Critical thinking. Strategies for clinical practice

Clinical Reasoning in Experienced Nurses

As an essential component of nursing practice, clinical reasoning is used to assimilate information, analyze data, and make decisions regarding patient care. Little is known about the reasoning strategies of experienced nurses who are not yet experts. This qualitative descriptive study explored the cognitive strategies used by experienced nurses as they considered assessment findings of assigned patients. To date, few studies of nurses' clinical reasoning have been conducted in a practice setting during actual patient care. A small group research design was employed using the think-aloud (TA) method with protocol analysis. A total of 15 experienced nurses were asked to “think aloud” about patient assessment findings. Data were audiotaped, transcribed, and analyzed using the three steps of protocol analysis. The results suggest that experienced nurses used a conceptual language to reason about assessment findings and used heuristics to reason more quickly and efficiently.

Training for suicide risk assessment and suicide risk formulation

Suicide and suicidal behaviors are highly associated with psychiatric disorders. Psychiatrists have significant opportunities to identify at-risk individuals and offer treatment to reduce that risk. Although a suicide risk assessment (SRA) is a core competency requirement, many lack the requisite training and skills to appropriately assess for suicide risk. Moreover, the standard of care requires psychiatrists to foresee the possibility that a patient might engage in suicidal behavior, hence to conduct a suicide risk formulation (SRF) sufficient to guide triage and treatment planning. An SRA gathers data about observable and reported symptoms, behaviors, and historical factors that are associated with suicide risk and protection, ascertained by way of psychiatric interview; collateral information from family, friends, and medical records; and psychometric scales and/or screening tools. Based on data collected via an SRA, an SRF is a process whereby the psychiatrist forms a judgment about a patient's foreseeable risk of suicidal behavior in order to inform triage decisions, safety and treatment plans, and interventions to reduce risk. This paper addresses the need for a revised training model in SRA and SRF, and proposes a model of training that incorporates the acquisition of skills, relying heavily on case application exercises.

Suicide risk assessment and suicide risk formulation: essential components of the therapeutic risk management model

Suicide and other suicidal behaviors are often associated with psychiatric disorders and dysfunctions. Therefore, psychiatrists have significant opportunities to identify at-risk individuals and offer treatment to reduce that risk. Although a suicide risk assessment is a core competency requirement, many clinical psychiatrists lack the requisite training and skills to appropriately assess for suicide risk. Moreover, the standard of care requires psychiatrists to foresee the possibility that a patient might engage in suicidal behavior, hence to conduct a suicide risk formulation sufficient to guide triage and treatment planning. Based on data collected via a suicide risk assessment, a suicide risk formulation is a process whereby the psychiatrist forms a judgment about a patient's foreseeable risk of suicidal behavior in order to inform triage decisions, safety and treatment planning, and interventions to reduce risk. This paper addresses the components of this process in the context of the model for therapeutic risk management of the suicidal patient developed at the Veterans Integrated Service Network (VISN) 19 Mental Illness Research, Education and Clinical Center by Wortzel et al.

Suicide risk assessment and risk formulation part II: Suicide risk formulation and the determination of levels of risk

The suicide risk formulation (SRF) is dependent on the data gathered in the suicide risk assessment. The SRF assigns a level of suicide risk that is intended to inform decisions about triage, treatment, management, and preventive interventions. However, there is little published about how to stratify and formulate suicide risk, what are the criteria for assigning levels of risk, and how triage and treatment decisions are correlated with levels of risk. The salient clinical issues that define an SRF are reviewed and modeling is suggested for an SRF that might guide clinical researchers toward the refinement of an SRF process.

Critical thinking: Reported enhancers and barriers by nurses in long-term care: implications for staff development

Nursing acknowledges critical thinking as an important guide to clinical decision making. Agreement on how to define, teach, and evaluate this skill is lacking. The purpose of this study was to evaluate critical thinking in practice using a survey that asked nurses to evaluate work-related factors that enhance or pose barriers to the use of critical thinking in practice. Results indicated that enhancers and barriers to practice included teamwork, staffing patterns, and staff and administrator support. A relationship with patients was the most satisfying factor, whereas paperwork was the least. Staff development educators must consider the work environment aspects that affect performance and create the life long learning needed for increased competency in practice.

Critical thinking, delegation, and missed care in nursing practice

OBJECTIVE

The aim of this study was to understand how nurses use critical thinking to delegate nursing care.

BACKGROUND

Nurses must synthesize large amounts of information and think through complex and often emergent clinical situations when making critical decisions about patient care, including delegation.

METHOD

A qualitative, descriptive study was used in this article.

FINDINGS

Before delegating, nurses reported considering patient condition, competency, experience, and workload of unlicensed assistive personnel (UAP). Nurses expected UAP to report significant findings and have higher level knowledge, including assessment and prioritizing skills. Successful delegation was dependent on the relationship between the RN and the UAP, communication, system support, and nursing leadership. Nurses reported frequent instances of missed or omitted routine care.

CONCLUSION

Findings from this project provide insight into factors that influence delegation effectiveness. These can guide CNOs and frontline nurse leaders to focus on implementing strategies to mitigate the consequence of missed care. Ineffective delegation of basic nursing care can result in poor patient outcomes, potentially impacting quality measures, satisfaction, and reimbursement for the institution.

Implementation and evaluation of critical thinking strategies to enhance critical thinking skills in Middle Eastern nurses

The purpose of this study was to develop, implement and evaluate critical thinking strategies to enhance critical thinking skills in Middle Eastern nurses. Critical thinking strategies such as questioning, debate, role play and small group activity were developed and used in a professional development programme, which was trialled on a sample of Middle Eastern nurses (n = 20), to promote critical thinking skills, encourage problem solving, development of clinical judgment making and care prioritization in order to improve patient care and outcomes. Classroom learning was transformed from memorization to interaction and active participation. The intervention programme was successful in developing critical thinking skills in both the nurse educators and student nurses in this programme. This programme successfully integrated critical thinking strategies into a Middle Eastern nursing curriculum. Recommendations are as follows: (1) utilize evidence-based practice and stem questions to encourage the formulation of critical thinking questions; (2) support the needs of nurse educators for them to effectively implement teaching strategies to foster critical thinking skills; and (3) adopt creative approaches to (i) transform students into interactive participants and (ii) open students' minds and stimulate higher-level thinking and problem-solving abilities.

A descriptive inquiry of the definitions of critical thinking and enhancers and barriers reported by nurses working in long-term care facilities

Critical thinking has been an outcome of nursing education since the 1980s. There remains a lack of agreement on definitions, methods of teaching, and methods of evaluation among practicing nurses. This study asked practicing nurses to define critical thinking. It also asked nurses to describe what work-related factors enhanced or posed barriers to the use of critical thinking in practice. Elements of the definitions presented were found to be consistent with current nursing definitions of critical thinking. Enhancers and barriers overlapped and were found to be consistent among the nurses at all facilities studied, with implications for continuing education and staff development.

Critical thinking: A two-phase framework

This article provides a comprehensive review of how a two-phase framework can promote and engage nurses in the concepts of critical thinking. Nurse education is required to integrate critical thinking in their teaching strategies, as it is widely recognised as an important part of student nurses becoming analytical qualified practitioners. The two-phase framework can be incorporated in the classroom using enquiry-based scenarios or used to investigate situations that arise from practice, for reflection, analysis, theorising or to explore issues. This paper proposes a two-phase framework for incorporation in the classroom and practice to promote critical thinking. Phase 1 attempts to make it easier for nurses to organise and expound often complex and abstract ideas that arise when using critical thinking, identify more than one solution to the problem by using a variety of cues to facilitate action. Phase 2 encourages nurses to be accountable and responsible, to justify a decision, be creative and innovative in implementing change.

Critical thinking in nursing education: literature review

The need for critical thinking in nursing has been accentuated in response to the rapidly changing health-care environment. Nurses must think critically to provide effective care while coping with the expansion in role associated with the complexities of current health-care systems. This literature review will present a history of inquiry into critical thinking and research to support the conclusion that critical thinking is necessary not only in the clinical practice setting, but also as an integral component of nursing-education programmes to promote the development of nurses' critical-thinking abilities. The aims of this paper are to: (i) review the literature on critical thinking; (ii) examine the dimensions of critical thinking; (iii) investigate the various critical thinking strategies for their appropriateness to enhance critical thinking in nurses; and (iv) examine issues relating to the evaluation of critical-thinking skills in nursing.

Critical thinking in African American mothers who care for adult children with HIV: a cultural analysis

This research study defines critical thinking in nursing and examines the thinking processes revealed by 15 African American mothers who are caregivers to adult children with HIV. The purpose of this cultural analysis was to compare the mothers' decision-making processes with their critical-thinking processes. Their culture, heritage, faith, and value of family influenced caregivers in this study. Their testimony revealed the patterns of creating a different path of care, weaving together resources, choosing among negative alternatives, and selecting stories to tell. Mothers' decisions were based on complex and holistic knowledge of their situations and culture and could be termed multilogical, a type of thinking considered necessary for managing complex situations. Health providers can benefit from an understanding of these decision-making processes.

Individual and organizational accountability for development of critical thinking

Advanced abilities to think critically are necessary to improve clinical systems, decrease errors and sentinel events, and engage staff involvement to refine patient care systems. The authors explore practical methods, based on current research, to promote mature critical-thinking skills in healthcare professionals, from patient care clinical judgment to a leadership perspective. Individual and organizational accountabilities for expanding critical thinking skills are investigated, and a problem-solving model is proposed as a coordinated strategy.