As Buckingham and Adams (2000) state, “getting a better understanding of their decision making processes has important benefits for nurses”, and for their employers and their patients (p 982). Critical thinking in nursing is related to the traditional nursing model of assessment, planning, implementation and evaluation, a fundamental nursing process (Lee et al, 2006). Because of the universal application of the nursing process, and its efficacy, there is an assumption that “the process of clinical problem-solving is well understood” (Taylor, 2000 p 842-849). This essay explores the critical thinking process related to one client, and evaluates the quality of that process and its relationship to effective planning and implementation of nursing care.
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Some theorists link critical thinking in nursing to diagnostic practice, particularly in relation to advanced nursing practice, and cite this as a new phenomenon (Lee et al, 2006). This author however, would argue that this is a part of nursing practice in every case, and that critical thinking and diagnostic processes are very similar, except it has never been called diagnosis in nursing until recently. However, Lee et al (2006) do cite the means by which nursing judgements on which plans of care are based, including systems-processing type judgements and intuitive reasoning. One of the criticisms of nursing decision making, however, and a problem which continues to trouble the profession, is the reduction of this process to little more than intuitive processes rather than rational ones (Buckingham and Adams, 2000). This is partly because “nurses have struggled continually to articulate the nature of their expertise” Buckingham and Adams, 2000 p 982). But the literature demonstrates that intuitive processes tend to represent subconscious decision making combined with conscious decision making, and this author believes that both are of equal value and importance in coming to decisions and planning nursing actions and ongoing care. Aitken (2003) suggests that clinical decision making starts with the development of a hypothesis, which is then proved or disproved by further gathering of clinical data, objective and subjective, including objective tests and nursing-process related observations and questioning.
“Hypotheses were used to summarize attributes that had already been acquired, describe the possible problem that existed and direct future attribute acquisition.” (Aitken, 2003 p 481).
Offredy (1998) in research on nurse practitioners found that hypothesis generation as part of the decision making process occurred even before the client history had been taken, and that this kind of ‘hunch’ was one which they believed to be borne out in later more objective clinical evaluation. This is related to the level of experience of the nurse (Offredy, 1998).
Lee et al (2006 p 61)) cite the following variables as affecting critical thinking processes: knowledge; experience; discipline specific training, which provides the diagnostic labels that can be used to ‘classify and explain the data’ involved ; and the task. Aitken (2003) suggests that the strategies which are applied to nursing decision making is not necessarily a conscious plan but could be a process which is more subconscious. This may be related to what Offredy (1998) describes as pattern recognition.
In this case, the critical thinking process was based on Jaslyn’s symptoms and presentation in terms of physical and emotional state, which in turn were identified and informed by the nurse’s own knowledge, nursing and symptom related knowledge, and by the nurse’s experience gained from training and previous practice. There were key factors which highlighted Jaslyn’s state of health/illness and also flagged up the warning signs that signified Jaslyn’s immediate needs. These were identified both through objective data and subjective data, which in terms of Maslow’s hierarchy of needs, could be seen as safety and security needs, related to the patient’s expressed suicidal thoughts, and physiological needs, related to her physical condition, which, once met, would allow for interventions to support in meeting her self-esteem and other psychological and emotional needs. Prioritisation of safety and physiological needs may be derived from previous nursing experience, as already suggested, because, as Aitken (2003) suggests, clinical decision making processes can be affected by the decision-making environment, and also by “the potential consequences of each of the [potential] alternative decisions” (p 477).
Thus previous experience of nursing, combined with knowledge from my training, which is also affected by the socialisation process of nursing, and by the shared knowledge of colleagues, placed the greatest emphasis on the prevention of harm occurring, which led to the decision to provide close supervision of the patient to prevent self-harm. Another attribute of this decision making process, one which I had hitherto not recognised, was the use of what Aitken (2003) calls “a think aloud” method (p 483). This is very much evident in the kind of decision making I engage in, and critical reflection suggests that I have learned this process from colleagues, because the process seems to be a communal one, in which colleagues (including myself) verbalise their judgements on findings and gain confirmation from each other that their findings and actions are correct. This might also be a means of trying to reduce the potential for error which is inherent in the decision making process, and constitutes the risk element of the process (Buckingham and Adams, 2000; Round, 2001).
The application of the nursing process has shown me that processes of decision making are based on experience, but that some of this experience is derived from shared knowledge and experience with colleagues. Throughout the decision making process involved in this case, decision making was more collaborative than unilateral, signifying the fact that no clinical decision is made in isolation. The decision making process was borne out in the clinical progression of the case, and reflection demonstrates that decision making is both objective, and informed by intuition, but that what is called intuition is simply the bringing to bear of knowledge developed through experience.
Aitken, L.M. (2003) Critical care nurses’ use of decision-making strategies. Journal of Clinical Nursing 12 476-483.
Buckingham, C.d. and Adams, A. (2000) Classifying clinical decision making: a unifying approach. Journal of Advanced Nursing 32 (4) 981-989.
Lee, J, Chan, A.C.M. and Phillips, D.R. (2006) Diagnostic practise in nursing: a critical review of the literature. Nursing and Health Sciences 8 57-65.
Offredy, M. (1998) The application of decision making concepts by nurse practitioners in general practice. Journal of Advanced Nursing 28 (5) 988-1000.
Round, A. (2001) Introduction to clinical reasoning. Journal of Evaluation in clinical practice7 (2) 109-117.
Taylor, C. (2000) Clinical problem-solving in nursing: insights from the literature. Journal of Advanced Nursing 31 (4) 842-849.
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