Seven nursing students were selected, by invitation, in accordance with the following inclusion criteria: current status as a nursing student agreement to participate in the study by signing the Terms of Free Prior Informed Consent TFPIC , attendance in the 9th semester of the UFPB undergraduate nursing course, these students were approaching the conclusion of the course and had practically applied the nursing diagnosis during different internships; and performance of theoretical and practical educational activities, in units at the Lauro Wanderley University Hospital HULW incorporatingnursing diagnoses.
Data collection derived from the case study was executed with the participants. A clinical case was presented, and the identification of the relevant objective and subjective data was requested following an interpretation of the data, data grouping was suggested to establish different nursing diagnoses. Finally, the identification of a priority nursing diagnosis was articulated. Based on the resolution of the clinical case, the study participants exercised critical thinking based on self-reflection.
To facilitate this exercise, the following question was developed by the researcher: What critical thinking skills did you use to follow the steps of the nursing diagnosis process and why did you use them? Participants were asked to endorse items related to critical thinking skills that, in their perception, were used in the nursing diagnosis process.
After identification of the critical thinking skills, they were asked to justify the importance of these skills in the process.
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Following data collection, a descriptive analysis of critical thinking skills was carried out, with skills identified and distributed in order of frequency. This information provided a basis for directing focus group discussions regarding the conceptual definition of these skills and to build a theoretical model of critical thinking in the nursing diagnosis process.
In consideration of the ethical aspects of research with human subjects, the TFPIC outlined the aim of the study and the commitment of the researcher to maintain the confidentiality of the study participants.
Of the seven participants, six individuals cited analysis, technical and scientific knowledge and logical reasoning as critical thinking skills that are important in identifying a priority nursing diagnosis. Clinical experience was cited by five of the participants and knowledge about the patient and the application of standards were skills mentioned by three participants. Finally, two participants referred to discernment and contextual perspective skills.
The frequency of the cited critical thinking skills thought to be utilized in the nursing diagnosis shown in Figure 1. Based on the participant's justifications regarding the use of specific critical thinking skills in the nursing diagnosis process, the identified characteristics are presented in Chart 1. The three critical thinking skills most often cited included analysis, technical and scientific knowledge and logical reasoning, as shown in Figure 1.
Analysis, according to the participants, is an essential critical thinking skill in the nursing diagnosis process because it enables an evaluation and detailing of the clinical history from the observation and relating of the patient data to justify the identification of health problems. This analysis requires the grouping of main signs and symptoms to comprehend the priority health needs of the patient.
The application of technical and scientific knowledge is considered fundamental to critical thinking skills as it assists in the knowledge of pathophysiology to comprehend and relate signs and symptoms , favoring the comparison of clinical situations with data from the literature to evaluate the clinical manifestations. Thus, it was comprehended that the base of technician-scientific knowledge favors the development of the nursing diagnosis process by allowing the nurse to understand the relation of signals and symptoms to establish problems and care.
Based on the perception of the participants, the use of logical reasoning was observed at the moment of relating of the objective and subjective patient data , aimed at understanding the relationship of the identified data with the health problem of the patient. Thus, logical reasoning can provide the organization of the data obtained to then proceed to the grouping of the data that will support the identification of the nursing diagnosis.
Clinical experience, as the second critical thinking skill most often cited in this study, provides nurses with knowledge derived from their clinical practice. Clinical experience, according to the participants, helps to identify the priority nursing diagnosis due to experience in similar clinical cases enabling perception and observation of data from similar clinical cases. Knowledge about the patient and the application of standards are the third most-cited skills mentioned by participants.
Knowledge about the patient, according to participants, is critical in gathering data for in the nursing diagnosis process, as it is a comprehension of the symptoms of the patient - subjective analysis , that accounts for data related to the personal and family contexts. When establishing a nursing diagnosis, it is considered essential to have knowledge of the clinical history of the patient and their family context.
Regarding the application of standards, the participants cited this as an important critical thinking skill required in the nursing diagnosis process because it enables a clinical evaluation based on the literature. In addition to this evaluation, the application of standards facilitates the grouping of data based on standards and evidence from the literature.
Critical thinking skills in the nursing diagnosis process
Discernment and contextual perspective were the least cited critical thinking skills in this study. According to participants, discernment is provided in the nursing diagnosis process by enabling the reflection of clinical situations based on the evaluation of the data. This evaluation enables the judgment of priority nursing diagnoses. Contextual perspective was considered relevant in the nursing diagnosis process due to its role in allowing an analysis of evidence from a holistic perspective. Based on these results critical thinking skills were perceived to be interrelated and, based on the resolution of the clinical case used in this study, participants acknowledged a relationship between these skills and the steps of the nursing diagnosis process.
The diagnostic process is commonly understood as a series of perceptual and cognitive activities in which observations lead to inferences and, in turn, lead to more observations. The initial conclusions raised from the observation of some data will be improved in that new observations are carried out for the naming of the problems identified 3. The direction of this process requires collecting, processing and interpreting data based on relevant theories, enabling the integration between data identified and theoretical knowledge.
Therefore, clinical experience, judgment to make decisions and critical thinking permeate the steps of the diagnostic process 8. It can be seen that this cycle of activities requires a series of critical thinking skills for the perception, recognition and classification of information in an attempt to comprehend the complexity of human responses to health problems or life situations. Thus, it appears that the diagnostic process involves the recognition of the signs or factors that are presented by a patient. This recognition requires the collection of reliable and relevant data.
When relevant data have been obtained and considered, information must then be interpreted and grouped to construct patterns that inform the development of plausible explanations, or diagnostic hypotheses related to these indications. To clarify the relationship patterns between factors and articulate diagnostic hypotheses, the use of theoretical knowledge and practical experience, common sense, ethical judgment, intuition and critical thinking are required 5. According to the study participants, technical and scientific knowledge and clinical experience permeate all the phases of the nursing diagnosis process.
Clinical experience promotes the development of specific nursing knowledge and requires theoretical knowledge to enable the nurses to compare data identified with information from the literature. The analysis involves the application of standards and requires knowledge about the patient and their contextual perspective for the data collection. It is believed that, for the investigation and evaluation of the biopsychosocial aspects of human beings, it is necessary to compare identified data with standards in the literature, as well as knowing the specifics of the human being and their life context.
The analysis process begins with the data collection and continues with its interpretation and with its grouping based on the application of standards and logical reasoning. At this moment, logical reasoning enables the coherent evidence to be related in the determination of inferences as diagnostic hypotheses.
Thus, it is understood that the judgment of these hypotheses requires logical reasoning and insight to justify the relationship between data in order to judge them, with a view to making a decision regarding the priority nursing diagnosis In the clinical case used in this study, the participants were asked to identify a priority nursing diagnosis and, explain the different diagnostic hypotheses that could be raised; however, the interest of the study was the identification of the nursing diagnosis that represented the primary health needs of the patient in the clinical case presented.
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Different diagnostic hypotheses were identified, yet nursing students experienced difficulties, in selecting a priority nursing diagnosis. They identified a number of nursing diagnoses and, among them, established the order of priority according to the health needs presented by the patient.
In this context, it is accepted that the nurse's decision-making process should be based on a thorough evaluation of the patient's signs and symptoms by understanding their interrelationship as well as their relevance for patient care.
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Observations revealed some difficulty in establishing priority nursing diagnoses within the context of theoretical and practical activities with nursing students, when they are based on the classification systems used in professional practice. Regardless of the classification system used in the clinical practice, it is believed that it is essential to develop, both in the teaching and the nursing practice, the act of questioning the differences and similarities between the diagnostic concepts and their definitions; to comprehend the relationship between the signs and symptoms observed and, overall, to evaluate the main health needs of a patient so that a nursing diagnosis, selected as the priority, guides the planning of the appropriate nursing care.
Thus, it is understood that discernment can be developed as an important critical thinking skill in the nursing diagnosis process through questions directed towards reflecting on certain clinical situations. It follows, therefore, that the difficulty in identifying priority nursing diagnoses represents a challenge for nurses to logically asses the relationships between signs and symptoms and to delineate their capacity for discernment.
These findings highlights the necessity of using strategies designed to develop critical thinking abilities, in nursing education as well as in clinical practice. An underlying assumption of the nursing diagnosis process is that the nurse must take a questioning stance, when interpreting and categorizing to identify the diagnosis.
Notably, some questions may guide the evaluation of clinical situations that are intended to identify nursing diagnoses, such as the following examples:. What other sources of information are available? Is the participation of the patient, family or other professionals necessary for the care? What nursing interventions can be planned to facilitate these results? It is widely believed that this questioning can promote the development of cognitive skills of required for critical thinking, such the search for information, analysis, the application of standards, logical reasoning and discernment.
This questioning can help both the nursing student as well as the nurse, to expand their technical and scientific knowledge and to transform the knowledge based on their clinical experience. Furthermore, the questions can instigate the necessity to comprehend the nursing diagnosis as a way to assist the nurse in the understanding of human responses and in the planning of the nursing care with a focus on achieving efficient results. It is also believed that the case studies associated with the development of conceptual maps can help in the development of logical reasoning and, consequently, can facilitate the discernment for decision making regarding the priority nursing diagnosis as they allow for the visualization of interrelated concepts arranged in a configuration that expresses a meaning and, therefore, contributes to the understanding of specific phenomena of the clinical practice.
The use of specific critical thinking skills at different stages of the nursing diagnosis process was observed in this study and it appears that their application, both in nursing education and in the clinical practice, facilitates the identification of accurate nursing diagnoses. Furthermore, it should be noted that accurate diagnoses are essential for directing nursing interventions aimed at achieving positive health outcomes Based on this reasoning, the development of critical thinking skills can potentially improve the accuracy of nursing diagnoses.
This study demonstrated that a series of critical thinking skills was important to formulate an outcome of the nursing diagnosis process.
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