AORN Journal
Volume 91, Issue 2 , Pages 197-199, February 2010

Thinking Critically

Article Outline

 

Critical thinking can be defined formally or informally. A formal definition described by Facione, Facione, and Sanchez refers to a process of making reasoned judgments based on the consideration of available evidence, contextual aspects of a situation, and pertinent concepts.1 I propose another, less formal and more skeptical definition of critical thinking: deciding what to do and when, where, why, and how to do it. I would suggest that the value of “skepticism”—questioning and doubting—to critical thinking lies in the importance of asking questions to clarify what is reasonable, what evidence is available, what is the context of a particular situation, and what is pertinent.

Perioperative nurses can appreciate these multifaceted questions related to decisions involving patient care. For example:

■What intervention is appropriate for a patient in the preoperative area whose apparent response to the preoperative sedative is to stop breathing? (Determine whether the patient is breathing; intervene)

■When and where does one intervene? (Now, in the preoperative area)

■Why? (To reestablish breathing and oxygenation)

■How? (Initiate cardiopulmonary resuscitation [CPR]; alert the anesthesia care provider to reestablish breathing; assist with intubation if necessary; obtain medications to reverse apnea).

This scenario incorporates responses related to the nurse's judgment that the patient is apneic. The nurse's awareness of the situation (ie, situational awareness) encompasses the knowledge that the patient has been premedicated, which has attendant respiratory risks. Prompt, assertive, and clear communication to the anesthesia care provider (ie, “The patient has stopped breathing”) in addition to the anticipation of possible interventions (eg, CPR, intubation, medication reversal) reflect both knowledge of the potential complications of sedation and one's experience in similar circumstances. In an emergency situation, the nurse may assist with an intervention (eg, intubation); may function as a “go-fer” (eg, retrieve the crash cart, medications, supplies); and/or initiate the intervention (eg, perform CPR). Determining the most effective response is an important part of critical thinking. Other important considerations include knowing one's limits (ie, knowledge gaps); knowing what resources are available (eg, personnel, equipment); and understanding the team culture within the workplace. These factors affect clinical practice and are significant safety considerations.

Being a team player is an important component of critical thinking because the nurse needs to identify not only the composition of the team but also his or her role within a particular team. For example, in the preoperative area, the circulating nurse performing the preoperative patient interview would be part of the team that also includes anesthesia personnel and preoperative nursing personnel. If the patient experiences a cardiac arrest, the circulating nurse's role would be affected by the contextual attributes of the preoperative area (eg, location of supplies, available medications, emergency communication techniques, immediately available staff members). Were the patient to experience a cardiac arrest in the OR, the team's composition would differ because there would be different team members than in the preoperative area (eg, surgeon, scrub person), and the perioperative circulating nurse's role would reflect intraoperative protocols to resuscitate the patient (eg, open the chest to perform cardiac massage).

Although any patient who experiences a cardiac arrest requires CPR to ensure the airway, breathing, and circulation, the judgment of how the resuscitation should be performed is influenced by the human and material resources available. Arriving at this judgment must be predicated on a mental checklist of questions that narrow our options toward those most likely to benefit the patient. In order to arrive at an accurate situational awareness of the patient's problem; identify the probable interventions; and be familiar with the available resources (eg, personnel, equipment, supplies), we must be willing to question assumptions, expert opinion, and available evidence. I have often said, “assume the best about people and the worst about situations.” Healthy skepticism and doubt about what is occurring may not always be popular, but it is likely to promote better decisions and solutions.

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Developing the Skill of Critical Thinking 

Critical thinking is a process for solving problems, and this is the ultimate outcome we wish to achieve. Critical thinking is an intellectual skill that must be developed, much as any other perioperative nursing skill, such as administering medications, prepping, or using surgical equipment. Such intellectual skills are more likely to grow and thrive in an environment where questioning, curiosity, risk taking, and skepticism are not only tolerated but encouraged. Someone wishing to develop critical thinking habits is less likely to be motivated in an atmosphere where questions are treated as intrusions and skepticism is considered disloyal. Nurses can foster critical thinking through words and actions that promote analysis, alternative options, and enthusiasm for looking at situations in new ways.2 The article “Developing critical thinking in the perioperative environment”3 in this issue of the Journal provides valuable approaches and learning strategies for developing critical thinking skills.

Promoting critical thinking skills also requires assessment of an individual's level of knowledge and experience. Thus, Benner's novice-to-expert continuum4 plays a crucial role in identifying a clinician's learning needs and the competencies required to determine a particular patient's needs and formulate appropriate interventions. The novice or advanced beginner's capabilities would be stretched—or perhaps insufficient—in an emergency situation, whereas the competent, proficient, or expert nurse's interventions would be more likely to achieve an optimal patient outcome.

Although it may seem obvious that the experienced nurse would respond more effectively to an emergency, what may be less obvious is that developing a desired level of critical thinking, judgment, and decision making requires a collective effort on the part of all members of the surgical team. Preceptors, educators, and mentors play a vital role in helping less experienced nurses to develop the necessary knowledge of the actual problem, what to do about it, and also when to do it.

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Effective Application 

In an 1879 lecture to the first year class of the Harvard Medical School, Oliver Wendell Holmes, one of the best known physicians of the 19th century, said that “no remedy is useful unless employed at the right moment.”5(p7),6(p847) Holmes' rationality and his spirit of skepticism were the foundation of both his intellectual skill and his effective application of those skills to patient care. Our role as critically thoughtful patient advocates continues to rely on the rational appraisal of existing evidence, a healthy skepticism to responses that send the message “this is the way it must be done,” and an ongoing desire to strengthen our professional practice—no matter how talented we are.

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References 

  1. Facione NC, Facione PA, Sanchez CA. Critical thinking disposition as a measure of competent clinical judgment: the development of the California Critical Thinking Disposition Inventory. J Nurs Educ. 1994;33(8):345–350
  2. Rubenfeld MG, Scheffer BK. Critical Thinking TACTICS for Nurses: Tracking, Assessing, and Cultivating Thinking to Improve Competency-Based Strategies. Sudbury, MA: Jones and Bartlett; 2006;
  3. Jones JH. Developing critical thinking in the perioperative environment. AORN J. 2010;91(2):248–256
  4. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Additon-Wesley Publishing Co; 1984;
  5. Introductory—September 26, 1879. Unpublished lecture to the first year class at Harvard Medical School. Cambridge, MA: Harvard University, Houghton Archives; 1879;Ms.Am.1234.7
  6. Bryan CS, Podolsky SH. Dr Holmes at 200—the spirit of skepticism. N Engl J Med. 2009;361(9):846–847

PII: S0001-2092(09)00931-4

doi:10.1016/j.aorn.2009.11.062

AORN Journal
Volume 91, Issue 2 , Pages 197-199, February 2010

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