It is generally agreed that critical thinking is knowing how to think, how to apply, how to analyze, how to synthesize, and how to evaluate. Whereas the traditional
Agreeing on means to attain goals Exploring means to achieve goals Mutual goal setting Disturbance Reaction Action
Dimension 3: Human Interaction
Dimension 1:
Nursing Process Assessment Diagnosis Planning (mutual) Intervention Evaluation Dimension 2:
Conceptual Focus Perception Communication
Interaction Transaction Self Role
Growth and development Stress/stressor Coping Time
Personal space
FIGURE 9-1
Three-dimensional nursing process based on King’s Theory of Goal Attainment. (Modified from Alligood, M. R. [1995]. Theory of goal attainment: Application to adult orthopedic nursing. In M.
A. Frey & C. L. Sieloff [Eds.], Advancing King’s systems framework and theory of nursing [p. 212].
Thousand Oaks, CA: Sage.)
TABLE 9-1 Nursing Process: Theory and Method
Nursing Process as Method* Nursing Process as Theory† A system of interrelated actions A system of interrelated concepts
Assess Perception of nurse and client
Communication of nurse and client Interaction of nurse and client
Plan Decision making about goals
Agree to means to attain goals
Implement Transactions made
Evaluate Goal attained (if not, why not?)
*Yura, H., & Walsh, M. (1983). The nursing process. Norwalk, CT: Appleton-Century-Crofts.
†King, I. M. (1981). A theory for nursing: Systems, concepts, process. New York, John Wiley (now published by Delmar, Albany, NY).
From King, I. M. (1992). King’s theory of goal attainment. Nursing Science Quarterly, 5(1), 23, with permission from Sage Publications.
166 PART 2 Application
nursing process of “assess, plan, implement, and evaluate” provides a method, the critical thinking process emphasizes the intellectual skills of apprehension, judg-ment, and reasoning.
Rubenfeld and Scheffer (1999) conducted a study to define critical thinking in nursing. They formulated the following consensus statement to reflect the essence of critical thinking in nursing:
Critical thinking in nursing is an essential component of professional account-ability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisi-tiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyz-ing, applying standards, discriminating information seekanalyz-ing, logical reasonanalyz-ing, predicting, and transforming knowledge (Rubenfeld & Scheffer, 1999, p. 5).
The development and use of critical thinking in nursing has received consider-able attention both in nursing education and in practice over the past two decades.
However, critical thinking has always been an integral component in King’s per-spective of nursing. In an early publication, Daubenmire and King (1973) present-ed a diagram (Figure 9-2) titlpresent-ed “Methodology for the Study of Nursing Process.”
Critical thinking is illustrated by the use of terms such as analyze, synthesize, verify, and interpret. King explicitly linked critical thinking to the mental acts of judgment that are implicit in perception, communication, and interactions leading to trans-action (King, 1992) and the concept of decision making (King, 1999). Later, King (1999) added that ethical theories and principles, along with the nursing process, had structured critical thinking and its pedagogy in most nursing programs.
The delivery of nursing care to patients involves a process of thinking as well as doing. In contrast to the traditional nursing process as a system of interrelated actions, King’s perspective of the process reflects the science of nursing. Critical thinking provides the rationale for actions taken by the nurse and serves as an ex-cellent fit with the premises of this text.
The following discussion illustrates critical thinking questions based on con-cepts within King’s systems framework that are essential in carrying out activities of assessing, planning, implementing, and evaluating.
At the first step of King’s process of nursing, the nurse meets the patient and communicates and interacts with him or her. Assessment is conducted by gathering data about the patient based on relevant concepts. The nurse considers the follow-ing questions:
• What are the patient’s perceptions of the situation?
• What are my perceptions of the situation?
• What other information do I need to assist this patient to achieve health?
• What does this information mean to the situation?
• What conclusion (judgment) does the patient make?
• What conclusions (judgments) do I make?
The end result of these critical thinking activities is a comprehensive patient assessment tailored to the patient and his or her situations.
The next step of King’s process of nursing is identifying goals and planning to achieve those goals. The nurse considers the following questions:
• What goals do I think will serve the patient’s best interest?
• What are the patient’s goals?
• Are the patient’s goals and my professional goals congruent?
• If the goals are not congruent, what further communication and inter-action are needed to achieve congruence?
• What are the priority goals?
• What does the patient perceive as the best way to achieve the goals?
• Is the patient willing to work toward the identified goals?
Analyzes nurse-patient situation (physiological, verbal, or nonverbal behavior communi-cated or observed); actions of the nurse; factors in system;
identified patterns of behavior;
relationships identified in observations, collected
information, and knowledge.
Observes
& measures change in patient state and recognizes changes in nurse state by identifying
patterns of behavior:
physiological and psychological
variables.
Recognizes behavior may be influenced
by past experience.
Perceptions, feelings, and thoughts must be inferred for
each individual until communicated through
verbal or nonverbal behavior.
Views the nursing process as an ongoing dynamic interpersonal process in which nurse and patient are each affected by behavior of
the other and by factors in the system in which
they operate.
Interprets patterns of behavior based on knowledge of
theories and concepts of human behavior.
Synthesizes the information to plan and implement nursing acts to increase the patient’s
resources or alter biopsychosociocultural
stresses.
Verifies interpretation by further
observation and measurement within nurse-patient situation.
FIGURE 9-2
Methodology for the study of the nursing process. (From Daubenmire, M. J., & King, I. M. [1973].
Nursing process: A system approach. Nursing Outlook, 21[8], 515.)
168 PART 2 Application
• What do I perceive as the best way to achieve the goals?
• Are the goals short-term or long-term?
• What mutual modifications need to be made to achieve goals in the plan?
This step is congruent with planning in the traditional nursing process.
The third step in King’s process of nursing results in transactions being made.
Transactions occur as a result of perceiving the other person(s) and the situation, making judgments about those perceptions, and taking some action in response.
Reaction to action(s) leads to interaction between the nurse and patient, which leads to transactions that reflect a shared view and commitment. The nurse consid-ers the following questions:
• Am I doing what the patient and I have agreed upon?
• How am I carrying out the actions?
• When do I carry out the action?
• Why am I carrying out the action?
• Is it reasonable to think that the identified goals will be reached by car-rying out the action?
This step reflects implementation in the traditional nursing process.
The fourth step in King’s process of nursing is goal attainment or failure to at-tain the goal. During this process the nurse considers the following questions:
• Are my actions helping the patient achieve our mutually defined goals?
• How well are the goals being met?
• What actions are working?
• What actions are not working?
• How is the patient responding to my actions?
• What other information do the patient and I need to modify our plan?
• Are there barriers hindering goal achievement?
• How might the plan be changed to achieve goals?
This exercise in critical thinking is comparable to the evaluation step in the traditional nursing process.
Although nurses are expected to exercise critical thinking, King (1999) em-phasized that patients also engage in the critical thinking process. The nurse has the responsibility to communicate and interact with the patient to ensure that their thinking is transparent to one another. Goals cannot be mutually achieved unless the nurse and the patient share their perceptions, feelings, values, and conclusions.
King (1999) used the term participative decision making to make the active role of the patient explicit.
In summary, the traditional nursing process is a system of interrelated ac-tions, the methods by which nursing is practiced. The critical thinking process reflects highly developed thinking skills essential for nursing practice in the twen-ty-first century. The transaction process (goal attainment) requires knowledge of concepts from King’s conceptual system as well as knowledge of those professional interactions described in the Theory of Goal Attainment. King (1999) compared the nursing process, the critical thinking process, and the transaction process to il-lustrate the application of her theory when addressing ethical issues in contempo-rary nursing practice. Relationships among the nursing process, the critical think-ing process, the transaction process, and the ethical decision-makthink-ing process are shown in Table 9-2.
The applicability of these interrelated processes in contemporary professional nursing practice is illustrated in the nursing care of the cases of Debbie and Clare that follow.
TABLE 9-2 Relationship Among the Four Processes
Nursing
Process Critical Thinking
Process Transaction Process Ethical Decision-Making Process Assess and apply
knowledge of relevant concepts
Conceptualize Patient and nurse perceive each other and situation, make judgments, mental action, and reactions. Interaction is an ongoing process characterized by communication.
Identify ethical issues.
The nurse:
• Gathers additional information • Validates perception
• Delineates and validates patient concerns
• Establishes mutuality and trust
Gather information about ethical issues.
Identify goals and plans to achieve
Analyze and synthesize
Make decisions about goals.
Goal must be mutually set.
Make decisions for actions to meet goals.
Incorporate ethical decision making into a plan of action related to goals and means to achieve goals.
Implement actions to meet goals
Transactions made:
• Not directly observed • Inferred from interactions
Take action to resolve ethical issues.
Evaluate goal attainment
Evaluate Goals attained; if not, why not?
Unmet goals can result from:
• Identification of incorrect or incomplete data
• Incorrect interpretation as the result of perceptual error, lack of knowledge, or goal conflict • Contributing nurse, patient,
system barriers
Ethical issues resolved? If not, why not?
Modified from King, I. M. (1999). A theory of goal attainment: Philosophical and ethical implications. Nursing Science Quarterly, 12(4), 292-296.
CASE HISTORY OF DEBBIE
Debbie is a 29-year-old woman who was recently admitted to the oncology nursing unit for evaluation after sensing pelvic “fullness” and noticing a watery, foul-smelling vaginal discharge. A Papanicolaou smear revealed class V cervical cancer. She was found to have stage II squamous cell carcinoma of the cervix and underwent a radical hysterectomy with bilateral salpingo-oophorectomy.
170 PART 2 Application