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Chapter: Medical Surgical Nursing: Critical Thinking,Ethical Decision Making, and the Nursing Process

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Critical Thinking Process

Rationality and Insight - Components of Critical Thinking - Critical Thinking in Nursing Practice

Critical Thinking Process


Critical thinking is systematic and organized. The skills involvedin critical thinking are developed over time through effort, practice, and experience. Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, andself-regulation (Ignatavicius, 2001). Critical thinking requiresbackground knowledge and knowledge of key concepts as well asstandards of good thinking (Prideaux, 2000). The critical thinkeruses reality-based deliberation to validate the accuracy of data and the reliability of sources, being mindful of and questioning inconsistencies. Interpretation is used to determine the significanceof data that are gathered, and analysis is used to identify patientproblems indicated by the data. The nurse uses inference to drawconclusions. Explanation is the justification of actions or interventions used to address patient problems and to help a patientmove toward desired outcomes. Evaluation is the process of determining whether outcomes have been or are being met, andself-regulation is the process of examining the care provided andadjusting the interventions as needed (Ignatavicius, 2001).Critical thinking is also reflective, involving metacognition,cal thinker must be insightful and have a sense of fairness andintegrity, the courage to question personal ethics, and the perseverance to strive continuously to minimize the effects of egocentricity, ethnocentricity, and other biases on the decision-making process (Alfaro-LeFevre, 1999).


Certain cognitive or mental activities can be identified as key com-ponents of critical thinking. When thinking critically, a personwill do the following:

Ask questions to determine the reason why certain developments have occurred and to see whether more information is needed to understand the situation accurately.

Gather as much relevant information as possible to consideras many factors as possible.

Validate the information presented to make sure that it isaccurate (not just supposition or opinion), that it makessense, and that it is based on fact and evidence.

Analyze the information to determine what it means and tosee whether it forms clusters or patterns that point to certain conclusions.

Draw on past clinical experience and knowledge to explainwhat is happening and to anticipate what might happennext, acknowledging personal bias and cultural influences.

Maintain a flexible attitude that allows the facts to guidethinking and takes into account all possibilities.

Consider available options and examine each in terms of itsadvantages and disadvantages.

Formulate decisions that reflect creativity and independentdecision making.

Critical thinking requires going beyond basic problem solvinginto a realm of inquisitive exploration, looking for all relevant factors that affect the issue, and being an “out-of-the-box” thinker.It includes questioning all findings until a comprehensive picture emerges that explains the phenomenon, possible solutions, andcreative methods for proceeding (Wilkinson, 2001). Criticalthinking in nursing practice results in a comprehensive patientplan of care with maximized potential for success.


Using critical thinking to develop a plan of nursing care requiresconsidering the human factors that might influence the plan. Thenurse interacts with the patient, family, and other health careproviders in the process of providing appropriate, individualizednursing care. The culture, attitude, and thought processes of thenurse, the patient, and others will affect the critical thinking processfrom the data-gathering stage through the decision-making stage;therefore, aspects of the nurse-patient interaction must be con-sidered (Wilkinson, 2001). Nurses must use critical thinkingskills in all practice settings—acute care, ambulatory care, extended care, and in the home and community. Regardless ofthe setting, each patient situation is viewed as unique and dynamic. The unique factors that the patient and nurse bring tothe health care situation are considered, studied, analyzed, andinterpreted. Interpretation of the information presented then allows the nurse to focus on those factors that are most relevantactive evaluation, and refinement of the thinking process. Thecritical thinker considers the possibility of personal bias when interpreting data and determining appropriate actions. The criti-and most significant to the clinical situation. Decisions aboutwhat to do and how to do it are then developed into a plan ofaction.

Fonteyn (1998) identified 12 predominant thinking strategies used by nurses, regardless of their area of clinical practice:

Recognizing a pattern

Setting priorities

Searching for information

Generating hypotheses

Making predictions

Forming relationships

Stating a proposition (“if–then”)

Asserting a practice rule

Making choices (alternative actions)

Judging the value

Drawing conclusions

Providing explanations

Fonteyn further identified other, less prominent thinking strategies the nurse might use:


Posing a question

Making assumptions (supposing)


Making generalizations

These thought processes are consistent with the characteristics of critical thinking and cognitive activities discussed earlier. Fonteyn asserted that exploring how these thinking strategies are used in various clinical situations, and practicing using the strate-gies, might assist the nurse–learner in examining and refining his or her own thinking skills.

Because developing the skill of critical thinking takes time and practice, critical thinking exercises are offered as a means of practicing one’s ability to think critically. Ad-ditional exercises can be found in the study guide that accompa-nies the text. The questions listed in Chart 3-1 can serve as a guide in working through the exercises, although it is important to remember that each situation is unique and calls for an ap-proach that fits the particular circumstances being described.

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