You are on page 1of 16

1

Running head: CRITICAL THINKING

Critical Thinking: A Concept Analysis


Melissa Dean
Methodist College
Critical Thinking: A Concept Analysis
One of the biggest struggles for student and inexperienced nurses is critical thinking. The
aim of this analysis is to determine the fit between the definition of the concept and its clinical
application (McEwen & Wills, 2014, p. 55). In reviewing the literature, a multitude of
examples have established that lack of critical thinking can have detrimental effects to patient
outcomes. One study conducted of nurse leaders found that 19% were satisfied with the new
graduates ability to conduct appropriate follow-up, recognize a change in patient status, and
ability to interpret assessment data (Brier et al., 2015, p. 834).
There are complex and accelerated dynamics that occur in a hospital setting that mandate
that new nurses and students accordingly. Cazzell and Anderson firmly supports deductive
development through the integration of neuroscience theory into the nurse education curriculum,
simulation, and teaching strategies (p. 88). Another study provides further examples from
studies that state that 118 students observed urinary catheterization and out of that number
only 1 student participated in the skill (Eun & Young, 2014, p. 108). This is inadequate to

develop the skill required to perform the task. Practice of all skills are required in order for
critical thinking in students to be fostered.
According to Phillips and Burrell (2009), To engage effectively in critical thinking, it is
essential to develop a keen ability to overcome and become self-aware of biases, false
assumptions, myths, and faulty paradigms that can hamper effective decision making (p. 144).
Making the leap from book learning to application can be scary at best. Throw human lives into
the mix and it can be intimidating. Nursing faculty recognize that beginning nursing students
lack the knowledge and experience needed to think like a nurse (Ward & Morris, 2016, p. 64).
Being able to walk into a room and assess the situation and respond accordingly is a vital aspect
to any nurse.
Method
The method that will be used in this concept analysis is Walker and Avant (2014). This
style is referred to as a mixed method of analysis. It utilizes three methods of analysis
combined or in a consecutive manner using qualitative synthesis, quantitative synthesis and
literary synthesis (McEwen & Wills, 2014, p. 58). The intention of using a concept analysis in
this point is to recognize differences between the model attributes and any extraneous
characteristics to present an understanding of the concept itself.
Identify Uses of the Concept of Critical Thinking
There are diverse explanations used to identify the concept of critical thinking and many
definitions that can be interpreted in various ways. Definitions range from the generic to the
complex. The concept can be defined as a whole, in the nursing profession and beyond to
include other practices such as law enforcement and medicine.
Definitions of Critical Thinking

CRITICAL THINKING

Cambridge dictionary defines critical thinking as the process of thinking carefully about
a subject or idea, without allowing feelings or opinions to affect you (2016). This sounds
generic when applied to the nursing process. The University of Louisville states that thinking
critically can be defined as the intellectually disciplined process of actively and skillfully
conceptualizing, applying, analyzing, synthesizing and evaluating information gathered from or
generated by, observation, experience, reflection, reasoning, or communication, as a guide to
belief and action (2016). Yet another example states that critical thinking is a process or ability
indicates that it is a skill or competency-based attribute that can be taught (Gupta & Upshur,
2012, p. 940).
Synonyms
To give examples of synonyms, the concept must be broken down into its two separate
words. First, the word critical. Synonyms would include analytical, diagnostic, and exacting.
This also includes other synonyms that may not apply to our concept, such as belittling,
condemning or sarcastic (thesaurus.com, n.d.). Next, we move to thinking. Synonyms that can
be used interchangeably for thinking are cognitive, introspective, studious, and pensive, as well
as reasonable, reflective and engrossed (thesaurus.com, n.d.).
Critical Thinking in Nursing
Elemental and crucial concepts learned in nursing programs are essential to the
development of a higher standard of care. Ward and Morris (2016) speak of an initiative named
Think like a nurse (p. 64). The initiative speaks of the process in which critical thinking is
developed. It relies on much of what students learned of the nursing process, but also includes
Maslows Hierarchy of Needs and the Five Steps of Clinical decision making. It adds that the
nursing process is the cornerstone and these concepts were selected because of the relevance

CRITICAL THINKING

and importance in a nurses way of knowing, thinking and decision making (Ward & Morris,
2016, p. 65).
This thought process can be further illustrated by the style in which the NCLEX is
presented. This systematic approach to testing, in which the nurse selects one priority that is the
fundamental nursing approach to critical thinking. This is the simply the beginning of the
process. The higher order thinking of a nurse breaks down a situation and goes above standard
recall of facts and information. Nurses strive to transcend common facts and look at the big
picture, the whole patient, and to anticipate what is to come.
We understand critical thinking to be purposeful, self regulatory judgement, which
results in interpretation, analysis, evaluation, and interface, as well as explanation of the
evidential, conceptual, methodological, criteriological, or contextual consideration upon
which that judgment was based (Facione, 1990, p. 2).
As we can see, critical thinking is dynamic in its process and essential to nurses. Without
it, nurses would be limited in their capacity to assist their patients. It takes a certain amount of
rationalization, along with intuition as well as the ability to make judgments on alternative
measures (Turkel et al., 2016, p. 244).
Critical Thinking in Law Enforcement
Law enforcement personnel have a complex set of skills that allow them to protect the
public from potential and actual dangers. They must be proactive to prevent or respond to
catastrophic events in society. This requires progressive thinking that considers multiple
plausible scenarios. Looking at basic law enforcement training, we can see critical thinking in
firearms training. Police are provided with tactical training. They engage in a variety of
scenarios in which a quick decision is required in order to respond. Decisions to shoot or not to

CRITICAL THINKING

shoot in a split second can make the difference between their own lives being lost or that of the
public.
Think of the variety of situations a police officer gets exposed to during the course of an
average day. Much of it likely becomes mundane to them. However, there is the potential for
the unusual cases. The ability to think critically allows them to adapt to this change and respond
accordingly. We look to police much like we do to medical personnel. We expect them to have
the ability to enter a situation and know how to resolve it (Bawden, Rowe, & SereniMassinger, 2015, p. 3).
Critical Thinking in Medicine
Critical thinking in medicine has similar implications as it does in nursing. The focus
may be altered but the potential outcomes are similar. According to Gupta and Upshur, critical
thinking plays a much larger role in the education and ethos of nursing in comparison to
medicine (Gupta & Upshur, 2012, p. 939). Doctors rely on nurses to think critically and report
results to the physician. This may change depending on the specialty. Lets look to emergency
medicine as an example. In this situation, time can really be a driving factor in patient care.
Clinicians do not have the time to research each possible solution for every patient complaint, yet
it is imperative to use good evidence-based protocols to direct our care (Smith, 2009).
Critical Thinking; a Personal Perspective
Examining the nursing process, we can see this in full effect. Nurses complete an
assessment of a situation, a patient, labs, and symptoms. Next comes a nursing diagnosis, what
is perceived to be the problem. In the planning stage it is determined what goals will be
implemented for the patient. Nursing implementation is implementing the action. Evaluation is
how the plan functioned to determine if it was effective or not. Critical thinking weaves through

CRITICAL THINKING

this process. Nurses thinking ahead to anticipate what is next for the patient. This could be
responding to crisis or simply educating patients about their diabetes in order to anticipate their
own needs.
Nurses begin this process before we even lay eyes on the patient. Prior to report, they
may look up labs and see a diagnosis. Some may even be able to visualize how the patient will
look. What kind of things will they ask in for in report? What kind of orders will they ask of the
doctor? In my perspective, critical thinking is seeing the whole picture and anticipating what is
ahead for my patients. Nurses want what is best for those under our care. In order to deliver
these outcomes, they must anticipate and react to an ever changing situation in the dynamic
environment of healthcare. What applies to nursing specifically is taking the entire patient
situation into consideration. Nurses often times come upon situations in which a hundred
conditions are occurring all at once and immediate responses are required in order to prevent a
more urgent situation. In my own experience, this is critical thinking. The ability to piece
together a puzzle in an efficient manner in order to obtain optimal patient outcomes.
Defining Critical Attributes
First lets define the term critical attributes. Once again, we must define the words
separately. Critical has several meanings including of decisive importance with respect to the
outcome (Cambridge Dictionary, 2016). The word attribute is a quality or feature of a person
or thing that is an important part of its nature (Cambridge Dictionary, 2016).
Critical Attributes
Critical thinking is more than a mere acquisition of intellectual traits. Confidence is
required, but just as important are contextual perspective, creativity, flexibility, inquisitiveness,
intellectual integrity, intuition, open mindedness, perseverance, and reflection (Kaddoura,

CRITICAL THINKING

2013, p. 4). In this case, I agree with Kaddoura and chose flexibility, creativity and intuition as
my critical attributes. Critical thinking is a purposeful process. Although the attributes of a
critical thinker, nurse or otherwise, may vary, the core remains the same. Robert and Peterson
state that it is recognizing a unique situation that needs further evaluation (Robert & Peterson,
2013, p. 87). This is exactly what a nurse is doing on a daily basis. Nurses are required to leave
biases from their assumptions when dealing with complex patient dynamics and view the
situation from all angles. Critical attributes in nursing may vary but could include some of what
is listed above. For nurses, intuition is vital, review of the facts, collection of data, assessment of
the patient, and reaction to patient events (Brier et al., 2015, p. 834). For this purpose, the
following critical attributes have been chosen for comparison, intuition, reflection, flexibility,
inquisitiveness, and perseverance.
Antecedents
First to define the term antecedents, we reference again a dictionary that states that it is a
the cause of an event or situation (Cambridge Dictionary, 2016). So, what is an antecedent to
critical thinking? Students do not always have this skill upon graduation or even passing after
passing the NCLEX. We can compare this development to what Benjamin Bloom has outlined
in Blooms Taxonomy. This framework discussed the different levels of learning from
knowledge, comprehension, application, analysis, synthesis and evaluation (Armstrong, 2016).
Relate critical thinking to Blooms Taxonomy we can see that the antecedents would be the
same. Begin with basic knowledge, memorizing labs as an example, and transitioning through to
finally arrive at evaluation where labs can be interpreted.
Personal Antecedents

CRITICAL THINKING

In personal growth as a nurse, it has been experienced in different stages. Book learning
and memorization are my personal antecedents. Book learning is very basic, and again goes
back to Blooms Taxonomy with memorization of facts being the initial steps. This can be seen in
memorization of lab results. Evaluation of the labs would be the next step. What can be
anticipated from the patient based off of the labs. What can of conclusions can be made from a
hemoglobin of 5 as an example. This type of growth can be experienced as a nurse starting from
the new graduate who has little experience in analyzing lab values to an experienced one that can
make predictions based off interpretation.
Consequences
The consequences of critical thinking, or the lack thereof, can be catastrophic. Worst
case scenario, death of a patient can occur. Patient safety is compromised when nurses have
underdeveloped critical thinking skills, knowledge, and awareness. Incorporating critical
thinking into hospital orientation and ongoing educational offerings for all nurses is essential
(Turkel, Marvelous, Morrison, & Singletary, 2016, p. 244). My personal consequences could be
compromised patient safety, poor patient satisfaction, lack of approval from other staff members,
or loss of employment.
Empirical Referents
First lets define empirical referents by breaking down the two words. Empirical,
according to dictionary.com means based on what is experienced or seen rather than on theory,
while referents would be the incident to which a phrase or symbol refers (Cambridge Dictionary,
2016). This is the final step of concept analysis according to Walker & Avant (2014).
Critical thinking can be measured in the literature review by patient outcomes. This
substantiates the manifestation of the concepts. Empirical referents are the categories or groups

CRITICAL THINKING

of actual phenomena, that, by their existence, demonstrate the occurrence of the concept itself
(Walker & Avant, 2007/2013, p. 91). We can refer to the NCLEX exam as one example of
testing critical thinking as it applies to nursing.
Cases
Model Case
A model case exists when all of the critical attributes are present. My personal critical
attributes are flexibility, creativity and intuition. As an example, we can refer to many patient
situations. One example would be opening a patients door and immediately recognizing that a
patient is in distress. Seeing labored breathing, discoloration of the skin, mottling, restlessness,
reminds the nurse of other patient situations. This causes a reaction, making the nurse realize the
patient is in immediate danger and if they do not act soon, the patient will expire. The nurse
receiving report asks questions of the off-going nurse who states patient has been restless all
night and had to be restrained. Staff calls an urgent assessment team and begin to run tests, take
vitals and begin interventions. The patients appearance and their vitals indicate that that patient
is in respiratory distress. Respiratory rate is 38, pulse oximetry is in the seventies and blood
pressure is unobtainable without a Doppler. Supplemental oxygen is provided and when the
rapid response team arrives, arterial blood gasses are collected and the crash cart is ready. The
nurse assists other members of the rapid response team in initiated interventions. All these
interventions are based on our reactions to the patients signs, symptoms and results to testing.
Putting the picture together of what could possibly be occurring at this time. Patient starts to
somewhat stabilize, however the nurse still feels something is not quite right and continues to
push the doctor until the patient is transferred to a higher level of care. Patient is then transferred
to intensive care unit where he had to be intubated. Later it is discovered that patient had

CRITICAL THINKING

10

suffered a pulmonary embolism. Without immediately reacting to patients distress, outcome


could have been vastly different. In this case the nurse is using flexibility, creativity and
intuition.
Contrary Case
A contrary case, we see the absence of our critical attributes of flexibility, creativity and
intuition. A patient is on a tube feeding and begins to vomit out of her tracheostomy. The nurse
comes in to assess the situation and suctions the patient, ensures they are stable from a
respiratory perspective. Nothing else was checked. An hour later, the patient vomits again and
the same interventions are performed. Patient continues with this pattern throughout the day.
The nurse continues with the same interventions, but they have not checked the tube feeding nor
asked for a chest x-ray. If the nurse had thought about what could be happening with the patient,
they would have reacted to the vomiting and checked the feeding to make sure patient did not
have a malabsorption, or worse, that the feeding tube had ben dislodged. So it can be seen in this
case that flexibility, creativity and intuition are not used.
Borderline Case
Borderline cases exist when some of the attributes are in place, but not all of them. My
critical attributes are flexibility, creativity and intuition. In our borderline case, we will look at
another example in nursing. A patient has a slight fever. All other vitals are within defined
limits. Patient has vague complaints of not feeling right but can offer nothing specific.
Assessment reveals nothing extraordinary. The labs from the day before are unremarkable and
no labs have been done today. However, the nurse feels like something is not right. Their
intuition tells them that something else is wrong. The nurse tells the doctor their feelings, but the
doctor shrugs it off as nothing is obvious to lead anyone to believe that there is a problem. The

CRITICAL THINKING

11

nurse continues on their day, but keeps a close eye on this patient. Taking their vitals frequently
and rounding on them often. Later in the day, patient begins to have sudden onset of chest pain
and work up reveals a myocardial infarction. We can see that although intuition was present,
there was nothing to lead the nurse into one direction or the other.
Analysis
Critical thinking is challenging to develop. In order to foster this, we must transcend
conventional thought (Padgett & Padgett, 2010, p. 294). Experience appears to be a common
factor in mastering the skill. To encourage its progression, nursing schools have incorporated
simulations into their programs. This is especially important as institutions, such as hospitals
have increasing concerns with patient safety. Institutions have decreased the number of clinical
exposure for nursing students. This in turn allows a student few opportunities to practice in a
live environment. Labs and simulations allow students to develop clinical skills and practical
applications that assist them in integration into the nursing field. Clinical settings must also
foster continued development beyond nursing school as nurses graduate and enter the realm of
their new careers.
Simulations are vital to the development of critical thinking in students and new
graduates. Cazzell and Anderson attest that as students interact in the simulation environment
to deconstruct the simulated task, biochemicals may stimulate the conceptual system that
supports perception and anticipatory inferences (2016, p. 88). Simulations help improve
student confidence and assist in the development of the muscle memory required to master skill
sets.
Nurses are taught to treat patients without regard to their own feelings, but often take
their own opinions into consideration when they experience different clinical findings. When

CRITICAL THINKING

12

nurses make a phone call to a physician, they are often times guiding doctors with their opinion
of the situation. Many of the examples listed in the literature review state that opinion and bias
has no place in critical thinking. Careful consideration of the events would be a significant
component however; opinion is very much involved.
Implications for Nursing
Critical thinking in many fields is an important aspect of daily life. In nursing, it is of
vital importance and its absence has the potential to be catastrophic. We want our patients and
families to have superior and effective care. We want students and new graduates to have a
wider perspective in patient care.
Because nurses are with patients around the clock, they are charged with monitoring the
results of their own interventions as well as the interventions of others. A common
example is seen in a physicians request for information about a patients response to
interventions for digoxin-related cardiac arrhythmias. In order to do so, a nurse must
have followed a process that includes monitoring the effectiveness of actions and making
judgements about what interventions work or do not work in specific situations. By doing
so, the nurse can promote safe patient care and build the multifaceted knowledge base
(Robert & Peterson, 2013, p. 87).
There are strong implications in nursing for critical thinking. Not only do institutions
want patients to be happy and treated well, but they want them to thrive and heal. Nurses are the
eyes and ears of the health care world. They report back on interventions, are obligated to
respond with urgency when unexpected results occur and to be able to navigate through them.
Conclusion

CRITICAL THINKING

13

Most would agree that the ability to master this concept is of vital importance in the
nursing field. Without this ability, situations would be ignored and ultimately patients would
suffer. It is human nature to have a limited perception of what goes on around them. Humans
are subjective by nature, limited in their convictions to be able to visualize and react to the
abstract in situations. The challenge is to develop this skill among nursing students and new
graduates. This is vital in order to provide a high standard of patient care
Critical thinking is an important skill to develop for many fields, and nursing is no
exception. New graduations experience challenges as they make the transition from theory to
application. The ability to solve complex situations under pressure is vital to optimal patient
outcomes. Professors are obligated to provide students with the knowledge necessary to develop
skills to objectively analyze and evaluate situations. The goal as a nursing instructor is to
provide the tools necessary for students to build a foundation so that patients and the community
can be well cared for.

CRITICAL THINKING

14
References

Armstrong, P. (2016). Blooms Taxonomy. Retrieved from https://cft.vanderbilt.edu/guides-subpages/blooms-taxonomy/


Bawden, J., Rowe, W., & Sereni-Massinger, C. (2015). Policy Point -- Counterpoint: Mandating
Law Enforcement to Receive Annual Certification in Cultural Diversity through Critical
Thinking [Journal]. International Social Science Review, 91(2), 1-7. Retrieved from
http://digitalcommons.northgeorgia.edu
Brier, J., Carolyn, M., Haverly, M., Januario, M., Padula, C., Tal, A., & Triosh, H. (2015).
Knowing something is not right is beyond intuition: development of a clinical algorithm
to enhance surveillance and assist nurses to organize and communicate clinical findings
[Journal]. Journal Of Clinical Nursing, 24(5/6), 832-843. http://dx.doi.org/10.1111
Cambridge Dictionary. (2016). http://dictionary.cambridge.org
Cazzell, M., & Anderson, M. (2016). The Impact of Critical Thinking on Clinical Judgment
During Simulation With Senior Nursing Students [Journal]. Nursing Education
Perspectives, 37(2), 83-90. http://dx.doi.org/10.5480
Earvolino-Ramirez, M. (2007, April-June). Resilience: A Concept Analysis [Journal]. Nursing
Forum, 42(2), 73-82. Retrieved from http://www.nursingacademy.com/uploads
Eun, K., & Young, H. K. (2014). Effects of Multi-mode Simulation Learning on Nursing
Students Critical Thinking Disposition, Problem Solving Process, and Clinical
Competence. Korean Journal Of Adult Nursing, 26(1), 107-116. http://dx.doi.org/10.7475
Facione, P. A. (1990). Critical thinking: a statement of expert consensus for purposes of
educational assessment and instruction (ERIC Doc No.: ED 315 423). Retrieved from
https://assessment.trinity.duke.edu/documents/Delphi_Report.pdf

CRITICAL THINKING

15

Gupta, M., & Upshur, R. (2012). Critical thinking in clinical medicine: what is it? [Journal].
Journal Of Evaluation In Clinical Practice, 18(5), 938-944. http://dx.doi.org/10.1111
Kaddoura, M. (2013). New graduate nurses percieved definition of critical thinking during their
first nursing experience [Journal]. Educational Research Quarterly , 36(3), 3-21.
Retrieved from https://www.questia.com/library/journal
McEwen, M., & Wills, E. M. (2014). Theoretical basis for nursing (4 ed.). Philadelphia, PA:
Wolters Kluwer Health Lippincott Wiliams & Wilkins.
Padgett, C. E., & Padgett, S. (2010). is think outside the box 21st century code for imagination,
innovation, creativity, critical thinking, intuition? [Journal]. College Student Journal,
44(2), 294-298. Retrieved from https://www.questia.com/library/journal/
Phillips, W. E., & Burrell, D. N. (2009, Summer). Decision-making skills that encompass a
critical thinking orientation for law enforcement professionals [journal]. International
Journal of Police Science & Management, 11(2), 141-149. http://dx.doi.org/10.1350
Robert, R. R., & Peterson, S. (2013, March). Critical Thinking at the Bedside: Providing Safe
Passage to Patients [Journal]. MEDSURG Nursing, 22(2), 85-118. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/23802494
Smith, M. D. (2009). Critical Thinking: Looking Beyond the Symptoms [Journal]. Fire
Engineering, 162(10). Retrieved from http://www.fireengineering.com/
Synonyms, thesaurus.com. (n.d.). http://www.thesaurus.com/browse/critical?s=t
Turkel, M. C., Marvelous, J., Morrison, D., & Singletary, B. (2016, July). Critical Thinking
Among Practicing Medical-Surgical Registered Nurses [Journal]. MEDSURG Nursing,
25(4), 224-250. Retrieved from http://www.medsurgnursing.net/cgibin/WebObjects/MSNJournal.woa

CRITICAL THINKING

16

University of Louisville. (2016). http://louisville.edu/ideastoaction/about/criticalthinking/what


Walker, L., & Avant, K. (2013). Empirical Referents. In Strategies fortheory construction in
nursing. Norwalk, CT: Appleton & Lange. (Reprinted from Medsurg Nursing, 22(2), 85118, 2007)
Ward, T. D., & Morris, T. (2016, Summer). Think like a nurse: A critical thinking initiative.
ABNF Journal, 27(3), 64-66.

You might also like