Consequently, CT is defined as a basic competency of nurses to organize the nursing process and solve the problems of patients 2 , thus enabling the safe and effective provision of care in different clinical environments 5 , 7.
Critical Thinking in Nursing Practice | Nurse Key
Given the nature of care in emergency services, decision making must be precise, considering it is a systemic evaluation and judgement process that comprises cognitive and behavioural skills that are inherent to critical thinking 4 , 8 - 9. Based on the premise that structural elements of CT permeate the clinical practice of nurses, expanded and in-depth studies on analysing these elements is therefore justified, within the context of emergency services, to support strategies that enhance this skill in the diagnostic process. It was therefore important to determine which elements of critical thinking are used by nurses during clinical decision making in emergency services.
For this reason, the purpose of this study was to analyse the elements that structure critical thinking during the decision-making process of nurses in emergency units of general public hospitals. The presented data was obtained from explanatory, qualitative research conducted at the emergency units of three general and public hospitals in the municipality of Porto Alegre, Rio Grande do Sul, Brazil. Study participants were 20 nurses selected according to convenience, of which 12 worked in the general hospital's emergency unit, six in the emergency service of a benchmark trauma hospital and two in emergency rooms of a maternity and children's hospital.
Criterion for inclusion was: practicing nurse with at least one year of experience in the study field. Nurses that conducted management or administrative roles and who were hired for a probationary period were excluded from the study. Data were collected from April to June by means of a questionnaire that was completed by the participants.
The first item of the questionnaire included identification, sex, age, academic background, professional background, graduate studies and attendance to permanent education course. The second item presented a problem-situation portrayed as a validated clinical case study The case study was about an elderly man with a medical diagnosis of congestive heart failure who sought assistance due to chest pain and shortness of breath, and other relevant signs and symptoms. Based on this clinical case, nurses had to list the patient's health problems, prescribe nursing care and mention the expected results.
After this stage, participants had to list, by order of priority and within a pre-established framework, the first five structural elements of CT they had used to solve the clinical case 5. Then nurses were asked to define the elements they selected. Obtained data were analysed using the content analysis method 11 that comprises three distinct stages: pre-analysis, exploration of material and treatment of results and interpretation.
The first stage consisted of organizing definitions of CT elements used by the nurses, which are configured in record units. The second stage consisted of creating categories based on similarity of content and the framework adopted in this study 3 - 5.
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The CT elements prioritized by the nurses were associated to these categories. Treatment of these results and interpretation, which is the third stage of content analysis, was conducted using the adopted theoretical framework.
All subjects who participated in this study signed an Informed Consent agreement and were identified using numbers to protect their identities. Collected data allowed the characterization of participating nurses in relation to sex, age, and academic and professional background in the study field. Most of the subject were women 18 , with an average age of In relation to background, 15 nurses had an academic background of at least eight years and a median of two to six years of experience in the study field.
The characterization of complementary education of nurses showed that 18 had graduate studies in different nursing practice fields and two nurses had master's-level studies. In relation to permanent institutional education courses, those on the Systematization of Nursing Care SAE and adult patient care were the most common, attended by eight and four nurses, respectively.
Of all the participants, eight nurses had not attended any such courses. Content analysis revealed three categories that were related to structural elements of CT listed by the nurses: associating theoretical and practical bases for clinical decision making: technical and scientific knowledge and clinical experience ; thought process and clinical decision making: clinical reasoning, clinical judgement, intuition, prediction ; basis for nurses' clinical judgement: patient assessment, ethics, knowledge of the patient, cultural knowledge, application of normality and ethical standards.
These categories and the respective structural CT elements are discussed below, based on the theoretical framework adopted in this study. Clinical experience and technical and scientific knowledge are essential components and complements to define patient care actions. Clinical experience was defined by nurses as:.
Similar situations that occur in all my shifts during my work routine help me recognize the different pathologies. Nurse Capacity constructed in time, through daily experiences with patients, to reach excellence in nursing care. Associated to clinical experience, technical and scientific knowledge was defined as being the basis to implement actions, as suggested by other nurses.
Knowledge and function of physiological standards can be used to build a model based on experiences with patients.
Evaluation of the clinical case study provided to the nurses revealed that priorities of clinical decision making are technical and scientific knowledge and clinical experience as elements of CT. The association that participants of this study made between signs and symptoms of diseases and cases of their clinical practice or previous experience with patients that have similar symptoms showed the development of critical thinking for clinical decision making.
From the viewpoint of nurses, clinical experience has a direct relationship with daily work experiences in the emergency units, and helped these professionals to recognize clinical situations and identify the specific care needs of patients. Similar results were obtained in a study conducted with clinical practice nurses showing that experience and academic background of these professionals was essential to increase critical thinking skills 2.
In the context of professional background, clinical experience was pinpointed and defined by scholars as being an important competency for the development of critical thinking, resulting from knowledge acquired by nurses and their experiences in specific situations of their daily care routine 13 - Analysis and interpretation of the case study allowed nurses from this study to identify and define structural elements that, according to their evaluation, constituted critical thinking and led to clinical decision making: clinical reasoning and clinical judgement, intuition and prediction.
Clinical reasoning and clinical judgement are different, albeit complementary, aspects in the exercise of nurses' evaluations, being that the former leads to judgement, or decision making From these structural CT elements in this category emerged the inter-relation of these elements in the clinical reasoning process expressed in the following statements. It is thought directed to a problem-situation with the purpose of making the best decision.
The interview, the physical exam, symptoms of the disease are relevant factors that lead to the set of decisions that have to be made in the diagnostic process, which requires clinical reasoning. As a complement to the definitions above, nurse 13 emphasized clinical reasoning and its importance in the context of care. Necessary to evaluate patients in the short, medium and long term in relation to measures, urgent care, care plans, nursing prescriptions and expected results.
Knowing how to identify possible complications by observing the patient, who directs you to possible problems or situations. Intuition, one of the mental habits of critical thinkers, is defined as the perceptive sensation of knowing without conscious use of reason; immediate knowledge that is not dependant on reasoning 7 , Intuition, associated to cognitive CT skills, guides nurses when making precise clinical decisions. The clinical judgement of nurses was based on the following structural CT elements: patient evaluation, ethics, knowledge of patient, cultural knowledge, application of normality standards.
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Technological advancements in healthcare have contributed to the quality of diagnostic and therapeutic processes. However, during patient evaluation, anamnesis and physical examinations are basic instruments of the nursing process 13 - Consequently, participants of this study stated anamnesis, physical examination and the application of normality standards as being the structural elements of critical thinking that support the clinical judgement of nurses. Important for the construction of anamnesis that will support interventions.
I am referring to information such as: Does not take medication, does not follow diet. Nurse 6. Knowing signs and symptoms of the disease through patient evaluations is an important element that guides the prescription of nursing care. Inter-personal, technical and intellectual skills 4 for conducting clinical examinations are essential elements in clinical practice. When evaluating patients, nurses must consider and respect the knowledge and culture of patients, and know how to listen to them 14 , which helps to recognize signs and symptoms and their motives for seeking healthcare services.
In nursing care practices, the ability to listen to others is fundamental because it helps to determine the best way to communicate with patients according to their cultural level and knowledge of their health status 14 , which was emphasized in the following statements:. Clinical judgement was listed and defined by 10 of the 20 nurses in this study, who associated it to adequate investigation of data on clinical histories, the conduction of physical examinations and recognition of signs and symptoms related to the patient's problem.
In nursing care, data collection is the first stage of the nursing process 1. The scientific interpretation of these data refers to the identification of nursing diagnoses, which are established in the nurse's clinical judgement and guide the remaining stages of the nursing process 4. During data analysis, it was perceived that subjects with master's degrees were more familiar with the structural elements of clinical thinking than the others, which is evident in the statement of Nurse 11, and corroborated in a study 2.
Based on the patient's history and evaluation, judgements are made to appropriately plan care. It should be noted that reasoning and clinical judgement, albeit conceptually different, involve cognitive and reflexive mental processes that are associated to previous clinical experiences, which are associated to technical and scientific knowledge that supports this thinking process Clinical judgements is structured according to the following skills: interpersonal, which involves the ability to communicate, listen and respect opinions; technical, including solid knowledge on clinical evaluation methods and scientific knowledge on health problems; intellectual, which refers to thought processes and the perception skills of nurses in relation to human responses 4 , The association of these skills helps nurses to make safe decisions and provide qualified care according to the real needs of patients.
Although verbal communication between nurses and patients in emergency environments can be impaired due to the clinical conditions of patients and characteristics of this sector, this process is fundamental when collecting data that will lead to the identification of needs, clinical judgements and the precise planning of care. Furthermore, the structural elements of critical thinking can also be present in all daily decision making of professional practices that are not directly involved in patient care, but are related to a multi-disciplinary team and management aspects that permeate the organization of complex services such as emergency care.
The analysis of structural elements of critical thinking defined by nurses of emergency services, in this study, showed that technical and scientific knowledge, patient evaluation, clinical experience, clinical reasoning and ethics were considered priorities by study participants during clinical decision making.
Critical Thinking, Clinical Reasoning, and Clinical Judgment
Critical thought is a skill that nurses need in order to improve clinical reasoning and subsequently implement a precise and safe care process. Study limitations were the need to validate elements that structure CT and their definitions by the nurses that participated in this research. This condition supports the need for future studies on this topic. Results helped to reveal the importance of critical thinking for clinical decision making. The growing complexity of health care in the nurses' practice scenarios demands that nurses use the different dimensions of critical thinking and behavioural and affective skills in the nursing diagnostic process.
This is a fundamental presupposition for education, research and care that targets the formation of thinkers with the necessary skills to practice a humanistic profession. Alfaro-Lefevre R. Porto Alegre: Artmed; Relationships between critical thinking ability and nursing competence in clinical nurses.
You need it to understand and anticipate changes in your patient's condition. You must be able to quickly and confidently assess situations and make the best care decision in each unique scenario. It is in situations like these that your critical thinking skills will direct your decision making. The more you practice it, the better you will become and the more naturally it will come to you.
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