Download Chapter 3: Clinical Judgment: Applying Critical Thinking and Ethical

Chapter Three Notes:
Critical Thinking:
 a purposeful reasoning process that uses specific thinking skills.
 Characteristics of a Critical Thinker include being open-minded, ability to
consider alternatives, and ability to recognize gaps in available information.
They recognize priorities change, requiring constant assessment. Barriers include
attitudes such as “my way is better”, which interfere with empowering clients.
Personal Value Systems
 Personal value system was developed over a lifetime that has been extensively
shaped by our family, religious beliefs and life experience.
 Professional value system refers to our nursing education and is essential to
developing critical thinking.
 Values are a set of personal beliefs derived from life experiences, interwoven with
each other.
 Value acquisition is the conscious assumption of a new value.
 Five core values of professional nursing have been identified by the American
Association of Colleges of Nursing (AACN): Human dignity, integrity,
autonomy, altruism, social justice.
Ethical Reasoning
 Ethics and Bioethics deal with moral choices.
 Ethical Theories and Decision-Making Models
o Ethical theories provide the bedrock from which we derive the principles
that guide our decision making. There’s no one right answer to an ethical
dilemma: the decision may vary depending on which theory the involved
people subscribe to. As we become a more culturally diverse society,
other equally viable viewpoints may become acculturated.
o The utilitarian or goal-based model says that the “rightness or wrongness”
of an action is always a function of its consequences. Rightness is the
extent to which performing or omitting an action will contribute to the
overall good of the client. Good is defined as maximum welfare or
happiness. When a conflict in outcome occurs, the correct action is the
one that will result in the greatest good for the majority.
o The deontological or duty-based model is person-centered. The
“rightness” of an action is determined by other factors in addition to its
outcome. Respect for every person’s inherent dignity is also a
consideration. Decisions based on this duty-based model have a religioussocial foundation. Rightness is determined by moral worth, regardless of
the circumstances or the individual involved. Decisions about what is in
the best interest of the client require consensus among all parties involved.
o The human rights-based model is based on the belief that each client has
basic rights. The client has the right to life and the nurse has the duty to
save lives. May face cases where the quality of life is intolerable and
there is no hope for a positive outcome.
Conflict arises when a nurse’s professional values differ from the law in his or her state
of residence or when the nurse has not come to terms with the situations in which his or
her personal values differ from the profession’s values. Three principles that can assist
us in decision making are autonomy (the client’s right to self-determination), beneficence
(implies that a decision results in the greatest good or produces the least harm to the
client) and justice (in ethics, being fair or impartial -unnecessary treatment, social worth).
*Veracity – truthfulness
*Autonomy- client’s right to self-determination
*Beneficence- implies that a decision results in the greatest good or produces the least
harm to the client
*Justice- being fair or impartial
Steps in Ethical Decision Making
 In using both the ethical decision-making process and the critical thinking
process, nurses must be able to tolerate ambiguity and uncertainty.
 Values clarification is a technique that can help you identify and prioritize your
values. Serves as a base for helping clients identify the values they hold
important.
 The seven criteria for acquisition of a value are:
o freely chosen
o chosen from alternatives
o chosen after careful consideration of each alternative
o must be pride in and happiness with the choice
o must be willingness to make the values known to others
o must be acted upon in response to the choice
o in a pattern of behavior consistent with the choice (value is incorporated
into individual’s lifestyle).
The process of critical thinking is systematic, organized, and goal-directed. The ten steps
that should be used in critical thinking are:
1. Clarify concepts – identify whether a problem actually exists. Look for clues,
identify assumptions, case discussion.
2. Identify your own values
3. Integrate data and identify missing data- think about the knowledge gained in
prior courses and during clinical experiences.
4. Obtain new data – constantly consider whether you need more information.
Evaluate conflicting information. Change approach to improve chances of
obtaining information.
5. Identify the significant problem – analyze existing information, make inferences,
prioritize.
6. Examine skeptically – weigh positive and negative factors and differentiating
facts that are credible from opinions that are biased or not grounded in true facts.
Keep an open mind, challenge your own assumptions, consider whether any of
your assumptions are unwarranted, discriminate between facts and inferences,
make sure you have considered all problems.
7. Apply criteria – laws, legal precedents, protocols.
8. Generate options and look at alternatives – evaluate major alternative points of
view, involve experienced peers to assist in decision-making, use clues from
others, identify arguments.
9. Consider whether factors change if the context changes
10. Make the final decision – justify conclusion, evaluate outcomes, test decision or
conclusion by implementing appropriate actions.
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Moral uncertainty occurs when a nurse is uncertain as to which moral
rules apply to a given situation.
Ethical or moral dilemmas arise when two or more moral issues are in
conflict. Two or more conflicting, but equally right answers.
Moral distress results when a nurse knows what is “right” but is bound to
do otherwise because of legal or institutional constraints.