Download Developing Critical Thinking in the Perioperative Environment

Developing Critical Thinking
in the Perioperative
Environment
JACKIE H. JONES, EdD, MSN, RN
ABSTRACT
Critical thinking is considered an essential skill for nurses by many, including major
accrediting agencies, health care administrators, and AORN. This is in part because
of the environment in which nurses function. Health care, medicine, technology, and
nursing are dynamic and constantly changing. The perioperative environment is
complex, fast paced, unique, and oftentimes unpredictable. Critical thinking skills
enable perioperative nurses to function effectively and evolve in this ever-changing
environment. Nursing education programs are mandated to teach critical thinking
skills. It is the practice arena, however, that refines, hones, and grows these skills.
This article provides an overview of critical thinking in the context of nursing, as
well as strategies and interventions designed to teach critical thinking skills. AORN
J 91 (February 2010) 248-256. © AORN, Inc, 2010
Key words: critical thinking, perioperative nurse education, critical thinking strategies.
F
ew concepts are as persistently ambiguous
as critical thinking. Its very nature is embedded in and obscured by a multiplicity
of definitions. In fact, not much has changed
since Beyer proclaimed, “The term critical thinking is one of the most abused terms in our thinking skills vocabulary. Generally, it means whatever its users stipulate it to mean”1(p32) Efforts to
measure, operationalize, or even prove the existence or value of critical thinking are at least as
elusive as its definition. The purpose of this article is to provide an overview of critical thinking
in the context of nursing, to minimize some of
the ambiguities surrounding the concept of critical
thinking, and to provide strategies to promote its
development.
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NURSING PRACTICE AND CRITICAL
THINKING
The concept of critical thinking is plagued by
many uncertainties, so the steadfast belief in its
importance, both to individual nurses and collectively to the nursing profession, may be surprising. Health care, medicine, and nursing, however,
are dynamic professions that experience constantly changing and evolving knowledge, skills,
technology, and innovations. As a result, skills
that are achieved and mastered one day can become outdated or obsolete in a fairly short time.
The boundaries of nursing practice continue to
expand, and the body of knowledge and skills
that nurses need increases exponentially. Additionally, although the nursing environment is
© AORN, Inc, 2010
CRITICAL THINKING
dynamic on its own, it also must be adaptable and
evolve in response to changes in other health care
fields. Critical thinking skills are essential for
nurses to adapt and function in this ever-changing
environment.
The perioperative environment is consistently
fast paced, unpredictable, and complex. In this
environment, perioperative nurses are expected to
work in a variety of surgeries with patients of all
ages and myriad presentations, many of which
they may never have encountered.2 Critical thinking skills enable perioperative nurses to understand and apply an array of standards and guidelines to a variety of situations and specialty
areas.3 In fact, critical thinking skills have long
been considered essential to the provision of safe
and effective nursing care throughout the nursing
literature:





“Nurses need finely honed critical thinking
skills in order to be safe, competent, and skillful practitioners of their profession.”4(p67)
Critical thinking skills can aid in the “delivery
of safe, comprehensive, individualized, effective and innovative care which stems from the
competent clinical judgment of thinking
professionals.”5
Critical thinking behavior has been associated
with positive perioperative patient safety
outcomes.6
Critical thinking “results in safe, competent
practice and improved decision making, clinical judgments, and problem solving.”7(p276)
Critical thinking enables expertise in practice;
it is critical for safe, effective, and efficient
care.8
NURSES’ INTEREST IN CRITICAL
THINKING
Nurses have exhibited a growing interest in critical thinking, as revealed in the nursing literature.
Turner7 reviewed articles on critical thinking in
nursing literature from 1981 to 2002. Results of
this review showed that between 1981 and 1991,
only seven articles were published about critical
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thinking in nursing; however, between 1992 and
2002, the number of published articles grew to
401. The increase during this period clearly demonstrates a growing interest and awareness of the
importance of critical thinking to nursing.
This awareness is shared by accrediting agencies and other leading health care organizations.
For example, nursing education programs are
mandated by both the National League for Nursing9 and the American Association of Colleges of
Nursing10 to include critical thinking skills as part
of the curriculum, and critical thinking skills were
deemed a core competency for nurses of the 21st
century by leading health care organizations.11
Specific to the perioperative area, critical thinking
has been identified as an essential skill for nurses
to practice effectively in this specialty.12
Despite this focus, evidence points to a deficiency of critical thinking skills in new nurses. In
a survey of 117 nurse educators, 82 nurse administrators, 23 recent bachelor of science in nursing
graduates, 96 experienced bachelor of science in
nursing graduates, and 11 deans or directors of
nursing programs, critical thinking was consistently listed as one of the most important entrylevel competencies; however, it was also consistently ranked among the lowest observed
competencies.13 Other researchers had similar
findings. For example, del Bueno assessed the
critical thinking skills, primarily as clinical judgment, of 10,988 inexperienced nurses during a
10-year period at 144 hospitals and 31 systems
and found that less than 35% met entry-level expectations.14 Critical thinking was assessed using
a variety of patient-focused exercises.
DEFINITIONS OF CRITICAL THINKING
With the awareness of the importance of critical
thinking in nursing evident, why is there a disparity
between mandates to teach critical thinking and outcomes assessments of critical thinking in practicing
nurses? At least part of the answer lies with the vast
number of definitions and meanings assigned to the
concept, which provides a foundation for ongoing
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confusion. The absence of terminological precision
ing in the context of nursing.15 The definition was
is evident when reviewing the literature; there are
formulated by nurses and tailored to nursing pracliterally hundreds of definitions or attributes astice. The conceptualization of critical thinking
signed to the concept of critical thinking. Results of
that emerged from the Delphi study was as
7
Turner’s literature review showed that between
follows:
1981 and 1991, there were 36 different attributes (ie,
. . . an essential component of Professional
specific attributes thought to be part of critical thinkaccountability and quality nursing care. Criting) and five surrogate terms (ie, terms used almost
ical thinkers in nursing exhibit these habits
interchangeably with critical thinking). Additionally,
of the mind: confidence, contextual perspecthe study showed that between 1992 and 2002, these
tive, creativity, flexibility, inquisitiveness,
numbers rose to 162 different attributes and 43 surintellectual integrity, intuition, openrogate terms. In total, in the nursing literature, there
mindedness, perseverance, and reflection.
were almost 200 different attributes thought to be a
Critical thinkers in nursing practice the cogpart of critical thinking as well as 48 surrogate
nitive skills of analyzing, applying standards,
terms. This study clearly demonstrates the lack of
discriminating, information seeking, logical
clarity about critical thinking in nursing.
reasoning, preAlthough a precise
dicting, and
definition may be
transforming
lacking, however,
Nearly all definitions of critical thinking include
knowledge.15(p357)
there are commonalilogic, reasoning, knowledge, and cognitive
A consistent defities in the many defi- skills. Critical thinking is contextualized and
nition and a common
applied in different ways in different disciplines language with which
nitions and attributes
and specialty areas.
associated with the
to discuss critical
concept. For the
thinking should make
most part, definitions
outcomes assessment
indicate that critical
more accurate and easier to perform. Clinical
thinking is about the way information is procompetence is the desired outcome for a nurse
cessed. Nearly all definitions include logic, reawho practices the cognitive skills of critical thinksoning, knowledge, and cognitive skills. Critical
ing, such as
thinking is oftentimes described as an upgraded
 analyzing,
version of problem solving or decision making
 applying standards,
and is described as a nonlinear process. Critical
 discriminating
thinking is usually not considered a “one size fits
 seeking information,
all” concept but is believed to be contextualized
 reasoning logically,
and applied in different ways in different disci predicting, and
plines and specialty areas. In addition, it is often
 transforming knowledge.
presented as something that takes time and experience to develop.
Adopting a definition of critical thinking that
works in the discipline of nursing would eliminate, or at least minimize, the conceptual lack of
clarity. Toward accomplishment of this goal, a
group of nursing experts from nine countries participated in a Delphi study to define critical think250
AORN Journal
Although research has not clearly established a
link between critical thinking and clinical competence, it is likely that this deficiency can be attributed to the various ambiguities that surround critical thinking. Intuitively, the better and more
flexible one’s thinking, the more effectively one
can function in clinical environments.
CRITICAL THINKING
LEARNING ARENAS
A compelling question then arises—where should
critical thinking be taught? Nursing programs are
mandated to teach critical thinking skills to students; therefore, nursing education must begin the
process. The focus of nursing education, however,
is to prepare generalist nurses and to help students begin thinking like a nurse.16 To accomplish this, nursing educators dispense valuable
nursing knowledge, and students are expected to
assimilate that knowledge and apply it in the limited time spent in clinical environments. The reality is that the fast pace of nursing programs often
leaves students with little time to reflect on and
assimilate information before moving on to another course with different knowledge and skills
to learn. Unfortunately, critical thinking skills
learned in academic settings are not always
clearly transferable to practice.17 Nursing educators bear the responsibility for laying a foundation
of critical thinking skills, a foundation that will
serve as a scaffold on which to build and expand.
The perfect arena in which to add layers to this
foundation, to teach, refine, and hone critical
thinking skills in nurses, is practice.
Developing critical thinking is, and must be, a
shared responsibility between education and practice. Nursing practice environments provide the
most authentic context in which nurses can learn.
They present reality with all its different types
and levels of complexities and all the untidiness
and confusion that is lacking in school.18 This is
especially true in critical care environments such
as the perioperative area. Critical thinking skills
are contextualized, varying not only from discipline to discipline, but also from specialty to specialty, requiring “the use of knowledge in a specific
set of circumstances.”14(p281) The perioperative environment is unique and requires nurses to learn a
unique set of skills and knowledge. Critical thinking
skills specific to the perioperative environment are
best learned in the perioperative environment.
According to Tanner, critical thinking requires
“cultivation and practice”16(p299); cultivation and
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practice best occur in the framework of practice.
Practice has the additional advantage of having a
definitive outcome in the pursuit of critical thinking skills, which is clinical competence. Benner19
provides information about the five stages of developing an expert nurse:

novice,
advanced beginner,
 competent,
 proficient, and
 expert.

Experience is a prime requisite for acquisition
of excellence in nursing practice. The transition
from novice to expert, which includes acquisition
of critical thinking skills, requires experience and
time. It is important to note that even an expert
nurse experienced in one area may revert to being
a novice nurse when transitioning to a new area.
The amount of perioperative-specific information
is minimal in many schools of nursing and exposure to perioperative nursing is limited in most
practice areas, so this may be especially valid for
nurses beginning their career in, or transitioning
to, the perioperative area.
DEVELOPING CRITICAL THINKING
There is a great deal of literature detailing strategies and techniques to develop critical thinking
skills. In the practice environment, these strategies
can be tailored or modified to teach critical thinking to both new nurses and to experienced nurses
who are transitioning into the perioperative area.
Using a variety of strategies enhances the learning
experience and helps to keep everyone more engaged with the processes.20 Some activities are
designed to occur in a fairly short time frame;
others are designed to occur after a longer period.
A crucial first step to developing critical thinking skills is to create an environment that encourages a spirit of critical thinking and is supportive
of learning critical thinking. This should be a safe
environment where questions, reflection, and discussion are encouraged. It is the responsibility of
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TABLE 1. Resources
Summary and analysis of strategies
Billings DM, Halstead JA. Teaching in Nursing: A Guide
for Faculty. 3rd ed. St Louis, MO: WB Saunders Co;
2008.






Recommended readings
Rubenfeld MG, Scheffer BK. Critical Thinking TACTICS
for Nurses: Achieving the IOM Competencies. 2nd ed.
Sudbury, MA: Jones and Bartlett Publishers, LLC;
2009.
Alfaro-LeFevre R. Applying Nursing Process: A Tool for
Critical Thinking. 7th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2009.
Jackson M, Ignatavicius D, Case B. Conversations in
Critical Thinking & Clinical Judgment. Sudbury, MA:
Jones and Bartlett Publishers, LLC; 2005.

Workbooks/activities promoting critical thinking
Alfaro-LeFevre R. Critical Thinking and Clinical Judgment:
A Practical Approach to Outcome Focused Thinking.
4th ed. Philadelphia, PA: WB Saunders Co; 2008.
Lunney M. Critical Thinking to Achieve Positive Health
Outcomes: Nursing Case Studies and Analyses. 2nd
ed. New York, NY: Wiley-Blackwell; 2009.
Schuster PM. Concept Mapping: A Critical-Thinking
Approach to Care Planning. 2nd ed. Philadelphia, PA:
FA Davis Company; 2007.
Preusser BA. Winningham & Preusser’s Critical Thinking
Cases in Nursing: Medical-Surgical, Pediatric,
Maternity, and Psychiatric Case Studies. 4th ed. St
Louis, MO: Elsevier Mosby; 2008.
Preusser BA. Winningham & Preusser’s Critical Thinking
in Medical-Surgical Settings: A Case Study Approach.
3rd ed. St Louis, MO: Elsevier Mosby; 2005.

the leader or manager to provide an environment
in which it is safe for nurses to ask questions, to
explore alternative ways, and to present ideas.21
There are a number of excellent summaries and
analyses of the many strategies that can be used
to promote critical thinking (Table 1), including







252
algorithms,
dilemmas,
debate,
case studies/problems/reports/scenarios,
cooperative learning,
demonstration,
narrative pedagogy,
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












games,
learning contracts,
concept mapping,
problem-based learning,
questioning,
Socratic questioning,
reflection,
journaling,
critical thinking vignettes,
role playing,
case conferences,
imagery,
large or small group discussion,
self-learning modules,
simulation,
computer-assisted instruction,
unfolding case studies,
computer simulations,
written assignments,
portfolios, and
a variety of discourse strategies.
Many of these strategies are designed to develop the habits of the mind and the attitudes and
dispositions of a thinker such as confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, openmindedness, perseverance, and reflection.15
Successful strategies should support the development of a mind that is engaged in the process of
critical thought; therefore, it is important to
choose strategies or a combination of strategies
that are flexible, active learning strategies that
encourage as much interactive participation as
possible.
Many of the interventions feature clinical scenarios in which the nurse reflects upon and analyzes decisions made or interventions chosen during patient care. These situations can be either
real or fictional (Table 2). If fictional is preferred,
nurse leaders can create clinical scenarios to discuss. It is important that the learner provide a
rationale for decisions made or interventions chosen. According to Paul, critical thinking is “the art
CRITICAL THINKING
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TABLE 2. Clinical Scenario
A 45-year-old woman experienced intermittent right upper quadrant pain for four months. An abdominal ultrasound revealed
stones in her gallbladder. Conservative treatment with symptomatic support was successful; however, symptomatic episodes
continued and resulted in the patient opting for surgical intervention. The patient underwent a laparoscopic cholecystectomy
with general anesthesia and endotracheal intubation. The surgeon used standard four-trocar technique with carbon dioxide
insufflation. The patient is Caucasian, 5 ft 6 inches tall, and weighs 125 lbs. Orders on her admission to the postanesthesia
care unit are as follows:
1.
2.
3.
4.
5.
6.
7.
8.
Vitals: according to routine
Intake and output: according to routine
Diet: ice chips, advance to clear liquids as tolerated
Activity: out of bed as desired when awake
Dressings: maintain dressings, reinforce as needed
Indwelling urinary catheter: discontinue on arrival
Oxygen: discontinue when awake
Medications:
a. droperidol 1.25 mg to 2.5 mg every hour as needed for nausea
b. morphine 1 mg to 2 mg IV every 30 minutes as needed for pain
c. oxycodone and acetaminophen 1 to 2 tablets every 4 to 6 hours as needed for pain
9. IV: discontinue when taking fluids well
10. Transfer to home when discharge criteria are met
Open-ended questions:
A. What are the most likely potential complications that you would need to watch for during the postoperative period?
B. What nursing interventions should you expect to perform?
C. What complications of the anesthetic would you watch for during the postoperative period?
D. What is the Aldrete scoring system and how it used postoperatively in ambulatory surgery?
E. What discharge education would you anticipate giving this patient?
Contextual change:
Consider how your care and responses would differ if your patient had the following attributes or comorbidities:
1. The patient has type 1 diabetes.
2. The patient is morbidly obese.
3. The patient is 75 years old.
4. The patient is a heavy smoker.
of thinking about your thinking while you are
thinking in order to make your thinking better
. . .”22(p643) To facilitate this process, the leader
should ask open-ended questions about care
decisions:






What are relevant facts about your patient?
What interventions did you choose to
implement?
Why did you make this decision?
What data were used to make the decision?
What were the reasons behind the actions/
interventions taken?
How does new information alter your
interventions?

What other approaches might you use?
This Socratic questioning not only causes
learners to reflect on clinical situations and the
way in which information was processed, but it
also helps them to realize the limits of their
own knowledge. A similar experience can be
created between a preceptor and a new hire.
Preceptors who ask questions instead of giving
answers or conducting a show-and-tell session
aid in the development of critical thinking
skills.14 As a new-hire nurse progresses through
the precepted experience, higher-level questions
should be used to develop higher-level problemsolving abilities and critical thinking.
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This type of reflection and analysis allows
Groups can be structured to meet monthly or
the nurse to discover the interrelationship and
bimonthly, focusing on journal articles with
connection between various components of pacontent relevant to perioperative nursing. A
tient care, treatments, and outcomes. Reflection
similar activity is small learning groups that
is a major step in the development of critical
meet monthly to discuss a particular issue, prothinking. Not only is it important to think about
cedure, or problem-solving approach that can
the decisions made, but it also is important to
promote the development of critical thinking.
reflect on how that decision was made. Such
Using a framework of experiential learning
reflection on practice decisions is an important
theory (ie, knowledge is created through experi8
mechanism for learning critical thinking.
ence), a six-week orientation program for RNs
In addition to
with no previous
these strategies, the
perioperative nursliterature has many
One benefit to using a critical thinking exercise ing experience was
examples of innovadesigned by the surin a group format is that new nurses can
tive exercises that
gical services clinilearn how seasoned nurses make decisions.
Hearing how others synthesize and interpret
have been tailored
cal educator at
information is invaluable for developing critical
to a specific situaMiriam Hospital,
thinking
skills.
tion or environment.
Providence, Rhode
In one example using
Island, to aid in dethe self-regulated
veloping perioperalearning model, a perioperative nurse internship
tive nurses who can think critically and inde23
was modified to include reflective journaling.
pendently.25 Incorporating a combination of
Analysis of the journal entries showed that this
concrete experiences, guided reflection, abstract
pedagogical method promoted development of
conceptualization, and active experimentation,
clinical reasoning. Concept maps (ie, visual diathis program encouraged active participation
grams of key concepts such as disease process,
and supported the different learning styles of
medications, diagnostic tests, therapeutic interparticipants. Integrating critical thinking skills
ventions, and the relationships between them)
into perioperative orientation can help new
have been used successfully by staff developnurses conceptualize past knowledge.
ment instructors to teach critical thinking skills
An example of a simple approach designed
to new graduates and preceptors.24 Simulation
to encourage reflection and develop critical
offers many opportunities to teach critical
thinking in practice is an exercise called the
thinking skills and comes with a variety of
context transporter.18 Using this approach, the
mentor prepares a relatively short reflection on
technological capabilities. Although simulators
a practice issue and presents it to the protégé.
are more commonly used to validate competenThe protégé then reads the reflection and recies, some of the high-fidelity simulators can be
flects on his or her opinion about the issue.
very useful in promoting clinical reasoning and
Contextual changes are then made in the scecritical thinking. Meaningful scenarios can be
nario, and the protégé must consider appropricreated or replications or partial replications of
ate revisions to previously made practice decireal-life patient situations can be modified to
sions. This exercise occurs over time and can
achieve development of critical thinking skills.
involve more than one practitioner and/or
Journal clubs also have been cited in nursing
protégé.
literature as contributing to development of
17
Most of these learning strategies can be
critical thinking in the practice environment.
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CRITICAL THINKING
modified for an individual; from a preceptor to
a protégé; or for use in small group activities,
such as staff meetings. A benefit of using a
group format is that the learner gets to listen to
how seasoned nurses make decisions. Hearing
how others synthesize information and interpret
data is invaluable and contributes to the development of critical thinking. The importance of
role modeling should not be underestimated;
inexperienced nurses can benefit greatly from
observing expert nurses.
Educational opportunities are essential to development of critical thinking.26 There are
many ways that these opportunities can occur:
continuing education activities, attendance at
conferences or workshops, orientation, participation in interdisciplinary patient rounds, or
staff meetings. These are all good opportunities
to bring critical thinking and clinical practice
together.
Creating, tailoring, and implementing these
strategies or exercises takes time initially. Perhaps the most significant challenges to teaching
critical thinking in practice environments are
the time constraints and demands on nurses’
time; however, after strategies have been chosen and developed, implementation will involve
less time with experience. With planning and
commitment, the challenges can be met and the
reward will be nurses with enhanced critical
thinking skills.
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2.
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CONCLUSION
Critical thinking skills are necessary for nurses
to be able to change as the profession of nursing and health care evolves. Critical thinking is
a process that takes time to develop and is not
readily acquired in the classroom.27 The responsibilities for teaching critical thinking do
not belong exclusively to either education or
practice. Both have a role to play, and both
must be committed to fulfilling their role.
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Jackie H. Jones, EdD, MSN, RN, is an assistant professor, WellStar School of Nursing,
Kennesaw State University, Kennesaw, GA.
Valuable Resources Are Available Through the AORN Library
The AORN Library houses approximately 5,500 books, 400 audiovisuals, and 450 journals
covering a wide variety of topics, from nursing and surgery to OR management, informatics,
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Information on topics relevant to perioperative nursing is available by visiting
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f For tips on searching the AORN Journal and finding articles in other journals,
view answers to frequently asked questions at www.aorn.org/PracticeResources/
AORNLibrary/LibraryFAQs.
f For resources on hot topics in perioperative nursing, review the Journal Club
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f For details about the library’s Literature Search Service, visit
www.aorn.org/PracticeResources/AORNLibrary/LibraryServices.
f For information about AORN’s growing collection of archival materials
related to the history of AORN and perioperative nursing, visit
www.aorn.org/PracticeResources/AORNLibrary/HistoricalNursingArchives.
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