Applying critical thinking to nursing, in RCN

Module overview

Critical thinking and writing are skills that are not easy to acquire. The term ‘critical’ is used differently in social and clinical contexts. Nursing students need time to master the inquisitive and ruminative aspects of critical thinking that are required in academic environments. This module outlines what is meant by critical thinking in academic settings, in relation to both theory and reflective practice. It explains how the focus of a question affects the sort of critical thinking required and offers two taxonomies of learning, to which students can refer when analysing essay requirements. The module concludes with examples of analytical writing in reference to theory and reflective practice.

Keywords

academic assignments, clinical reasoning, CPD, continuing professional development, critical analysis, critical appraisal, education, reflection, reflective practice, students, study skills, studying.

https://www.youtube.com/watch?v=zAlfASZ_GgY

Aims

The aim of this module is to enable one to have a better understanding of the different types and levels of critical thinking that relate to both theoretical and reflective forms of analytical writing. The module provides a classification of levels of critical thinking and gives examples of analytical writing in the contexts of theory and reflective practice.

Intended learning outcomes

After reading this module and completing the time out activities, you should be able to:

• Define the term ‘critical’ as used in clinical practice.
• Outline the differences between ‘being critical’ when analysing theories or concepts and reviewing your experience in nursing.
• Use your enhanced understanding of critical thinking to clarify with your tutors what is required in your coursework assignments.
• Describe different levels of critical thinking and the purpose of each.

Introduction

The module leads one through the process of critical thinking and analytical writing in a series of steps (Figure 1).

Figure 1

• First, you are encouraged to revisit your understanding of what it means to be critical. Misconceptions about critical thinking can undermine efforts to write effective and convincing course assignments.
• Second, you are invited to explore the concept of critical thinking in a scholarly context, in relation to theory and reflective practice.
• Third, different aspects of critical thinking are classified, according to a hierarchy to represent and explain different levels of critical thought.
• Finally, you are encouraged to examine how critical analysis might be represented within your coursework.

You should demonstrate your analysis using an appropriate form of words. Critical thinking requirements are always assignment specific, so you should apply the relevant aspects of critical thinking to the objectives set within an assignment. Being able to clarify the critical thinking levels involved should enable you to enquire more precisely about what is being asked of you, if an assignment is unclear.

Critical thinking

It can be exasperating to be asked to demonstrate a critical approach in your coursework, without a clear understanding of what critical thinking and analytical writing involve.

It is important for nurses to be able to think and write critically in terms of both theory and experience. The nurse should be able to discriminate true from false, defensible from indefensible, high priority from low priority, and practicable from impracticable.

For nursing students, critical thinking should be exercised in a variety of contexts, including (Price and Harrington 2013):

• Writing case studies.
• Making portfolio entries.
• Reviewing research.
• Preparing evaluative reports.
• Putting forward arguments for healthcare improvement.

• However, teachers sometimes struggle to articulate precisely what is required within a course assignment, and coursework essay instructions may not always explain what type of critical thinking is called for. ‘Critically discuss…’ can mean different things. There is a risk that students second-guess the requirements of an assignment and may be disappointed when the marker indicates that they have not demonstrated what was required.

Differentiating theory and experience-centred critical thinking

Several classifications (taxonomies) have been devised to explain what critical thinking entails. They indicate how it can become progressively more sophisticated. A distinction should be made between critical thinking associated with more abstract areas of reasoning, for example, that which is required in response to an assignment such as, ‘Critically discuss the competing merits of two theories of nursing taught within this module’, and that which is more intimately associated with reflective experience of practice, such as, ‘Critically review what is personally involved in empathically listening to a patient you have cared for’. Both forms of critical thinking may be required in some cases, for example, ‘Prepare an analysis of a chosen clinical skill, noting how theory and experience have influenced how you proceeded’. There are, however, many instances when one or other form of critical thinking predominates.

Theory-based critical thinking

Critical thinking based on theory involves an examination of the arguments, focusing on that which can be ascertained from collating the information obtained. The nursing student should be able to justify their reasoning, with reference to evidence in the literature and/or clinical experience (Price and Harrington 2013).

Critical thinking skills in rehabilitation

• It is necessary to have an understanding of the concepts involved, for example, rehabilitation, motivation and support, and how they relate to one another. The ability to conceive of an abstract concept such as rehabilitation is important to further conceptualise care. We can only assist patients in a purposeful way if we agree what we are trying to do.
• Rehabilitating a patient implies that we can all agree about what improvement looks like, and what constitutes recovery, patient learning, and the learning leads to the patient becoming independent.
• To think critically about rehabilitation we require a considerable amount of information, for example about conditions such as diabetes, about human psychology and about pharmacology, and we need to attempt to determine how it fits together.
• For rehabilitation to work, we should understand about the challenges the patient faces, about motivation and learning, and about what we can provide or do to enable their self-care in the future. Each of these elements is in itself abstract and theoretical, but we must combine them to demonstrate that we can articulate a therapeutic pathway.

Experience-centred critical thinking

Critical thinking in the area of reflective practice is a more introspective activity that concerns values, attitudes, motives and skills and how they relate to a particular context. Notably, it deals with the interactions of individuals and how they interpret current experience (Price and Harrington 2013). We work with the meanings ascribed to a situation by the different people involved. So for example, the nurse explores why they promote a particular form of rehabilitation to Gillian. This necessarily involves a review of what the nurse thinks of as self-care. What is it reasonable to expect the patient to do and why? Why is patient education proving problematic?

What role do I expect the patient to have when I explain rehabilitation? Critical thinking in reflective practice involves a progressively deeper examination of the individual nurse’s values and beliefs, the rationale for understanding care in a particular way and for working with patients on the basis of that (Price and Harrington 2013). Ascribed meanings are important in nursing. We are better placed to demonstrate care that is individualised and respectful of patient dignity through an understanding of the ascribed meanings of others.

Foci for critical thinking

Nursing course modules involve a series of intended learning outcomes that you are expected to achieve. The learning outcomes set become more exacting as learning progresses, challenging you to demonstrate your growing competence. The basis for writing learning outcomes for modules is often a taxonomy, describing increasingly sophisticated learning.

Heer (2012) and colleagues at the Iowa State University Centre for Excellence in Learning and Teaching developed a learning taxonomy based on the work of Bloom (1956). They discuss how there are different foci for required student work in theoretical reasoning. It is important that any assignments set are clear about which focus is being assessed (Table 2). When assignment questions involve too many foci, it is much more difficult to provide a clear answer. If the focus or foci appear to be unclear, you should confirm which foci are being assessed with your tutor.

You may be required to focus on facts. The purpose of this type of assessment is to ascertain that you are able to present the relevant facts and that you describe them accurately. In the example assignment task in Table 2, it is essential that you understand the role of insulin in the body so that you are able to help patients with type 1 and type 2 diabetes. Assessing your understanding of facts is important. It may be unsafe to apply your knowledge in practice if you are confused about facts. One of the main challenges for tutors teaching university courses is to assess the facts adequately and concisely, before other foci of assessment are added.

You may be asked to focus on concepts and to demonstrate how these operate. Mastery of concepts is important in health care. For example, if you tell a patient with diabetes about a carefully balanced diet, you have not necessarily taught them about it. Teaching involves confirming that learning has taken place, and providing your explanations in a way that makes learning easier, starting from what the patient already knows (Roszler and Rapaport 2014). Often nurses believe that they have taught something to a patient, when they may have only told them about it.

Table 2

You may be asked to focus on procedural matters, especially skills. Nursing practice involves doing the right things in the right order, and so procedure is important. Taking a patient history is given as an example (Table 2). It is important to establish respect for the patient and their anxieties and to progress incrementally to the details of their perceived problems or needs (Hardy 2013). To proceed with questions about discrete problems, without consideration of how the patient has felt or has been coping, may seem abrupt and produce less accurate information.

The final focus in your assignment may be strategic matters. This involves what is required for different elements of care to be combined to achieve success.

None of these learning foci are considered to be at a higher level than the others; they serve only to clarify what you should concentrate on. The more apparent the required focus of writing is, the easier it will be for you to answer to the best of your ability. Assignments that include several different foci are common, because of the large number of ideas taught within a module and the limited number of assignments that tutors can set. Where there are multiple foci to be addressed, it is important to clarify with your tutor what is required within different sections of the question. Questions that include different foci, without separate sections for each, can be problematic and may lead to confusion. In such cases it is important to read the notes that accompany the assignment to be sure those assessment expectations are clear.