ZHAN Lin，LEE Shirleatha,FLEMING Belinda

(Loewenberg School of Nursing,University of Memphis,Memphis,TN 38152,USA)

Critical thinking has been emphasized in nursing as an essential skill for nurses for more than fifty years[1].The concept of critical thinking was introduced to Chinese nursing in the middle of 1990s.Since then there has been conceptual confusion,ambiguity,and misuse of this concept.One example is to equate critique to critical thinking. The conceptual ambiguity may be caused by a language translation in which critical thinking is translated in Chinese language as “Pi Pan Thought”.“Pi Pan” in English means “critique.”In this paper,the authors intend to provide readers with an analysis of critical thinking for conceptual clarity and to invite dialogue and debate to signify the importance of using critical thinking in nursing education and professional practice.

1 Critical Thinking Defined

Critical thinking is defined as“discipline thinking that is clear,rationale,open-minded,and informed by evidence” “Mental process of actively and skillfully conceptualizing,applying,synthesizing,and evaluating information to reach an answer or conclusion”[2].Philosophically,the writings of Socrates,Plato,Aristotle[3],and later Lipman[4],Paul[5],and Kuhn[6]have reflected a school of thoughts in which critical thinking is considered as ideal and focuses on what people are capable of doing in the context of “perfections of thought”[7].The ideal critical thinker is inquisitive in nature,open-minded,flexible and fair-minded;has a desire to be well-informed;understands diverse viewpoints;and is willing to suspend judgment as well as consider other perspectives[8-9].However,this school of thought to critical thinking may not always correspond to reality[10]as reality is dynamically changing.

Academicians in philosophy,psychology,and education have studied critical thinking for years.The American Philosophical Association[11]defined critical thinking as purposeful,self-regulatory judgment that uses cognitive tools such as interpretation, analysis,evaluation,inference,and explanation of the evidential,conceptual,methodological,criteriological,or contextual considerations on which judge is based.From these perspectives,critical thinking is defined as a particular quality:(1)good thinking that meets specified criteria or standards of adequacy and accuracy[12];(2)“reflective and reasonable thinking that is focused on deciding what to believe or do”[13];(3)“skillful, responsible thinking that facilitates good judgment”[4];(4)“purposeful,self-regulatory judgment that results in interpretation,analysis,evaluation,and inference,as well as explanation of the evidential,conceptual,methodological,criteriological,or conceptual considerations upon which that judgment is based”[8-9];(5)“thinking that is goaldirected and purposive”; “thinking thataimed at forming a judgment”[14];(6)“the propensity and skill to engage in an activity with reflective skepticism”[15];(7)“disciplined, self-directed thinking that exemplifies the perfection of thinking appropriate to a particular mode or domain of thought”[16].

2 Components of Critical Thinking

Thinking critically involves questioning any underlying assumptions.Critical thinkers reason and evaluate to make a sound decision or to bring a resolve to problem,rather than taking propositions at face value.Critical thinking involves modes of cognitive and intellectual skills of analyzing arguments,making inferences,using inductive and deductive reasoning,judging and evaluating,making decisions,and solving problems.Critical thinkers are mindful,inquisitive,and respectful for diverse viewpoints.

Paul[5,7]has articulated the following eight elements of thought in critical thinking:(1)The problem,question,concern or issue that is discussed or thought about by the thinker.What the thinker is attempting to figure out.(2)The purpose or goal of the thinking that we attempt to figure something out and to accomplish something.(3)The frame of reference or points of view or even world view that we hold about the issue or problem.(4)The assumptions that we hold to be true about the issue upon which we base our claims or beliefs.(5)The central concepts,ideas,principles and theories that we use in reasoning about the problem.(6)The evidence, data or information provided that support the claims we make about the issue or problem.(7)The interpretations,inferences,reasoning,and lines of formulated thought that lead to our conclusions.(8)The implications and consequences that follow from the positions we hold on the issue or problem.

Function of critical thinking is to help one’s thought process move away from underlying assumptions,mystification,fallacies,and rush conclusion.Critical thinking requires one’s ability to question received wisdom,authority,and tradition and to suspend judgments until one understands accurately and adequately.Critical thinkers are fair-minded and use intellectual standards to evaluate own thinking as well as logic of others’thinking.Perhaps,there is no such thing called a perfect thought;yet there is a process toward perfection of thinking through critical thinking training and strategies. This approach indicates that critical thinking can be cultivated and developed as a thinking process described below:

3 Critical Thinking and Nursing

In nursing,critical thinking is defined as“being influenced by knowledge and experience,using strategies such as reflective thinking as a part of learning to identify the issues and opportunities,and holistically synthesize the information in nursing practice”[17].

Other authors[18]define critical thinking as:an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind:confidence,contextual perspective,creativity,flexibility,inquisitiveness,intellectual integrity,intuition,open-mindedness,perseverance,and reflection.Critical thinkers in nursing practice use the cognitive skills of analyzing,applying standards,discriminating,information seeking,logical reasoning,predicting,and transforming knowledge.

NationalLeague forNursing Accreditation Commission[19]defines critical thinking as:the deliberate nonlinear process of collecting,interpreting,analyzing,drawing conclusion about,presenting,and evaluating information that is both factual and belief and has ethic,diagnostic and therapeutic dimensions.

American Association of Colleges of Nursing[20],in its early document Essentials of Baccalaureate Nursing notes,“critical thinking underlies independent and interdependent decision making;” “critical thinking includes questioning,analysis,synthesis,interpretation,inference,inductive and deductive reasoning,intuition,application,and creativity”.AACN[20]further articulates how coursework and ethic experience provide graduates with knowledge and skills in critical thinking to:(1)use nursing and other appropriate theories and models,and an appropriate ethic framework;(2)apply research-based knowledge from nursing and the sciences as the basis for practice;(3)use clinical judgment and decision making skills;(4)engage in self reflective and collegial dialogue about professional practice;(5)evaluate nursing care outcomes through the acquisition of data and the questioning of inconsistencies,allowing for the revision of actions and goals;(6)engage in creative problem solving.

Both nursing education and practice emphasize the importance of critical thinking for application of knowledge/evidence and experience to direct clinical judgments and actions towards achieving optimal or positive patient care outcomes.Knowledge in healthcare is evolving and thus critical thinking is needed as a higher-order of cognitive and intellectual process involving modes of thought-analyzing, reasoning,questioning,judging,and evaluating-an issue or a problem of concern in the context of patient caring.

4 Critical Thinking and Nursing Practice

Critical thinking is the disciplined, intellectual process of applying skillful reasoning as a guide to belief or action[5,21-22].In nursing practice,critical thinking involves the ability to think in a systematic and logical manner with openness to question to ensure safe nursing practice and quality care[23].What makes the thinking of a nurse different from a doctor,a dentist or a pharmacist?It is how nurses’thinking is disciplined,based on standards and ethic conduct of nursing principles,and nursing specific knowledge and skills.Practitioners in nursing think like a nurse and act like a nurse.To “think like a nurse” requires that nurses conceptualize learned scientific and artistic knowledge; the ideas,contents,and theories of nursing,and develop intellectual capacities and skills.Practitioners in nursing ought to be disciplined, self-directed, and critical thinkers.

In nursing practice,clinical reasoning is a process whereby knowledge and experience are applied in considering multiple possibilities to achieve the desired goals[24]while considering patient situations[25].Critical reasoning also involves figuring out difficult questions,recognizing one’s own thinking that could be flawed or limited by lack of in-depth understanding of the problem or a lack of an issue,evaluating one’s thinking to a defensible,well-reasoned view of the problem in a given circumstance.Nurses need not only think deeply and broadly but also they strive to think clearly,accurately,precisely,logically and completely.The quality of one’s thought helps recognize when thoughts are unclear,imprecise,vague or inaccurate.Quality of a nurse’thinking improves over time to build expertise in clinical reasoning and decision making. In the process,irrelevant,inconsistent and illogicalthoughts are eliminated to enable sound reasoning. Critical thinking mind and intellectual habits are necessary for proficiency in reasoning and sound clinical judgments for safe decision-making.

To develop attitudes and dispositions of a fairminded thinker,nurses ought to be willing to suspend judgments until we truly understands another point of view. Superficial thinking leads to poor clinical reasoning and thus unsafe nursing practice.Reasoned judgments involve monitoring own thinking;questioning and reflecting on the quality of thinking. To reason effectively, intellectual skills are essentials such as information gathering,focusing,remembering,organizing,analyzing,generating,integrating and evaluating.

5 Critical Thinking and Nursing Education

Critical thinking is considered as one important student learning outcome in nursing higher education.Nurse educators cultivate students’critical thinking by integrating the essential knowledge,experiences,and clinical reasoning that support professional practice[23].Nursing students are expected to think independently,have intellectual curiosity,be fair-mindedness,and be able to analyze,synthesize,and evaluate.To cultivate students’critical thinking skills,educators pedagogically provide students with case scenarios,simulated clinical situations and activities, and controversial issues.The focus of classroom and clinical activities is to develop an understanding of scholarly and clinical knowledge through the effective use such intellectual abilities and skills as reasoning,questioning,analyzing,evaluating,and judging.

As students encounter increasingly more complex practice situations they are required to think through and reason about nursing in a greater depth and draw on deeper,more sophisticated comprehension of what it means to be a nurse in clinical practice.Students are required to apply theoretical knowledge for reflective practice based on the sound reasoning of intelligent minds committed to safe,effective patient care.A holistic a pproach to critical thinking includes developing students’cognitive and intellectual skills through critical listening,writing,reading,speaking,inquiry,and reflection.

Critical listening refers to how one is listening so as to maximize his/her accurate understanding of what another person is saying[26].Critical listening involves entering empathetically and analytically into the perspective of others,and in nursing practice,listening to perspectives of patients and their families.Critical listening is an essential skill for nurses to interact,collect data,and communicate with patients and their families as well as other health care providers.

Critical writing involves organizing expression of ideas and thoughts in a coherent,logic,and concise manner.Critical writing seeks accuracy and adequacy,elaborates a claim or a point to make it intelligible to others,and presents ideas or points of view in a logic and consistent manner.Nursing care plan is an example for developing students’critical writing skills as disciplined writing requires disciplined thinking and disciplined thinking is achieved through disciplined writing[26].

Critical reading is an active and intellectually process in which the reader participates in an inner dialogue with the writer.Nursing students need to be critical readers so as to enter into a point of view of the author, look for assumptions, key concepts and ideas,reasons and justifications,supporting examples,parallel experiences, and implications and consequences.Critical readers assess and interpret structural features of the written text accurately and fairly[5,7].

Critical speaking is an active process of expressing verbally a point of view,ideas and thoughts that others attain an understanding of the speaker’s perspective on an issue. Monitoring how we express ourselves verbally help ensure that we maximize accurate understanding of what we mean through active dialogue and openness to feedback on our views[26].

Critical inquiry is an important quality for safe practice in which nurses pose questions about practice,seek answers to difficult questions in practice,admit to one’s areas of ignorance, and have intellectual curiosity and perseverance. Critical inquiry as one function of critical thinking involves truth seeking,open-mindedness,and tolerance for others’views with recognition of the possibility of one’s own bias.

Critical reflection “requires that the thinker examine the underlying assumptions and radically question or doubt the validity of arguments,assertions,and even facts of the case”[27]. Critical reflection as part of critical thinking is as a crucial professional skills as inductive and deductive analysis.

6 Conceptual Clarity

Critical thinking is a complex intellectual process.The concepts of critical thinking, clinical reasoning,and clinical judgment are often used interchangeably in nursing literature.Conceptually,critical thinking is a broad term that includes modes of thoughts of reasoning and judging. Clinical reasoning is a specific term that refers to ways of thinking using both inductive and/or deductive approaches to particular patient care issues.Clinical judgment refers to the outcome of critical thinking or clinical reasoning, that is, the conclusion,decision,or opinion one makes. “Critical”as used in “critical thinking” implies the importance or centrality of a cognitive and intellectual process to an issue,question,or problem of concern.Critical thinking involves reasoning,reflecting,analyzing,judging, problem solving, and evaluating. Critical thinking in nursing is guided by professional standards,policies,and ethical principles,and is grounded by knowledge and skills.Critical thinking skills can be developed to help nurses think critically for promoting safety and quality of patient care.

In conclusion,critical thinking is a dynamic process that requires purposeful and controlled thinking.Critical thinking is not simply being “critical”,but rather refusing to draw conclusions without carefully clarifying,examining assumptions,uncovering hidden facts,and evaluating evidence[28].It is having the ability to suspend judgments until one understands accurately and adequately.Critical thinkers are inquisitive,selfinformed,open-minded,and willing to reconsider[28].This process improves the nurse’s ability to make independent decisions and thus improves patient outcomes.

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