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Running head: CONCEPT ANALYSIS: CRITICAL THINKING

Concept Analysis: Critical thinking Christine Williams Graceland University Theory in Nursing NURS5121-1 Dr. Sitler January 27, 2013

Background on Critical Thinking Identification of the Concept of Critical Thinking Critical thinking is considered crucial for health care professionals to perform effectively in a constantly changing health care arena. Recognizing challenging problems, examining situations, and calculating situations from an assortment of viewpoints is vital to guarantee ideal patient outcomes (Goshorn & Byers, 1997). Purpose of a Critical Thinking Analysis Consensus as to what the definition of critical thinking is has yet to be communicated in the multifaceted advances of health care. The Joint Commission (2010) expressed concern about patient care quality and safety, and is looking at the modernization of nursing education in order to provide clinically stronger nurses. When critical thinking is concretely defined, more research can be applied to the integration of critical thinking skills and procedures that would provide improved quality and safety in health care at all levels. Critical thinking simplifies goals, processes data, studies assumptions, discriminates standards, assess and evaluate evidence, and implements change (Scriven & Paul, 1987; The Joint Commission, 2010). Assumptions Underlying Critical Thinking A widespread assumption at the core of critical thinking is that Information or data is equivalent to thinking skills. Critical thinking is an objective which, when done thoroughly, expedites accurate judgments. Another assumption is one who makes decisions is confident of their choices. Gathering information or essential data, organizing the data, reviewing priorities, consideration of risks, and identifying problems are influenced by perceptions of ones self and their knowledge. These assumptions lead to the essential analysis of critical thinking to elucidate the current definitions (Marchigiano, Eduljee, & Harvey, 2011; Harbison, 2001).

Development of Theoretical Definition Definitions in Literature Ennis postulates the purpose of critical thinking is in seeking the truth or at the very least a reasonable explanation. This does not mean that the truth will be discovered by critical thinking, but that the goal will result in the truth. He advocates the use of sensitivity, experience, background knowledge, and understanding of the situation when contemplating issues (Ennis, 2008). Scriven and Paul (1987, 2008), report critical thinking is an intellectually driven process that scrutinizes essential concerns using various methods of reasoning, and interlaced modes of thinking from a variety of sources, such as psychology, anthropology, economics, philosophy, moral thinking, and mathematics. Scheffer and Rubenfeld (2000) developed a series of competences that can be utilized to learn, teach and assess critical thinking. Their Components and Dimensions of Critical Thinking look at investigation, interpretation, application, generation, evaluation, and justification of critical thinking. This approach clarifies terminology, examines issues and data, reviews processes, develops rational, investigates findings, looks at strengths and weaknesses of opinions, and examines choices based on rationale. Vaughn (2005) claims, critical thinking is systematic and rational. Critical thinking is systematic because it involves well-defined processes and procedures driven by rational standards that are evaluated by how well reasoning is utilized. Elder (2007), accounts critical thinking is developed through reasoning that is self-guided and utilizes rationale, and reason in an intellectual manner that contribute to the growth of the individuals integrity, humility, civility, empathy, sense of justice, and confidence.

Comparative Analysis Although there was a vast amount of definitions found in the literature about critical thinking, the most common theme was the basic process of recognizing information and justifying ones actions based on past evidence as rationalization for decision-making. Ennis (2008), and Elder (2007) felt experience and growth contributed to improved critical thinking skills. Scriven and Paul (1987, 2008) insist this must be accomplished with the integration of a multidisciplinary background, where Ennis (2008) the background of the situation was sufficient. Scheffer and Rubenfeld (2000), as well as Vaughn (2008), viewed following an established process and following procedure as key to developing to assist with decision-making. Develop your own model and contrary cases Exemplar case. Jose is a 48 year old man in jail for driving under the influence. The police brought him to the emergency department at a local community hospital after an assault by another prisoner, resulting in loss of consciousness. Besides a history of alcohol abuse, Jose, also suffered from hypertension, HIV, Hepatitis C, diabetes, and had valvular cardiac surgery, for which he was taking Warfarin. Jose presented in triage alert with a blood pressure of 210/136, heart rate of 112, moving all extremities, ambulating and a moderate headache. There was reported a positive loss of consciousness un-witnessed. The nurse that triaged the patient did not take a medical history. She assessed the situation as a prisoner in a brawl with another prisoner, and designated Jose to minor care in fast-track. The fast-track nurse, Liz, immediately noted he was triaged as a head injury and thought it peculiar the patient was assigned to a noncritical area of care. Upon assessing Joses vitals, loss of consciousness and reviewing his medical history, as well as his daily medication of Warfarin, she became alarmed. She also noticed that while the patient was setting up he was drift his upper body to the left slightly, a

complaint of increase severity of headache, but all other neuro assessment findings were negative. The provider had given an order to given an anti-hypertensive medication to the patient before seeing the patient relying on the triage nurse assessment of the situation. Liz would not give the medication, started an IV, placed patient on a monitor, notified CT Scan and ordered a stat Head CT and took Jose to radiology herself. Upon re-checking his blood pressure Liz found it to be 136/92. She rushed the patient to the cardiac procedure room and notified the ED physician of the bleed with cranial shift noted in CT. Jose became increasingly lethargic, combative, agitated, before he slumped over. Jose lost consciousness, he was intubated to protect his airway. The CT Scan showed a head bleed. Jose was flown to a large medical center for neurosurgery, but never recovered and died the next morning. This exemplar demonstrates how attitudes, believes, assumptions, and lack of information can cause catastrophic results. Is it possible that even if the triage nurse had the appropriate critical thinking skills Jose could have lived? It is probable that he would have died anyway? Delay in care due to judgment has caused many hospital related deaths. Contrary to the triage nurses actions, are those of Liz. She used her instincts, knowledge, information, implemented skills, followed policy, and took action. Did Lizs actions differ from the triage nurse because of attitudes and assumptions or did her life experiences and education level influence her critical thinking skills? Related case. Julie is a 5 year RN working in the emergency department of a local community hospital. Dr. Caputo is a new resident and is admitting Julies patient, Mrs. Leon. Mrs. Leon is a brittle diabetic and is in diabetic ketoacidosis. Her serum blood glucose is 789 and her serum potassium is 7.3. Dr. Caputo, wanting to chemically dialyze Mrs. Leon, orders regular insulin 25 units IV push stat, Dextrose 50% 25 grams, Kayexalate 30 grams, with 2,000

ml bolus of 0.9% normal saline. While Julie was drawing up the insulin, her colleague, Liz noted the large amount of insulin being drawn up. After questioning Julie and reviewing the orders with her, Liz suggested Julie speak with the charge nurse about the large insulin order. Julie did as was suggested, and the charge nurses response was to assist Julie to prepare the administration of the insulin. Liz, concerned for Mrs. Leon, paged her primary physician and Dr. Caputo to discuss the insulin order. The insulin dose was reduced to 10 units stat IV push, and the patient was then placed on an insulin drip to infuse via IV pump on a titration scale based on hourly blood sugar checks. Liz then gathered the charge nurse and Julie and educated them on the pathophysiology of chemical dialysis. Again we see Lizs actions as congruent to thinking critically, and her colleagues lack of knowledge or experience placing the patient in danger. Social context and values of concept Failure to think critically can result in death, financial losses, loss of employment, illness, addictions, academic failure, poor reputation, poor communication, and even violence. Mistakes can take place when the thinker is unable to apply the methods or because of character traits, such as prejudice, bias, misinformation, etc. The acquisition, analysis, and reasonable assumptions are elements that can guide all professional and academic disciplines. Approaches to critical thinking can come from a variety of fields, such as, anthropology, sociology, history, psychology, philosophy, mathematics, chemistry, biology, ecology, law, and ethics (Facione, 2010). Theoretical definition congruent with attributes and model cases The theoretical definition of critical thinking presented in this paper is congruent with the exemplar cases, comparative analysis, defining attributes, social contexts and values. Critical thinking is the use of scientific, experiential and situational knowledge that are utilized to assess,

prioritize, plan, implement, evaluate and then re-assess responses to choice actions. In order for one to become expert at critical thinking one must be willing to criticize oneself, reflect thoughtfully, collaborate with peers, expanding on their logic and criteria through education, as well as, continued personal and professional experiences in multiple disciplines. Operational definition of the concept Antecedents Nursing science and practice are characterized by three patterns of knowing: Scientific, Experiential, and personal. In the case of critical thinking, an antecedent would be that of knowing through literature and guidelines, life experience, or ones personal experience in situations. They give a perspective on nursing knowledge base. Unfortunately, there is no process for advancing practice. (Rolfe, 1998). Consequences Information alone is not adequate for knowing in actions, sound clinical judgment, and decision-making. Information is often misconstrued as knowledge and knowledge with judgment. This causes failure to unify knowledge through critical thinking that steers to the favored outcome of comprehensive clinical judgment (Fitzpatrick, J., 2005). Subjective barriers that can also interfere with critical thinking include our biased feelings, attitudes and values. Objective barriers include our life experiences, age, gender, and religion. Interpretation of data changes continuously based on research and not all events have a discoverable cause that can be identified with certainty. Empirical References and Measurement tool The Performance Based Development System (PBDS) is used by hundreds of health care agencies and by 46 states to assess critical thinking and interpersonal skills ability in nurses.

PBDS has been used for over 27 years, and results of the studies indicate that most new graduates do not meet expectations for clinical judgment skill (Del Bueno, 2005). PBDS uses a competency-assessment system to assess critical thinking as clinical judgment using three patient centered exercises. One, by prioritizing and managing a presented situation, two, by recognizing and managing peripheral intravenous problems using aseptic technique, and three, a simulation video is presented and the nurse must identify the problem, prioritize, manage, and implement care providing rationale within a given time-frame. The results are designated as acceptable (expert) or not acceptable (unsafe). This indicates to employers the ability of entry-level nurses to safely manage patient care is questionable (Del Bueno, D., 2005). Application to nursing Application to nursing practice Critical thinking skills can help nurses apply the process of examination. With these skills inquiry, evaluation, and reform of nursing and clinical care can take place, along with stimulating re-evaluation of established theory and practice. Critical thinking can be utilized to solve problems, reflection, and make definitive conclusions. Critical thinking creates greater possibilities for advancement in nursing knowledge. Facione (2010), reports one must be inquisitive, open minded, judicious, truth seeking, confident, analytical and systematic in order to be a strong critical thinker (Facione, 2010; Goshorn & Byers, 1997). Application to nursing research The overall goal of nursing research is to promote competency in critical thinking for optimal patient outcomes. Teaching effectiveness in higher education is continually being studied, but too often the focus is on reviewing facts and concepts in the disciplines at a fundamental level, rather than development of intellectual skills or values. Human reasoning using reaction and

reflection can be measured with a variety of tests, but they do not tell if poor skill are due to a poor pre-disposition for critical thinking or just lack of strong skills that can be developed with further training. Employing individual learning styles may not be effective in developing higher order of thinking. Ennis insists accountability of the individual as well at the higher education level, and employers must take place for further development of critical thinking skills. The concept and integration of critical thinking is therefore the next research step in providing high quality healthcare (Fitpatrick, 2005; Goshorn & Byers, 1997; Ennis, 2008).

References Del Bueno, D. (2005, Sept.-Oct.). A Crisis in Critical Thinking. Nursing Education Perspectives, 26(5), 278-282. Elder, L. (2007). Our Concept of Critical Thinking, Foundation for Critical Thinking. Retrieved Jan. 14, 2013, from http://www.criticalthinking.org/aboutCT/ourConceptCT.cfm. Ennis, R. H. (2008, March). Nationwide Testing of Critical Thinking for Higher Education: Vigilance. Teaching Philosophy, 31(1). Facione, P. A. (updated2010). Critical Thinking: What it is and Why it Counts? Retrieved Jan. 15, 2013, from http://www.insightassessment.com/pdf_files/what&why2006.pdf. Fitzpatrick, J. J. (2005, Sept.-Oct.). Critical Thinking: How Do We Know It in Nursing Education and Practice? Nursing Education Prespectives, 26(5), 261. Goshorn, J., & Byers, J. F. (1997, May). CORE Characteristics for Survival in Patient Care Redesign. AACN Clinical Issues, 8(2). Harbison, J. (2001). Clinical Decision-Making in Nursing: Theoretical Perspectives and their Relevance to Practice. Journal of Advanced Nursing, 35(1), 126-133. Joint Commission. (2010, Feb. 23). Initiative on the Future of Nursing at the Institute of Medicine, Robert Wood Johnson Foundation. Retrieved Jan. 15, 2013, from www.jointcommission.org. Marchigiano, G., Eduljee, N., & Harvey, K. (2011). Developing Critical Thinking Skills from Clinical Assignments: A Pilot Study on Nursing Students' Self-Reported Perceptions. Journal of Nursing Management, 19, 143-152. Rolfe, G., & Fulbrook, P. (1998). Advanced Nursing Practice: Education for the Advanced Practitioner (1st ed.). Oxford: Butterworth-Heinemann.

Scheffer, B. K., & Rubenfeld, M. G. (2000). A Consensus Statement on Critical Thinking in Nursing. Journal of Nursing Education, 39(8), 352-359. Scriven, M. & Paul, R. (1987, summer). Statement presented at the 8th Annual International Conference on Critical Thinking and Education Reform. Scriven, M., & Paul, R. (2008). Defining Critical Thinking, Foundation for Critical Thinking. Retrieved Jan. 15, 2013, from http://www.criticalthinking.org/aboutCT/definingCT.cfm. Vaughn, L. (2005). The Power of Critical Thinking: Effective reasoning about ordinary and extraordinary claims. Oxford: Oxford University Press.

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