Use of Critical Thinking to Achieve Positive Health Outcomes

Full text

1
Use of Critical Thinking to
Achieve Positive Health Outcomes
Margaret Lunney , RN, PhD
Chapter Objectives
By completion of this chapter, readers will be able to:
1. Describe the importance of quality - based nursing care;
2. Explain the relation of intelligence and critical thinking to
quality - based care;
3. Describe the need for case studies to facilitate development of
critical thinking for quality - based care.
The most important indicator of the quality of health care, including
nursing care, is the health outcomes of consumers (Committee on
Quality of Health Care in America, Institute of Medicine [IOM], 2001,
2004 ). The identifi cation of consumer health outcomes is a priority so
that the effectiveness of provider interventions can be described,
explained, and predicted. Three assumptions related to the focus on
health outcomes are: (1) the effectiveness of interventions varies among
health care professionals, (2) knowledge development of the effective-
ness of interventions is the responsibility of health care providers, and
(3) when effectiveness is compromised, people may be “ better off ”
without providers.
Health care providers can only provide quality - based care when
they have suffi cient intelligence and critical thinking competencies to
use existing knowledge to provide health care services. Knowledge is
necessary but not suffi cient to provide the appropriate health care
5
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6 Strategies for Critical Thinking to Achieve Positive Health Outcomes
services; ability to think about and effectively use knowledge is also
essential. The purposes of this chapter are to (a) review the importance
of quality - based nursing care, as demonstrated in the processes and
outcomes of care; (b) explain the relation of intelligence and thinking
to the achievement of quality - based care; and (c) describe the need for
case studies to develop critical thinking competencies.
Importance of Quality - Based Care
The quality of health care services has become a major focus of health
care providers, professional organizations, accrediting agencies, and
other stakeholders such as governmental agencies, foundations, and
insurance companies (e.g., Al - Assaf and Sheikh, 2004 ; Committee on
Reviewing Evidence to Identify Highly Effective Clinical Services,
IOM, 2008 ; Donabedian, 2002 ; Mechanic, 2008 ; Montalvo and Dunton,
2007 ). On its web page, the Robert Wood Johnson Foundation (2008)
summarized the issue of quality care in the United States with the fol-
lowing statement: “ Americans receive only about half of the recom-
mended care they should receive. Adopting quality improvement
strategies, reducing racial and ethnic disparities in care, and changing
how care is delivered at the local level can improve the care all
Americans receive. ”
A major reason for the current emphasis on quality is that research
fi ndings have shown that quality varies widely among localities, health
care agencies, and providers (Committee on Quality of Health Care in
America, IOM, 2001, 2004 ). When the quality of care varies widely,
many consumers are not receiving quality - based services. For example,
the results of a recent U.S. study of the quality of care provided in 73
hospital systems that represented 1,510 hospitals showed substantial
variability in system quality for pneumonia, surgical infection preven-
tion, acute myocardial infarction, and congestive heart failure (Hines
and Joshi, 2008 ). Medication errors is an example of the problems that
exist with quality. In the U.S., “ medication errors harm at least 1.5
million people every year ” (Institute of Medicine, 2008 ). The current
emphasis on quality - based services is intended to establish account-
ability for the quality of health care services provided to the public and
to make signifi cant improvements in quality.
Nurses have a signifi cant role in providing quality care (Aiken,
2005 ). According to Henderson ’ s defi nition of nursing (1964) , nurses
help consumers as needed with the health behaviors that they would
ordinarily do for themselves, e.g., eating, breathing, moving, obtaining
nutrition, and taking medications. Nurses help people with their
responses to health problems and life processes (NANDA International
(I), 2009 ). Nurses are legally and professionally responsible for any
interventions that they use to support consumer health, even when

Use of Critical Thinking to Achieve Positive Health Outcomes 7
those interventions have been prescribed by physicians (Aiken, 2005 ).
Because nurses make up the largest number of health care workers,
any efforts of nurses to improve quality - based care will probably have
broad positive effects on health care in general.
Evidence - Based Practice
It is widely accepted that the quality of care is best achieved by using
the best available research evidence for health care decisions (Committee
on Reviewing Evidence to Identify Highly Effective Clinical Services,
IOM, 2008 ; Melnyk and Fineout - Overholt, 2005 ). In many types of
health care, variance in quality exists because there is insuffi cient evi-
dence to establish consensus on the best way to approach the problem,
risk state, or need for health promotion. In other types of health care,
suffi cient research evidence is available, but providers do not use the
available evidence.
Nurse leaders collaborate with leaders from other disciplines to
promote evidenced - based practice for improved quality of care.
Strategies for nurses to learn how to critique research studies for pos-
sible use are taught in bachelor ’ s and master ’ s degree programs and
in health care agencies (American Association of Colleges of Nursing,
2006 ; Ireland, 2008 ; Leasure, Stirlen, and Thompson, 2008 ). Methods to
develop evidence - based practice projects and protocols are included in
master ’ s degree programs and implemented in clinical agencies.
Impact of Electronic Health Records on
Quality - Based Care
Electronic health records (EHR) are being implemented everywhere in
the world (Committee on Quality of Health Care in America, IOM,
2004; Olsson, Lymberts, and Whitehouse, 2004 ) and will eventually be
mandated for all health care events. The advantage is that when health
care events are electronically recorded the individual health records
can be aggregated with other health records to measure the outcomes
of care provided in specifi c localities and by specifi c agencies and pro-
viders. Health care data can be compared from one place to another to
determine the quality of care provided (Committee on Quality of
Health Care in America, IOM, 2004).
For decades, nurse leaders have been expecting and preparing for
the EHR. For example, NANDA - I was started in 1973 at the fi rst
meeting to classify nursing phenomena for computerized documenta-
tion (Gordon, 1982 ). This meeting was initiated by Drs. Kristine Gebbie
and MaryAnne Levine to identify the phenomena that should repre-
sent the focus of nursing care. Since that time, many nurse leaders have
been involved in health technology and informatics. For example,
nursing specialty groups have a strong presence within the

8 Strategies for Critical Thinking to Achieve Positive Health Outcomes
international and national informatics associations (see Appendix A ,
Webliography). These are the professional leaders who are planning
for and working toward worldwide implementation of EHRs. Judith
Warren, a past president of NANDA - I, is one of 18 members of the
most important U.S. government group for planning an EHR system,
the National Committee on Vital and Health Statistics.
Need for Standardized Nursing Languages ( SNL s )
Standardized nursing languages are organized systems of labels,
defi nitions, and descriptions of the three nursing care elements of
diagnosis (assessment is subsumed within diagnosis), outcomes, and
interventions — key aspects of the nursing process (Wilkinson, 2007 ).
These three elements are considered essential for establishing a nursing
minimum data set (NMDS) (Delaney and Moorhead, 1995 ). Some SNLs
are combinations of all three elements, e.g., the Omaha System (Martin
and Norris, 1996 ). NANDA - I, NOC, and NIC, the SNLs used in this
book, are three separate systems that are used together to represent
diagnosis of human responses (NANDA - I), the results or outcomes
of nursing care (NOC), and nursing interventions (NIC) (Bulechek,
Butcher, and Dochterman, 2008 ; Moorhead, Johnson, Maas, and
Swanson, 2008 ; NANDA - I, 2009 ). These three systems are used for this
book because they are the most comprehensive of all nursing language
systems and have strong research support.
SNLs are needed to achieve quality - based nursing care for three
reasons: (1) they represent three nursing care elements considered
essential for the NMDS, (2) they represent evidence - based nursing, and
(3) they serve as the fi le names for documentation in computerized
systems. The elements of an NMDS were described by nurse leaders
as the minimum data that should be available and communicated to
determine the quality of nursing care.
SNLs such as NANDA - I, NOC, and NIC represent evidence - based
nursing. Each of these languages was developed using nursing
research. The individual labels and descriptions of the NANDA - I clas-
sifi cation are based on research studies (NANDA - I, 2009 ). The NOC
and NIC labels and descriptions were developed and organized by
research teams, partially funded with millions of dollars from the
National Institute of Nursing Research. To develop these systems, the
research teams organized previous nursing knowledge, both research
and practical, that had evolved over decades.
SNLs provide the fi le names with which to record consumer data in
EHRs. Organized systems of fi le names are needed to organize and
retrieve data from electronic systems. The three systems of NANDA - I,
NOC, and NIC were developed with the EHR in mind; each label, for
example, is coded for the EHR. Consistent use of these labels enables
health care agencies to describe the services they provide and deter-

Use of Critical Thinking to Achieve Positive Health Outcomes 9
mine the quality of care. A medical - surgical unit, for example, can
describe the number of patients in a day, week, month, or year for
which the diagnosis of disturbed body image * was made and treated.
Inferences about the quality of care are made by comparing interven-
tions to evidence - based standards and measuring the outcomes of
nursing interventions.
Because SNLs are so useful to evidence - based clinical practice and
implementation of EHRs, nurses need to learn how to use critical think-
ing for selecting diagnoses, outcomes, and interventions. The following
section explains intelligence and critical thinking for application in
clinical practice.
Intelligence and Critical Thinking to Achieve Quality Care
For nurses to help people achieve positive health outcomes, they
need intelligence to think about, interpret, and act on clinical situa-
tions. Sternberg ’ s theory of intelligence (1988, 1997) provides a
framework for understanding this concept. From this perspective,
intelligence is described as the ability to function well in the external
world of work, home, play, and so forth, not by performance on an
intelligence test. Critical thinking is a dimension of nursing intelli-
gence that is necessary for using the nursing care elements of diag-
nosis and selecting appropriate outcomes and interventions. Nurse
clinicians and students have the potential to continuously improve
the quality of nursing care if they know about thinking processes
and critical thinking.
Sternberg ’ s Theory of Intelligence: The Triarchic Mind
Sternberg ’ s Theory of the Triarchic Mind (1988) focuses on intelligence
as it pertains to “ everyday ” matters in the lives of people. Sternberg
identifi ed fi ve major problems associated with previous theories of
intelligence. First, there was too much emphasis on the use of intelli-
gence in unusual and bizarre situations rather than in ordinary problem
solving. Second, positions pertaining to intelligence were politicized
(e.g., the argument about which was more important, genetics or envi-
ronment) before there was suffi cient evidence about how people think.
Third, technology was driving the science of intelligence — people were
being tested for intelligence without knowing what intelligence was all
about. Fourth, the belief that a single test score, the intelligence quotient
(IQ), revealed people ’ s intelligence was given too much credence in the
* Italics will be used throughout the book for the offi cial NANDA - I, NOC, and NIC labels.

10 Strategies for Critical Thinking to Achieve Positive Health Outcomes
face of evidence that intelligence was much more complex than an IQ
score could indicate. Fifth, the idea that intelligence is a “ fi xed entity ”
was promulgated and believed while research and experience demon-
strated that intelligence can be improved through guided instruction
and practice. Sternberg ’ s theory counteracts previous views and pro-
vides a more optimistic view of intelligence.
According to Sternberg ’ s theory, intelligence in everyday life is
mental self - management consisting of “ the purposive adaptation to,
selection of, and shaping of
…
environments relevant to one ’ s life and
abilities ” (p. 65). The process of mental self management makes it pos-
sible to continuously develop intelligence for functioning well within
our daily environments, for example, nursing care. Intelligence devel-
ops as an interaction or relation among three components: the internal
world of the individual, the external world of the individual, and the
person ’ s experience of the resultant interchange between internal and
external worlds (Figure 1.1 ). It is through these interrelationships that
people can improve their own intellectual functioning, including criti-
cal thinking.
Figure 1.1. Relationships among the various aspects of the triarchic theory of human
intelligence. Source: From The triarchic mind: A new theory of human intelligence (p. 68)
by R.J. Sternberg, 1988 , New York: Penguin Books. Reprinted with permission.
SELECTION SHAPING
ADAPTATION
COPING WITH RELATIVE
NOVELTY
TASK IS HIGHLY UNFAMILIAR TASK IS HIGHLY FAMILIAR
PERFORMANCE
COMPONENTS
KNOWLEDGE-ACQUISITION
COMPONENTS
METACOMPONENTS
COMPONENTIAL EXPERIENTIAL CONTEXTUAL
AUTOMATIZATION

Use of Critical Thinking to Achieve Positive Health Outcomes 11
The Internal World of the Individual
The internal world of the individual is comprised of three components:
metacomponents, knowledge - acquisition components, and perfor-
mance components. The metacomponents activate the other two
components, which in turn provide feedback to the metacomponents.
Metacomponents are the executive processes used to plan, monitor,
and evaluate problem solving. The knowledge - acquisition components
are processes used to learn how to solve problems. Performance com-
ponents are the lower order (intellectual) processes used to implement
the commands of the metacomponents. The performance components
refer to performance of the person ’ s mind (e.g., making a decision after
more complex thinking processes have led you to that decision), not
visible performance of the whole person.
Metacomponents are used to think about the nurses ’ role in relation
to the clinical situation. Nurses need to think about whether a con-
sumer has a problem that should be treated, the severity of the problem,
the priority of the problem, the prognosis of the problem, the interven-
tions that are needed, how the problem should be communicated to
others for a plan of care, the accuracy of the problem ’ s identifi cation,
and the effectiveness of the interventions in responding to the problem.
Knowledge - acquisition components are used to select related knowl-
edge. Examples of knowledge acquisition are use of books on nursing
diagnoses, nursing - sensitive patient outcomes, and nursing interven-
tions; checking an agency policy manual; seeking a family member to
obtain more information; and collaborating with another nurse to
understand the meaning of data.
In the performance components, when data are available for making
an accurate diagnosis, the diagnosis is selected in partnership with the
consumer, if possible. When a diagnosis is considered to be highly
accurate, an outcome is selected, a baseline score is assigned, and inter-
ventions are chosen. These three components are continuously interac-
tive in the internal world of the nurse diagnostician. Each aspect of the
internal world of a nurse provides feedback to the other two aspects
and has the potential to improve intelligence for the practical world of
nursing.
The External World of the Individual
The external world of an individual consists of all of the individual ’ s
environments. The individual uses intelligence to exist in these
environments. Intelligence serves three functions in the person ’ s
external world: (1) adapting to existing environments, (2) selecting
new environments, and (3) shaping existing environments into new
environments. For example, a woman who is being battered by a
male partner can use her intelligence to adapt to the situation,
leave the situation, or change the situation to fi t her needs. The environ-
ments in which people live and work are the contexts within which

12 Strategies for Critical Thinking to Achieve Positive Health Outcomes
intelligence exists. When intelligence is developing, the person consid-
ers the contexts of the external world and develops a fi t within these
contexts. People in various contexts use a wide variety of strategies to
function in the external world. People who function well in relevant
environments seem to capitalize on their strengths and compensate for
limitations by using other resources and seeking consultations.
Nurses must use their intelligence to function well in a variety of
environments or contexts. Sometimes there are serious time constraints
for health assessments and thinking about diagnostic and intervention
possibilities. Other times, the clinical situation is extremely complex
with multiple interacting variables related to pathophysiology, emo-
tional states, family processes, and so forth. With the complexity and
diversity of environments that form the context of nursing, nurses can
capitalize on their strengths to help them function well in a variety of
environments (e.g., ability to conduct interviews and physical exami-
nations, ability to collaborate effectively with families). They can also
compensate for weaknesses by collaborating with other nurses on
making diagnoses and validating diagnostic impressions with health
care consumers.
The Experience of the Individual
The three components of the individual — metacomponents, knowl-
edge - acquisition components, and performance components — are
applied at various levels of experience (i.e., from new experiences to
routine experiences) in the external world. There are differences in
the use of metacomponents, knowledge - acquisition components, and
performance components when a task in the external world is novel
as opposed to routine. After a task is performed a number of times,
it becomes routine or automatic. For example, brushing teeth is novel
to an infant but becomes routinized as the mother helps the child to
practice this skill. The ability to cope with novelty, including check-
ing whether aspects of the situation are familiar enough to rely on
previous knowledge and techniques, is considered an aspect of
intelligence.
In nursing situations, for example, the fi rst time that a specifi c diag-
nosis is used, it may require more emphasis on knowledge - acquisition
components than metacomponents. The performance components of a
nurse who is familiar with the human experience being diagnosed are
more competent or effi cient than those of a nurse who is unfamiliar
with the experience. The three mental processes of intelligence are
improved with repeated exposures to particular nursing diagnoses in
a variety of contexts. This aspect of Sternberg ’ s theory was supported
by nursing research conducted on the development of competence
(Benner, 1984 ). Benner showed that years of nursing experience was a
critical factor in development from the novice stage to more advanced
stages of competence.

Use of Critical Thinking to Achieve Positive Health Outcomes 13
Critical thinking involves specifi c types of thinking that occur in the
internal world of the individual (i.e., in the three components).
Knowledge of critical thinking, as it applies in nursing practice, and
refl ection on thinking processes (metacognition) enable nurses to
improve these aspects of the internal world.
Critical Thinking
A defi nition of critical thinking in nursing that was produced by a
study of expert nurse opinions serves as a basis for understanding the
subject (Scheffer and Rubenfeld, 2000 ; Rubenfeld and Schaffer, 2006 ).
Critical thinking in nursing is an essential component of professional
accountability and quality nursing care. Critical thinkers in nursing
exhibit these habits of the mind: confi dence, contextual perspective,
creativity, fl exibility, inquisitiveness, intellectual integrity, intuition,
open - mindedness, perseverance, and refl ection. Critical thinkers in
nursing practice the cognitive skills of analyzing, applying standards,
discriminating, seeking information, logical reasoning, predicting, and
transforming knowledge (Scheffer and Rubenfeld, 2000 , p. 357).
This defi nition was developed through fi ve rounds of a Delphi study
with 51 nurse experts in critical thinking. The defi nition includes the
characteristics of critical thinking from previous theoretical and
research - based activities considered important for nursing.
It is assumed that nurses, like other adults, vary widely in thinking
abilities; numerous studies have shown that adults demonstrate a wide
variance in thinking abilities of all types (Gambrill, 2005 ; Sternberg,
1988, 1997 ; Willingham, 2007a, 2007b ). Lunney (1992) substantiated
that nurses vary widely in the divergent thinking abilities of fl uency,
fl exibility, and elaboration. Fluency is the ability to think of many units
of information. Flexibility is the ability to mentally change from one
category of information to another. Elaboration is the ability to identify
many implications from a unit of information. Some nurses scored very
high, while others scored very low on fl uency, fl exibility, and elabora-
tion. These thinking abilities, however, can be improved through
instruction and practice (Gambrill, 2005 ; Sternberg, 1997 ; Willingham,
2007a ). One of the purposes of selecting diagnoses, outcomes, and
interventions for the case studies in this book is to further develop
thinking skills for application to future clinical cases.
The seven cognitive skills of critical thinking — analyzing, applying
standards, discriminating, seeking information, logical reasoning,
predicting, and transforming knowledge — are applied during the
nursing process (Scheffer and Rubenfeld, 2000 ; Table 1.1 ). The 10 habits
of mind developed by critical thinkers in nursing are evident in each
of the cognitive skills. Intuition as a habit of mind seems to be associ-
ated with increased experience and may be related to fewer of the
cognitive skills than other habits of mind. The seven cognitive skills

Table 1.1. Critical thinking in nursing: defi nitions of terms. *
Dimensions of Critical
Thinking
D e fi nitions
Cognitive skills
Analyzing Separating or breaking a whole into parts to discover the
nature, function, and relationships
Applying standards Judging according to established personal, professional, or
social rules or criteria
Discriminating Recognizing differences and similarities among things or
situations and distinguishing carefully as to category or
rank
Information seeking Searching for evidence, facts, or knowledge by identify-
ing relevant sources and gathering objective, subjective,
historical, and current data from those sources
Logical reasoning Drawing inferences or conclusions that are supported in or
justifi ed by evidence
Predicting Envisioning a plan and its consequences
Transforming knowledge Changing or converting the condition, nature, form, or
function of concepts among contexts
Habits of the mind
Confi dence Assurance of one ’ s reasoning abilities
Contextual perspective Consideration of the whole situation, including relation-
ships, background, and environment, relevant to some
happening
Creativity Intellectual inventiveness used to generate, discover, or
restructure ideas; imagining alternatives
Flexibility Capacity to adapt, accommodate, modify, or change
thoughts, ideas, and behaviors
Inquisitiveness An eagerness to know by seeking knowledge and under-
standing through observation and thoughtful question-
ing in order to explore possibilities and alternatives
Intellectual integrity Seeking the truth through sincere, honest processes, even if
the results are contrary to one ’ s assumptions and beliefs
Intuition Insightful sense of knowing without conscious use of
reason
Open - mindedness A viewpoint characterized by being receptive to divergent
views and sensitive to one ’ s biases
Perseverance Pursuit of a course with determination to overcome
obstacles
R e fl ection Contemplation upon a subject, especially one ’ s assump-
tions and thinking, for purposes of deeper understand-
ing and self - evaluation
* Scheffer, B.K., and Rubenfeld, M.G. (2000) . A consensus statement on critical thinking. Journal of Nurs-
ing Education, 39 , 352 – 359.
14

Use of Critical Thinking to Achieve Positive Health Outcomes 15
and the 10 habits of mind are mental processes of the internal world
of nurses.
Use of Cognitive Skills and Habits of Mind
The use of cognitive skills and habits of mind are discussed here in
relation to deciding on a diagnosis because that is the foundation for
selecting outcomes and interventions. The two aspects of critical think-
ing, cognitive skills and habits of mind, are interrelated (Scheffer and
Rubenfeld, 2000 ); cognitive skills are the context in which the habits of
mind are useful. Nurses can develop both aspects as they learn to
diagnose and intervene for diagnoses to achieve positive health out-
comes. To illustrate these relationships, the 10 habits of mind are
explained in relation to each of the cognitive skills. The cognitive skills
are presented in alphabetical order because most likely the order in
which they are used differs for various aspects of the nursing process.
Cognitive Skill of Analyzing
When a person presents with cues (signs and symptoms) that indicate
a nurse should assess that person ’ s health status, the nurse (internal
world, metacomponent) analyzes the presenting data and determines
what additional data are needed and which diagnoses are probable.
During the assessment process, the nurse synthesizes information and
analyzes how well the cues fi t with particular diagnoses.
Habits of Mind
A contextual perspective is needed to analyze cues in the context of the
whole situation (e.g., if a woman is smiling, it may not mean that she
is happy; rather, she may have been taught to smile to cover up bad
feelings). The nurse needs confi dence to trust the data analysis and
seek further consensus through mutual collaboration with health care
consumers and other providers. Creativity, fl exibility, inquisitiveness,
intuition, and open - mindedness are needed to consider a variety of
possible meanings of data. Intellectual integrity is also required for
analysis along with a commitment to spend professional time and
energy on the analysis process. Perseverance and refl ection are essen-
tial when the analysis is more diffi cult and time consuming than
expected.
Cognitive Skill of Applying Standards
The nurse (internal world, metacomponent) applies standards related
to the diagnostic process by: (a) using the principles of good com-
munication during the health history, (b) working collaboratively
with the consumer throughout the diagnostic process, (c) conducting
physical examinations using valid and reliable techniques, and (d)
using research and theory when making diagnoses. The nurse draws

16 Strategies for Critical Thinking to Achieve Positive Health Outcomes
these standards from memory or identifi es standards during informa-
tion seeking.
Habits of Mind
Confi dence is required when selecting the best standard for use in the
diagnostic process. A contextual perspective is needed to discern
the relevance of standards to the whole situation, e.g., the culture of
the individual. Creativity, fl exibility, inquisitiveness, intuition, and
open - mindedness are needed when the usual standards may not apply.
Intellectual integrity is essential when the applied standards are not
well accepted by others. Perseverance and refl ection are needed to
identify standards for application in unusual or diffi cult situations.
Cognitive Skill of Discriminating
The nurse (internal world, metacomponent) notices or discriminates
those cues or data in a clinical situation that are important to consider.
These cues are discerned in relation to the possible meanings of cues
(diagnoses) and the relevance of cues, e.g., low, moderate, high. This
process narrows the selection of cues for consideration during analysis
and other mental processes (internal world, performance component
intellectual).
Habits of Mind
Because cues and diagnoses are only meaningful in the context of the
whole situation, a contextual perspective is essential. Confi dence in self
is needed to isolate important cues. Creativity, fl exibility, inquisitive-
ness, intuition, and open - mindedness are required to notice unusual or
unexpected cues. Intellectual integrity is needed to follow up on cues,
despite the time, energy, and effort involved. Perseverance and refl ec-
tion are needed to discriminate cues that fi t with other cues for making
decisions about the diagnosis.
Cognitive Skill of Information Seeking
The nurse (internal world, knowledge - acquisition component) seeks
information to assist with and support the interpretation of cues as they
relate to diagnoses. Information sources may be the health care con-
sumer, the family, the health care record, the literature on a particular
health problem, the literature on human response concepts, and the lit-
erature related to developmental or cultural aspects of the consumer.
Habits of Mind
The mental habit of refl ection is needed to guide the nurse ’ s search for
new information. Intellectual integrity is needed to seek the most
appropriate source of information, even when the task is diffi cult or
unrewarding. It is important that nurses use creativity, fl exibility, and
inquisitiveness as they consider sources of information that are unusual

Use of Critical Thinking to Achieve Positive Health Outcomes 17
for the situation. Perseverance is needed when the required knowledge
is elusive, diffi cult to fi nd, or diffi cult to interpret.
Cognitive Skill of Logical Reasoning
The nurse (internal world, metacomponent) uses logical reasoning to
consider the meaning and relevance of cues in relation to diagnoses
and to converge to the most accurate diagnoses. Logical reasoning is a
process of evaluating, comparing, and judging existing data against
expected data. In previous decades, logical reasoning, inductive and
deductive, was considered to be the primary method of interpreting
data (e.g., Bandman and Bandman, 1995 ). Additional thinking strate-
gies such as intuition were acknowledged and accepted as seen in the
defi nition of critical thinking (Scheffer and Rubenfeld, 2000 ). The cogni-
tive skills of analysis, discrimination, and applying standards are inti-
mately involved with logical reasoning in making diagnoses.
Habits of Mind
Confi dence is needed to select the most appropriate diagnoses for a
data set. A contextual perspective enables the nurse to interpret data
in the context of the whole situation. Intellectual integrity is required
to select the most accurate diagnosis when the decision is a diffi cult
one. Intuition and open - mindedness are needed to recognize and
accept that logical reasoning may not be the most appropriate way to
make a diagnosis in a specifi c situation. Perseverance and refl ection are
needed when logical reasoning is more diffi cult than expected.
Cognitive Skill of Predicting
The nurse (internal world, metacomponents, and performance compo-
nents) predicts possible diagnoses from clusters of cues, anticipates
human responses for particular health states, and prioritizes diagnoses
for interventions and outcomes. Thinking abilities, clinical experience
in nursing, and knowledge are the basis for such predictions.
Habits of Mind
Confi dence is needed to make predictions. A contextual perspective or
consideration of the whole situation, not just the parts, improves the
validity of predictions. When the most accurate predictions are differ-
ent than the routine, the nurse needs to be open - minded enough to
accept explanations that are unusual, inquisitive enough to explore
alternative explanations, and fl exible enough to change from one cat-
egory of explanation to another. Creativity may be needed when expla-
nations are unusual or novel. Intellectual integrity is needed to accept
the predictions that are best indicated by the data. Intuition is needed
to discern cues and predict that which may not be evident through
logical reasoning. Perseverance and refl ection are needed when predic-
tions are more diffi cult to develop than usual.

18 Strategies for Critical Thinking to Achieve Positive Health Outcomes
Cognitive Skill of Transforming Knowledge
The nurse transforms knowledge by using the processes described
above to apply the general knowledge of diagnostic concepts to clinical
situations of varying contexts. Knowledge is transformed from one
form to another when general knowledge of diagnostic concepts is
used to help an individual, family, group, or community. For example,
general knowledge of self - esteem must be transformed for use with
people of various cultures. The meaning of self - esteem varies among
cultures so the concept cannot be universally applied. The nurse trans-
forms knowledge by integrating knowledge gained through clinical
experiences (practical knowledge) with theoretical knowledge (research
and theory). For example, the nurse with fi ve years of clinical experi-
ences working with post - operative patients with ineffective airway
clearance applies theoretical knowledge of this concept differently than
a nurse with one year of experience.
Habits of Mind
Without self - confi dence, the nurse cannot transform knowledge to
make a diagnosis, especially when the diagnosis is not one that is
routine. An inquisitive nurse is more likely to recognize opportunities
for transforming knowledge. Being able to incorporate the context of a
clinical situation with highly relevant data enables nurses to be more
accurate in diagnosis generation and transformation of knowledge.
With fl exibility, the nurse can mentally search multiple categories of
knowledge as indicated. Creativity supports the transformation of
knowledge through identifi cation of unusual connections or relation-
ships. Intuition is needed when the specifi c data for knowledge trans-
formations cannot be identifi ed. Perseverance and refl ection are needed
when knowledge transformations are more challenging than usual.
Intellectual integrity may be needed to accept knowledge transforma-
tions despite confl icts with assumptions and beliefs and to be able to
validate diagnoses with others.
Metacognition
Nurses ’ intelligence and critical thinking are improved through meta-
cognition (Pesut and Herman, 1999 ). Metacognition involves thinking
about thinking and is a tool for self - improvement. Development of this
skill provides a basis for growth as a professional. The seven cognitive
skills and 10 habits of mind provide the language, meanings, and
framework for nurses to think about their own thinking. Each of the
cognitive skills and habits of mind can be thought about and analyzed
independently, discussed with other nurses or instructors, or written
about in a journal for examination later.
An independent process of thinking about the diagnostic process
was referred to as self - monitoring of diagnostic reasoning (Carnevali,

Use of Critical Thinking to Achieve Positive Health Outcomes 19
1984 ; Lunney, 1989 ). It can be likened to having a bird sitting on your
shoulder and whispering in your ear: what are you thinking? how are
you thinking? (Carnevali, 1984 ). Refl ection, or refl ective practice (Johns,
2006 ), includes self - monitoring of thinking processes. Self - monitoring
can be described for self or others (e.g., an instructor) through a clinical
journal (Degazon and Lunney, 1995 ). Teachers can require students to
write clinical journals so they can refl ect on the thinking processes that
occurred during a clinical event. A course requirement to use metacog-
nition in clinical journals can stimulate ongoing use of thinking about
thinking.
Need for Case Studies to Develop Critical Thinking Skills
for Quality - Based Care
Case studies are needed for nurses and nursing students to learn criti-
cal thinking for diagnosis, outcomes, and interventions because meta-
cognition only achieves skill development when it is combined with
repeated practice of the thinking processes with the specifi c skill, e.g.,
use of NANDA - I, NOC, and NIC (Lunney, 2008 ; Willingham, 2007a ).
Many studies have substantiated that critical thinking skills only
advance when metacognition is combined with repeated experiences
of applying the requisite skills (Willingham, 2007a, 2007b ).
In the real world of nursing, there are not enough clinical experi-
ences that can be offered to nurses and student nurses for them to
become profi cient in applying the cognitive skills and habits of mind
to diagnose clinical cases and use NANDA - I, NOC, and NIC. Case
studies offer low - risk opportunities to use critical thinking and meta-
cognition to achieve evidence - based practice. The case studies and
analyses in this book stimulate metacognition by providing challenges
to the thinking processes of nurses and nursing students. Readers can
diagnose the clinical cases and match their diagnoses and thinking
processes with those of the case study authors.
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