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Chapter 8: Critical Thinking, the Nursing Process, and Clinical Judgment

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Title: Chapter 8: Critical Thinking, the Nursing Process, and Clinical Judgment


1
Chapter 8 Critical Thinking, the Nursing
Process, and Clinical Judgment
  • Bonnie M. Wivell, MS, RN, CNS

2
Defining Critical Thinking
  • Facione and others (1990)
  • Purposeful, self-regulatory judgment that results
    in interpretation, analysis, evaluation, and
    inference
  • Is essential as a tool of inquiry
  • A pervasive and self-rectifying human phenomenon
  • Ideal critical thinker is inquisitive,
    well-informed, trustful of reason, open-minded,
    flexible, fair-minded in evaluation, honest in
    facing personal biases, prudent in making
    judgments, willing to reconsider, clear about
    issues, orderly in complex matters, diligent in
    seeking relevant info., reasonable in selection
    of criteria, focused in inquiry, and persistent
    in seeking results

3
Paul and Elder (2005)
  • Critical thinking is a process by which the
    thinker improves the quality of his or her
    thinking by skillfully taking charge of the
    structures inherent in thinking and imposing
    intellectual standards upon them.
  • A well-cultivated critical thinker
  • Raises questions and problems
  • Gathers and assesses relevant info.
  • Arrives at conclusions and solutions that are
    well-reasoned
  • Is open-minded and recognizes alternative ways of
    seeing problems
  • Communicates effectively with others as solutions
    to complex problems are formulated

4
Critical Thinking in Nursing
  • A nurse exercising critical thinking asks the
    following questions
  • What assumptions have I made about this pt?
  • How do I know my assumptions are accurate?
  • Do I need any additional information?
  • How might I look at this situation differently?
  • Reflective thinking an active process valuable
    in learning and changing behaviors, perspectives,
    or practices occurs after nurse-patient
    interactions have ended

5
Critical Thinking in Nursing
  • Think on your feet Examining your thinking
    process during an interaction
  • As you move from novice to expert your ability to
    critically think will improve with practice
  • Driven by the needs of the pt. and family
  • Is more than your opinion
  • You must be able to describe how you came to a
    conclusion and support your conclusions with
    explicit rationales.

6
The Nursing Process
  • A universal intellectual standard by which
    problems are addressed and solved
  • A designated series of actions intended to
    fulfill the purposes of nursing to maintain the
    pts wellness and, if this state changes, to
    provide the amount and quality of nursing care
    the situation demands to direct the pt. back to
    wellness.
  • The cornerstone of nursing standards, legal
    definitions, and practice, hence it needs to be
    understood by all nurses

7
Phases of the Nursing Process
  • Assessment information gathered
  • Subjective/Objective
  • Primary source the pt.
  • Secondary source nurse observations or reports
    of family/friends
  • Tertiary sources medical records or reports
    from other healthcare providers
  • Collect, organize and protect confidentiality of
    data

8
Phases of the Nursing Process
  • Analysis and Diagnosis
  • 1973 NANDA published its first list of nursing
    diagnosis
  • 6th edition published in 2006, includes 167
    approved diagnoses
  • actual or potential health problems which
    nurses, by virtue of their education and
    experience, are capable and licensed to treat
  • www.evolve.elsevier.com/Chitty/professional/

9
Analysis and Diagnosis (Contd)
  • 5 components
  • Label
  • Definition
  • Defining characteristics
  • Risk factors
  • Related factors
  • P Problem (NANDA diagnostic label)
  • E Etiology (causal factors)
  • S s/s (defining characteristics)
  • Prioritize!!

10
Phases of the Nursing Process
  • Planning
  • Goals short/long term
  • S Specific
  • M Measurable
  • A Attainable
  • R Realistic
  • T Time bound

11
Phases of the Nursing Process
  • Nursing Interventions
  • Independent no supervision required
  • Dependent require instructions, orders or
    supervision, usually by a physician
  • Interdependent nurse must collaborate or
    consult with another health professional

12
Phases of the Nursing Process
  • Critical paths multidisciplinary plans of care
  • Implementation nursing orders or interventions
    are carried out
  • Evaluation nurse examines the pts progress in
    relation to the goals and outcome criteria to
    determine whether a problem is resoled, is in the
    process of being resolved, or is unresolved
  • The nursing process is a dynamic, nonlinear tool
    for critical thinking about human responses

13
Developing Clinical Judgment
  • Clinical judgment consists of informed opinions
    and decisions based on empirical knowledge and
    experience
  • Sound clinical judgment is created by using
    critical thinking, applying the nursing process,
    staying current with developments in practice and
    research, understanding your scope of practice,
    and acquiring substantial clinical experience.

14
Chapter 11 The Science of Nursing and
Evidence-Based Practice
  • Bonnie M. Wivell, MS, RN, CNS

15
Background
  • Nursing could achieve a high level of
    professional status only to the extent that the
    discipline was based on a scientific body of
    knowledge unique to nursing
  • Nurse researchers began developing knowledge
    unique to nursing and theorists began developing
    theories and testing them
  • Hence theory and research are the foundations of
    scientifically based nursing practice

16
Background
  • EBP began to emerge which required nurses to base
    their care and activities on research-based
    knowledge
  • The nursing process became a means of adapting a
    scientific framework to the management of patient
    care

17
Science and the Scientific Method
  • Scientific Method an orderly, systematic way of
    thinking about and solving problems
  • Quantitative research doing science that
    requires standardized experimental designs,
    measurable variables and outcomes, and
    statistical analyses
  • Qualitative research explore human responses in
    health and illness
  • Ethnography
  • Unstructured interviews
  • Participant observation

18
Pure and Applied Science and Research
  • Pure science summarizes and explains the
    universe without regard for whether the
    information is immediately useful information
    gathered solely for the sake of obtaining new
    knowledge
  • Joseph Priestly discovered oxygen in 1774 but
    didnt have an immediate use for the info
  • Applied science seeks to use scientific theory
    and laws in some practical way
  • How oxygen is best used in the care of premature
    infants with respiratory distress syndrome

19
Inductive and Deductive Reasoning
  • Inductive reasoning begins with a particular
    experience and proceeds to generalizations
  • Deductive reasoning proceeds from the general
    case to the specific the premises used must be
    correct or the conclusions will not be
  • Valid soundly founded
  • True in accordance with the fact or reality

20
Limitations
  • Traditional scientific approach used by
    quantitative researchers has been used
    productively by nurse researchers studying a wide
    range of nursing problems however this approach
    cannot solve all nursing problems
  • Health care settings are not comparable to labs
  • Human beings are far more than collections of
    parts that can be dissected and subjected to
    examination or experimentation
  • The scientific method fails to consider the
    meaning of patients own experiences the
    subjective view of reality

21
What is Nursing Research?
  • Seeking to understand and ease the symptoms of
    acute and chronic illness, to prevent or delay
    the onset of disease or disability or slow its
    progression, to find effective approaches to
    achieving and sustaining good health, and to
    improve the clinical settings in which care is
    provided.

22
Nursing Research
  • Phenomena events or circumstances related to
    improving patient care
  • A problem may be amenable to research if
  • The researchers ideas about the problem fit
    logically and dovetail with what is already known
    about the topic
  • The proposed research project is based on related
    research findings or is supported by similar
    ongoing research in other settings building
    nursing knowledge
  • The proposed research is carefully designed so
    that the results will be applicable in similar
    situations or will generate hypotheses for
    further research

23
Problem Solving vs Research
  • Problem solving specific to a given situation
    and is designed for immediate action practical
    knowledge, common sense, and experience
  • Research generalizable to other situations and
    deals with long-term solutions rather than
    immediate ones extensive review of lit to
    determine latest thinking and research

24
Evidence-Based Practice
  • Using the best available research findings to
    make clinical decisions that are most effective
    and beneficial for patients
  • Created in the 1980s by a Canadian university as
    an approach to clinical learning
  • The conscientious, explicit, and judicious use of
    current best evidence in making decisions about
    the care of individual patients
  • Integrating individual clinical expertise with
    the best available external clinical evidence
    from systematic research

25
The Research Process
  • Identification of a research problem
  • May replicate or design a similar study
  • Review of the literature (ROL)
  • Locate similar studies that have been completed
    or on which you can build to create a conceptual
    framework (organization of supporting ideas, on
    which to base the study)
  • Formulation of the research question or hypothesis

26
The Research Process Contd.
  • Design the study
  • Experimental design will researcher manipulate,
    influence or change participants in any way
  • Data collection instruments
  • Must be reliable (accurate) and valid (measures
    what it is supposed to be measuring)
  • Implementation
  • Data collection and analysis

27
The Research Process Contd.
  • Drawing conclusions based on findings
  • Facts must speak for themselves
  • Answer the question, What do these findings
    mean?
  • Discussion of implications
  • Suggestions of things that should be done in the
    future
  • Every good study raises more questions than it
    answers

28
The Research Process Contd.
  • Dissemination of findings
  • Publication and presentation of findings
  • Peer reviewed journals
  • Presentation at conference
  • Participants subjects
  • For safety and ethical reasons, there are
    limitations on the use of the scientific method
    with human beings
  • Informed consent
  • Institutional Review Board (IRB)
  • HIPPA

29
Relationship of Nursing Research to Nursing
Theory and Practice
  • Research ideas are generated from 3 sources
  • Clinical practice
  • Literature
  • Theory
  • Examples of changes in nursing practice
    stimulated by research
  • Improved care of pts with skin breakdown from
    pressure ulcer
  • Decreasing light and noise in ICU to prevent
    sleep deprivation
  • Using caps on newborns to decrease heat loss and
    stabilize body temp
  • Positioning patients following chest surgery to
    facilitate respiration

30
Summary
  • Nurse researchers have made significant
    contributions to improvements in nursing care
    practices
  • Nursing research is related to and informed by
    nursing theory and nursing practice and in turn
    influences them
  • Nurses of all education backgrounds have a role
    in research
  • EBP is the goal of nursing research
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