described my patient’s
type of pain and thought process.
● “That’s a really good idea, Kati. I’ll write for it and we’ll see if we can get
her off the opioids sooner.”
● She wrote for it. I gave it. It takes a few days to really kick in and once it did,
the patient’s pain and discomfort were significantly reduced. She said to get
rid of those other pain meds because they “didn’t do a damn thing,” and to
“just give her that nerve pain pill because it’s the only thing that works”.
● She was able to work with therapy more because her pain was tolerable and
was finally able to get rest.
● “Critical thinking does not develop
overnight. It takes time. You don’t
learn to talk overnight or walk
overnight. You don’t 
learn to critically think overnight .”

● Time, Exposure, Questioning, Confidence

boost your critical thinking
Terima kasih