Facione (1990) defines Critical Thinking as a purposeful self-regulatory judgment. Halpern (1989) defines it as a purposeful goal directed thinking. Critical Thinking is an essential component of Nursing since a nurse is always, by profession, confronted with complex situations, which demand accurate judgments, clinical decision-making and a continuous learning process.
Thus, a critical thinking involves a big process of reasoning and problem solving where all judgments and clinical decisions are based on evidence. In this process, there is an active ingredient of intuition, emotional intelligence and reflection.
In this process, there is also credibility of the data, scope for investigation and learning. Of course, Critical thinking in nursing is largely influenced by the psychological, physiological and environmental traits like age, level of confidence, bias, skills, fatigue, stress and co-workers.
Various nursing models like T.H.I.N.K. Model (Rubenfeld & Scheffer, 1995), Nursing judgment model (Kataoka-Yahiro & Saylor, 1994), Novice vs. Expert or Struggling vs. Exemplary nurses (Benner, 1984; Beeken, 1997) and Critical Thinking Interaction Model (Miller & Babcock, 1996) highlight the role of critical thinking in nursing practice. Thus, Evidence based nursing practice is an important aspect of Critical Thinking in nursing practice.
Evidence Based Nursing Practice:
Evidence based practice is the conscientious, explicit and judicious use of current best evidence in making decisions about the case of individual patients (Sackett, 1996).
Evidence based practice takes patient's perspective also into account. Hence, evidence based practice involves a big process of question building and this process of question building takes into account clinical findings, aeotiology, diagnosis, prognosis, therapy and prevention of diseases (Baum, 2003).
This question building process gives the idea on the most important question, the question which is encountered very often in practice and the question's relevance very often in practice and the question's relevance to the patient situation.
Evidence based practice is probably best understood as a decision-making framework that facilitates complex decisions across different and sometimes conflicting groups (Sackett, 1996). It involves considering research and other forms of evidence on a routine basis when making health care decisions.
Such decisions include choice of treatment, tests or risk management for individual patients, as well as policy decisions for large groups and populations (Baum, 2003). Of course, the best evidences are based on the conviction that a systematic documenting of a large number of high quality RCTs (Randomized with Concealment, Double blended, complete follow-up, intention to treat analysis) gives the least biased estimate.
Thus, this becomes level 1 evidence and recommendations based on level 1 evidence are Grade A. Various terminologies aid evidence based medical practice such as "Clinical practice guideline" which assists practitioner and patient make decisions about appropriate health care and "Randomized controlled clinical trial" where a group of patients is randomized into an experimental group and a control group. These groups are followed up for the variables and outcomes of interest.
According to Judith Green et.al (1998), Qualitative methods can help bridge the gap between scientific evidence and clinical practice, provide rigorous accounts of treatment regimens in everyday contexts, help us understand the barriers to using evidence based medicine, and its limitations in informing decisions about treatment.
Qualitative findings as discussed are often the first type of evidence available relating to innovations and contextual constraints relating to existing practice (David R. Thomas, 2000). Thus, the value of good qualitative data is that it can provide crucial information about context and processes related to health practices and interventions and can be useful in areas for which there is little or no previous research, the use of RCTs or other types of experiments is impossible and to complement quantitative data gathering providing data about unanticipated impacts of interventions.
Qualitative procedures can form information not obtainable using quantitative methods. Qualitative evidence is often the "best available" evidence until quantitative research is carried out (David R. Thomas, 2000).
Lincoln and Guba (1985) suggest that various techniques are necessary for improving and documenting the credibility of data. Having the participants together encourages sharing of views and test for misinformation and understanding amongst the participants, builds trust and good rapport with each other.
Trisha Greenhalgh et.al (2003), view evidence based practice as a sequence of framing a focused question followed by a thorough Search for research derived evidence supported by the appraisal of the evidence for its validity and relevance incorporating the user's values and preferences.
Henderson et.al (2004) have developed an instrument, suggested by Guba's Model of Trustworthiness of Qualitative Research, to evaluate the methodological rigor of qualitative papers expanding Sackett's Rules of Evidence Model for qualitative studies in clinical decision making and have proved that the appraisal instrument and the methodology straightforward, simple to use, and helpful in clinical decision making (Henderson et.al , 2004).
Evidence Based Nursing provides a practice with a strong application of the scientific method. This enables practice to proceed by a process of skeptical questioning rather than by embellishment with rhetoric (Baum, 2003).
Evidence Based Nursing Practice as a practice that helps in developing more transparent working practices to establish guidelines and standards. Evidence Based Nursing can become the basis for thousands of clinical and policy decisions about most aspects of health care, such as tests, treatments, risk factors, screening programs, and other forms of disease management.
Criticisms on evidence-based nursing have been that:
1.Evidence-based practice isn't new and it is what we have been doing for years,
2. Evidence based nursing disregards individualized patient care, and
3. Evidence based nursing lays over-emphasis on randomized controlled trials and systematic reviews. (Alba DiCenso et.al.1998).
Pravikoff et.al (2005) on close examination of nurses' perceptions about their access to tools and the skills to obtain evidence in their practice, using a stratified random sample of 3,000 RNs across the United States, have found that nurses frequently need information for practice on specific tasks but do not understand research nor have received any training in the use of tools that would help them find evidence to base their practice. Deborah J (1999) has also highlighted the theory practice gap that exists in nursing today as a barrier to evidence based nursing.
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To become a professional nurse requires that you learn to think like a nurse. What makes the thinking of a nurse different from a doctor, a dentist or an engineer? It is how we view the client and the type of problems we deal with in practice when we engage in client care. To think like a nurse requires that we learn the content of nursing; the ideas, concepts and theories of nursing and develop our intellectual capacities and skills so that we become disciplined, self-directed, critical thinkers.
Critical thinking is the disciplined, intellectual process of applying skilful reasoning as a guide to belief or action (Paul, Ennis & Norris). In nursing, critical thinking for clinical decision-making is the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care (Heaslip). Critical thinking when developed in the practitioner includes adherence to intellectual standards, proficiency in using reasoning, a commitment to develop and maintain intellectual traits of the mind and habits of thought and the competent use of thinking skills and abilities for sound clinical judgments and safe decision-making.
Intellectual Standards for Reasoning
Practitioners in nursing who are critical thinkers value and adhere to intellectual standards. Critical thinkers strive to be clear, accurate, precise, logical complete, significant and fair when they listen, speak, read and write. Critical thinkers think deeply and broadly. Their thinking is adequate for their intended purpose (Paul, Scriven, Norris & Ennis). All thinking can be examined in light of these standards and as we reflect on the quality of our thinking we begin to recognize when we are being unclear, imprecise, vague or inaccurate. As nurses, we want to eliminate irrelevant, inconsistent and illogical thoughts as we reason about client care. Nurses use language to clearly communicate in-depth information that is significant to nursing care. Nurses are not focused on the trivial or irrelevant.
Nurses who are critical thinkers hold all their views and reasoning to these standards as well as, the claims of others such that the quality of nurse's thinking improves over time thus eliminating confusion and ambiguity in the presentation and understanding of thoughts and ideas.
Elements of Reasoned Thinking
Reasoning in nursing involves eight elements of thought. Critical thinking involves trying to figure out something; a problem, an issue, the views of another person, a theory or an idea. To figure things out we need to enter into the thinking of the other person and then to comprehend as best we can the structure of their thinking. This also applies to our own thinking as well. When I read an author I'm trying to figure out what the author is saying; what problem or issue the author is addressing, what point of view or frame of reference he is coming from, what the goal or purpose is of this piece of writing, what evidence, data or facts are being used and what theories, concepts, principles or ideas are involved. I want to understand the interpretations and claims the author is making and the assumptions that underlie his thinking. I need to be able to follow the author's lines of formulated thought and the inferences which lead to a particular conclusion. I need to understand the implications and consequences of the author's thinking. As I come to understand the author in-depth I will also begin to recognize the strength and weakness of his reasoning. I will be able to offer my perspective on the subject at hand with a clear understanding of how the author would respond to my ideas on the subject.
The Elements of Thought
All thinking, if it is purposeful, includes the following elements of thought (Paul, 1990).
- The problem, question, concern or issue being discussed or thought about by the thinker. What the thinker is attempting to figure out.
- The purpose or goal of the thinking. Why we are attempting to figure something out and to what end. What do we hope to accomplish.
- The frame of reference, points of view or even world view that we hold about the issue or problem.
- The assumptions that we hold to be true about the issue upon which we base our claims or beliefs.
- The central concepts, ideas, principles and theories that we use in reasoning about the problem.
- The evidence, data or information provided to support the claims we make about the issue or problem.
- The interpretations, inferences, reasoning, and lines of formulated thought that lead to our conclusions.
- The implications and consequences that follow from the positions we hold on the issue or problem.
When nurses reason they use these elements of thought to figure out difficult questions and recognize that their thinking could be flawed or limited by lack of in-depth understanding of the problem at issue therefore, they critically monitor their thinking to ensure that their thinking meets the standards for intellectual thought.
In summary, as a critical thinker, I am able to figure out by reading or listening critically what nurse scholars believe about nursing and on what basis nurses act as they practice nursing. To do this I must clearly comprehend the thinking of another person by figuring out the logic of their thinking. I must comprehend clearly the thinking of myself by figuring out my own thoughts on the subject at hand. Finally, I must use intellectual standards to evaluate my thinking and the thinking of others on a given problem such that I can come to a defensible, well reasoned view of the problem and therefore, know what to believe or do in a given circumstance. To do this I must be committed to developing my mind as a self-directed, independent critical thinker. I must value above all else the intellectual traits and habits of thought that critical thinkers possess.
Intellectual Traits and Habits of Thought
To develop as a critical thinker one must be motivated to develop the attitudes and dispositions of a fair-minded thinker. That is, one must be willing to suspend judgments until one truly understands another point of view and can articulate the position that another person holds on an issue. Nurses come to reasoned judgments so that they can act competently in practice. They continually monitor their thinking; questioning and reflecting on the quality of thinking occurring in how they reason about nursing practice. Sloppy, superficial thinking leads to poor practice.
Critical inquiry is an important quality for safe practice. Nurses must pose questions about practice and be willing to attempt to seek answers about practice. Nurses must be willing to attempt to seek answers to the difficult questions inherent in practice, as well as the obvious. Question posing presupposes intellectual humility and a willingness to admit to one's areas of ignorance as well as, intellectual curiosity and perseverance and willingness to seek answers. Critical thinkers in nursing are truth seekers and demonstrate open-mindedness and tolerance for others' views with constant sensitivity to the possibility of their own bias.
Nurse's who are critical thinkers value intellectually challenging situations and are self-confident in their well reasoned thoughts. To reason effectively, nurses have developed skills and abilities essential for sound reasoning.
Critical Thinking Skills and Abilities
Critical thinkers in nursing are skilful in applying intellectual skills for sound reasoning. These skills have been defined as information gathering, focusing, remembering, organizing, analyzing, generating, integrating and evaluating (Registered Nurse's Association of British Columbia, 1990). The focus of classroom and clinical activities is to develop the nurse's understanding of scholarly, academic work through the effective use of intellectual abilities and skills. As you encounter increasingly more complex practice situations you will be required to think through and reason about nursing in greater depth and draw on deeper, more sophisticated comprehension of what it means to be a nurse in clinical practice. Nursing is never a superficial, meaningless activity. All acts in nursing are deeply significant and require of the nurse a mind fully engaged in the practice of nursing. This is the challenge of nursing; critical, reflective practice based on the sound reasoning of intelligent minds committed to safe, effective client care.
To accomplish this goal, students will be required to reason about nursing by reading, writing, listening and speaking critically. By doing so you will be thinking critically about nursing and ensuring that you gain in-depth knowledge about nursing as a practice profession.
Critical Thinking...a Holistic Approach
Critical Listening: A mode of monitoring how we are listening so as to maximize our accurate understanding of what another person is saying. By understanding the logic of human communication - that everything spoken expresses point of view, uses some ideas and not others, has implications, etc., critical thinkers can listen so as to enter empathetically and analytically into the perspective of others.
Critical Thinking: 1) Disciplined, self-directed thinking which implies the perfection of thinking appropriate to a particular mode or domain of thinking. 2) Thinking that displays master of intellectual skills and abilities. 3) The art of thinking about your thinking while you are thinking in order to make your thinking better: more clear, more accurate, or more defensible.
Critical Writing: To express oneself in languages required that one arrange ideas in some relationships to each other. When accuracy and truth are at issue, then we must understand what our thesis is, how we can support it, how we can elaborate it to make it intelligible to others, what objections can be raised to it from other points of view, what the limitations are to our point of view, and so forth. Disciplined writing requires disciplined thinking; disciplined thinking is achieved through disciplined writing.
Critical Reading: Critical reading is an active, intellectually engaged process in which the reader participates in an inner dialogue with the writer. Most people read uncritically and so miss some part of what is expressed while distorting other parts. A critical reader realizes the way in which reading, by its very nature, means entering into a point of view other than our own, the point of view of the writer. A critical reader actively looks for assumptions, key concepts and ideas, reasons and justifications, supporting examples, parallel experiences, implications and consequences, and any other structural features of the written text to interpret and assess it accurately and fairly. ( Paul, 1990, pp 554 & 545 )
Critical Speaking: Critical speaking is an active process of expressing verbally a point of view, ideas and thoughts such that others attain an in-depth understanding of the speaker's personal perspective on an issue. Monitoring how we express ourselves verbally will ensure that we maximize accurate understanding of what we mean through active dialogue and openness to feedback on our views. (Heaslip, 1993).
Paul, R.W. (1990). Critical Thinking: What Every Person Needs to Survive in a Rapidly Changing World. Rohnert Park, California: Center for Critical Thinking and Moral Critique
Norris, S. P. & Ennis, R.H. (1989). Evaluating critical thinking. Pacific Grove, CA: Midwest Publications, Critical Thinking Press