Critical Thinking #2

Box 2-6 Words to Describe Critical Thinking
Descriptors for CT habits OF the Mind
Confidence
My thinking was on track, decisive; I reconsidered and still thought I made the best decision; I knew my
conclusion was well founded; My thinking was clear, unambiguous, trustworthy; I was secure in my
thinking
Contextual Perspective
I could see the whole picture; I considered [reflected on, reconsidered] other possibilities; I took other
things [surrounding issues] under consideration; I redefined the situation in view of . . . ; Considering the
circumstances, I . . . ; I broadened my view/perspective/mind
Creativity
I let my imagination go; I was inspired to think of . . . ; I stretched my mind; I took my thinking outside
the box; I envisioned/dreamed up/invented . . . ; I tried to be visionary; My mind was fertile ground; I
used the artistic side of my brain
Flexibility
I changed directions in my mind; I gave up on that idea and went on to … ; I moved away from my
traditional thinking; I redefined the situation and started again; I questioned what I was thinking and
considered another path; I tried to be adaptable in my thinking; I let my thinking go with the flow
Box 2-6 Words to Describe Critical Thinking (continued)
Inquisitiveness
I had a strong desire for more knowledge; I itched to know more about . . . ; I was eager to know more; I
took a lively interest in . . . ; I pricked up my ears, stuck my nose in . . . ; I burned with curiosity; I was
really interested in . . . ; My mind was buzzing with questions
Intellectual Integrity
I was not satisfied with my conclusion, so I . . . ; Although it went against eve- rything I believed . . . ; I
need to get at the truth; I tried to find the bottom line; I racked my brain; I questioned my biases; I
asked myself difficult questions; I dug to the bottom; I reflected on my inferences; I examined why I
thought that …
Intuition
I felt it in my bones; I couldn’t put my finger on why, but I thought . . . ; Instinctively I knew … ; My hunch
was that … ; I had a premonition/inspiration/ impression . . . ; My natural tendency was to . . . ;
Subconsciously I knew that … ; Without thought, I figured out … ; Automatically I thought that … ; While
I couldn’t say why, I thought immediately . . . ; My sixth sense said that I should consider . . .
Open-mindedness
I tried to be receptive to new ideas; I tried not to judge; I listened to reason; I looked at both sides of the
issue; I tried to be objective and unprejudiced; I questioned why I thought that . . . ; I weighed the pros
and cons; I tried to be neutral
Perseverance
I was single-minded in my determination to … ; I persistently kept at it; I plodded on through my
thoughts; I was stubborn and tireless in my pursuit; I kept going, trying this and that; I would not accept
that for an answer; I had to overcome so many obstacles
Reflection
I pondered my reactions; I mulled it over in my mind; I ruminated over what I had thought and done; I
had to reexamine/rethink/reconsider/review things; I evaluated my thoughts; I wondered what I could
have done differently; I concentrated on my thinking process; I talked to myself about . . . ; I deliberately
meditated on what I was thinking
Scenario 1-1: Mr. Stone
Mr. Stone is a 60-year-old male. He was admitted to the hospital 3 days before the Christmas holiday for
emergency surgery after his left arm was severed midway between his wrist and elbow in an industrial
accident. He was in good health prior to the acci- dent but had smoked one to two packs of cigarettes
per day for 40 years. The surgery to remove the severed portion of his arm and prepare for a prosthesis
was successful. Nursing care included administration of pain medications, monitoring for infection at the
wound site, and assistance with activities of daily living. Mr. Stone was expected to be discharged in 2 to
3 days. On the second day after surgery, he developed pneumonia, and his hospital stay was extended 6
more days.
Discussion
Your answers about better thinking may be more general, but we’ll start using the lan- guage of the
dimensions of CT that we described earlier in this chapter (in Box 1-3). Consider thinking dimensions
that possibly were not used. If the nurses were applying standards, they would have designed care to
include coughing, incentive spirometry, and precise assessment of respiratory status when developing
their postoperative care plan, not just medications and wound care. If the nurses were using contextual
perspective, they would have more carefully assessed Mr. Stone’s smoking habits and any history of
respiratory problems. If the nurses were discriminating, they would have identified Mr. Stone as a very
high-risk patient for postoperative pulmonary complications because of his smoking. If the nurses were
predicting, they would have recognized the serious consequences of not developing a rigorous plan for
postoperative coughing and deep breathing. They might even have made a referral to respiratory
therapy to institute such a prevention plan.
Of course, Mr. Stone might have developed pneumonia in spite of all those nursing interventions;
however, with better CT, the chances of this outcome would have been greatly reduced. Not only did
Mr. Stone suffer the physical and emotional pain of the loss of an arm and early retirement, but because
of his potentially prevent- able pneumonia, he also was hospitalized over the Christmas and New Year’s
Day holidays, a time of year that he would have enjoyed with family and friends at home.
In addition to safe care, CT is important for effective and efficient care. Effective care is individualized
and accurate. It employs the correct interventions for the health situation at hand. Efficient care
requires timely thinking so that resources are used appropriately. If Mr. Stone’s nurses had been more
effective in their thinking, they would have individualized their assessment, accurately diagnosed his risk
for pneumonia right from the start, and implemented proper interventions. In addition, if Mr. Stone’s
nurses had used more CT, his hospital stay would have been shorter, thus saving time, money, and
energy. In short, his care would have been more efficient. This scenario demonstrates the impact that
thinking has on patients and their significant others. CT makes a huge difference in patient care
outcomes!
The group of stakeholders in the next circle includes the clinicians, the educators, and the IDT. The
stakeholders in this circle have the most direct impact on outcomes for patients.
Scenario 1-2: Juan’s Home Visit
Juan is a community health nurse. His home-care patient load today included 17-year- old Jenny and her
3-week-old newborn, Billy. This was Juan’s first home visit with Jenny, following up on a referral from
the pediatrician’s office because Billy had not gained weight since birth. Jenny was an unwed mother
living with her parents in a spacious, professionally decorated home in an upper-middle-class
neighborhood. Jenny looked tired and interacted only minimally with Juan, and she rarely looked at the
baby, who was rest- less and fussy in his bassinet. Jenny’s mother was home, and she did most of the
talking, explaining how she expected Jenny to take full responsibility for Billy’s care. In fact, Jenny’s
parents both worked and were frequently out of town on business, but because of Juan’s visit, Jenny’s
mother stayed home to assure the nurse that though the visit was well intentioned, it was certainly not
necessary.
Juan examined Billy and found some disturbing data. Billy had lost another 3 ounces, and there were
several dark areas on his back and legs. These markings had not been noted on the referral information.
Juan asked more questions. Jenny’s mother assured him that Jenny was doing a fine job; they would be
sure Billy got an extra feeding to gain his weight back; and all her children bruised easily, so Billy
probably inherited that trait.
Juan, however, had to make a tough decision. He didn’t want to believe the baby was being abused; this
was a normal-looking family in a decent neighborhood. But he couldn’t ignore the data: indications of
ineffective maternal bonding, failure to thrive, and the apparent recent bruising all pointed to possible
abuse. He also knew he was legally obligated to report suspected abuse. He was not comfortable with
his decision to file a formal report, but he was confident it was the correct decision and that he could
justify his reasoning. Juan found out later that the nurse at the pediatrician’s office had similar concerns,
but she only had the original weight loss data to go on. She told Juan that she didn’t want to bias his
thinking, so she didn’t share her suspicions with him until after his visit.
Discussion
The key thinking areas that Juan used in this situation were intellectual integrity (although he did not
want to believe that the infant was being abused, he had to consider the evidence), applying standards
(he was legally required to report suspected abuse), confidence (he trusted his reasoning ability), and
logical reasoning (he believed he had adequate evidence to support his suspicions).
Juan very likely also felt shocked, uncomfortable, and annoyed: shocked and uncomfortable that an
upper-middle-class family might be abusing a child, and annoyed that the nurse in the pediatrician’s
office had not been open about her suspicions before the visit. He believed that he would have been
open-minded enough to collect accurate information even if he had known of the nurse’s hunch.
When Juan reflected on the situation, he could justify and support his decisions. He knew his judgment
was sound. As an individual and a professional, he derived satisfaction from knowing that he may have
saved a life and provided an opportunity for a family to become more functional. He became a nurse
because he wanted to help people, and that goal was accomplished. By doing his job with compassion
and intellectual integrity, his behavior matched his role expectations, leading to job satisfaction.
Another way that CT benefits clinicians is by helping them move from novice to advanced beginner to
competent to proficient and, ultimately, to expert (Benner, 1984). Throughout this process, the clinician
moves away from the context-free rules of novice decision making to more sophisticated levels of
thinking. Thinking is essential to expert nurses, who can imagine the whole of a situation from a few
details. They use reflection in action; they have learned to trust their intuition. And they do all of this
consistently. Expert nurses engage all CT dimensions so naturally and with such ease that their decisions
look effortless. The hard work of the thinking behind their actions is rarely apparent unless they have
recognized how important it is to think out loud. Many experts don’t recognize how fine-tuned thinking
is, but they couldn’t be experts without it. This level of thinking benefits patients as well as nurses.
Scenario 1-3: Modeling CT
A patient was admitted to an inpatient medical–surgical unit for evaluation of cardiac arrhythmia. She
also had a history of mental illness. Her recent symptoms included nausea, diarrhea, and a low-grade
fever. This was the reflection the graduate student teaching assistant shared with his instructor detailing
how he had modeled his CT for an undergraduate nursing student:
I wanted the student to see how I was thinking through this problem and that it was OK to not have all
the answers. The patient had a long history of bipolar disorder and had been taking lithium for several
years, successfully managing her disease. The staff told us she was also a bit of a hypochondriac and that
this was the second time this month she was complaining of the flu. I told the student, “We have to be
careful and not let our perceptions affect our data collection; we have to be open-minded from the
beginning. Let’s use some inquisitiveness here and find out from the patient what is happening. We
need a little more contextual perspective, so we need to get some historical information, a sense of
what has been going on in her life recently, food allergies, and so on. I’m also wondering about the
possibility of lithium toxicity. Go grab a drug book and let’s check that out. What do you think? How do
her lab values compare to the norms? Let’s do some analysis here and look at all the pieces and then
think about how they do or don’t fit together. Think about it for a minute and tell me what dimensions
of our thinking will be needed next.” We discovered that the patient was, in fact, having a toxic reaction
to lithium. Her blood levels were over 1.5 mEq/L. She wasn’t just being a hypochondriac. I really tried to
use my CT words so that the student could see inside my brain. I had to figure this out all on my own—I
want my student to have a head start.

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