Winningham And Preusser Critical Thinking Cases In Nursing 4th Edition

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Few 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.

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 As a result, skills that are achieved and mastered one day can become outdated or obsolete in a fairly short time.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 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 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 entry-level 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 confusion. The absence of terminological precision is evident when reviewing the literature; there are literally hundreds of definitions or attributes assigned to the concept of critical thinking. Results of Turner's7 literature review showed that between 1981 and 1991, there were 36 different attributes (ie, specific attributes thought to be part of critical thinking) and five surrogate terms (ie, terms used almost interchangeably with critical thinking). Additionally, the study showed that between 1992 and 2002, these numbers rose to 162 different attributes and 43 surrogate terms. In total, in the nursing literature, there were almost 200 different attributes thought to be a part of critical thinking as well as 48 surrogate terms. This study clearly demonstrates the lack of clarity about critical thinking in nursing.

Although a precise definition may be lacking, however, there are commonalities in the many definitions and attributes associated with the concept. For the most part, definitions indicate that critical thinking is about the way information is processed. Nearly all definitions include logic, reasoning, knowledge, and cognitive skills. Critical thinking is oftentimes described as an upgraded version of problem solving or decision making and is described as a nonlinear process. Critical thinking is usually not considered a “one size fits all” concept but is believed to be contextualized and applied in different ways in different disciplines and specialty areas. In addition, it is often 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 thinking in the context of nursing.15 The definition was formulated by nurses and tailored to nursing practice. The conceptualization of critical thinking that emerged from the Delphi study was as follows:

… an essential component of Professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge.15(p357)

A consistent definition and a common language with which to discuss critical thinking should make outcomes assessment more accurate and easier to perform. Clinical competence is the desired outcome for a nurse who practices the cognitive skills of critical thinking, such as

  • ■analyzing,
  • ■applying standards,
  • ■discriminating
  • ■seeking information,
  • ■reasoning logically,
  • ■predicting, and
  • ■transforming knowledge.

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.

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 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 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

  • ■algorithms,
    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.
  • ■dilemmas,
  • ■debate,
  • ■case studies/problems/reports/scenarios,
  • ■cooperative learning,
  • ■demonstration,
  • ■narrative pedagogy,
  • ■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, open-mindedness, 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 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?
    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:
    • 1Vitals: according to routine
    • 2Intake and output: according to routine
    • 3Diet: ice chips, advance to clear liquids as tolerated
    • 4Activity: out of bed as desired when awake
    • 5Dressings: maintain dressings, reinforce as needed
    • 6Indwelling urinary catheter: discontinue on arrival
    • 7Oxygen: discontinue when awake
    • 8Medications:
      • adroperidol 1.25 mg to 2.5 mg every hour as needed for nausea
      • bmorphine 1 mg to 2 mg IV every 30 minutes as needed for pain
      • coxycodone and acetaminophen 1 to 2 tablets every 4 to 6 hours as needed for pain
    • 9IV: discontinue when taking fluids well
    • 10Transfer to home when discharge criteria are met
    Open-ended questions:
    • AWhat are the most likely potential complications that you would need to watch for during the postoperative period?
    • BWhat nursing interventions should you expect to perform?
    • CWhat complications of the anesthetic would you watch for during the postoperative period?
    • DWhat is the Aldrete scoring system and how it used postoperatively in ambulatory surgery?
    • EWhat 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:
    • 1The patient has type 1 diabetes.
    • 2The patient is morbidly obese.
    • 3The patient is 75 years old.
    • 4The patient is a heavy smoker.
  • ■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 problem-solving abilities and critical thinking.

This type of reflection and analysis allows the nurse to discover the interrelationship and connection between various components of patient care, treatments, and outcomes. Reflection is a major step in the development of critical thinking. Not only is it important to think about the decisions made, but it also is important to reflect on how that decision was made. Such reflection on practice decisions is an important mechanism for learning critical thinking.8

In addition to these strategies, the literature has many examples of innovative exercises that have been tailored to a specific situation or environment. In one example using the self-regulated learning model, a perioperative nurse internship was modified to include reflective journaling.23 Analysis of the journal entries showed that this pedagogical method promoted development of clinical reasoning. Concept maps (ie, visual diagrams of key concepts such as disease process, medications, diagnostic tests, therapeutic interventions, and the relationships between them) have been used successfully by staff development instructors to teach critical thinking skills to new graduates and preceptors.24 Simulation offers many opportunities to teach critical thinking skills and comes with a variety of technological capabilities. Although simulators are more commonly used to validate competencies, some of the high-fidelity simulators can be very useful in promoting clinical reasoning and critical thinking. Meaningful scenarios can be created or replications or partial replications of real-life patient situations can be modified to achieve development of critical thinking skills.

Journal clubs also have been cited in nursing literature as contributing to development of critical thinking in the practice environment.17 Groups can be structured to meet monthly or bimonthly, focusing on journal articles with content relevant to perioperative nursing. A similar activity is small learning groups that meet monthly to discuss a particular issue, procedure, or problem-solving approach that can promote the development of critical thinking.

Using a framework of experiential learning theory (ie, knowledge is created through experience), a six-week orientation program for RNs with no previous perioperative nursing experience was designed by the surgical services clinical educator at Miriam Hospital, Providence, Rhode Island, to aid in developing perioperative nurses who can think critically and independently.25 Incorporating a combination of concrete experiences, guided reflection, abstract conceptualization, and active experimentation, this program encouraged active participation and supported the different learning styles of participants. Integrating critical thinking skills into perioperative orientation can help new nurses conceptualize past knowledge.

An example of a simple approach designed to encourage reflection and develop critical thinking in practice is an exercise called the context transporter.18 Using this approach, the mentor prepares a relatively short reflection on a practice issue and presents it to the protégé. The protégé then reads the reflection and reflects on his or her opinion about the issue. Contextual changes are then made in the scenario, and the protégé must consider appropriate revisions to previously made practice decisions. This exercise occurs over time and can involve more than one practitioner and/or protégé.

Most of these learning strategies can be 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.


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.


  • Jackie H. Jones, EdD, MSN, RN, is an assistant professor, WellStar School of Nursing, Kennesaw State University, Kennesaw, GA.

Winningham & Preusser's Critical Thinking Cases in Nursing: Medical-Surgical, Pediatric, Maternity, and Psychiatric Case Studies3.43 · Rating details ·  14 Ratings  ·  0 Reviews

Improve your critical thinking skills with 148 realistic case studies from all four clinical practice areas: medical-surgical, pediatrics, maternity, and psychiatric nursing. Each case in Critical Thinking Cases in Nursing, 4th Edition covers a common problem, drawn from actual clinical experiences and written by nurses who are clinical experts. All cases have been thorougImprove your critical thinking skills with 148 realistic case studies from all four clinical practice areas: medical-surgical, pediatrics, maternity, and psychiatric nursing. Each case in Critical Thinking Cases in Nursing, 4th Edition covers a common problem, drawn from actual clinical experiences and written by nurses who are clinical experts. All cases have been thoroughly updated and revised to include current clinical practices, with integrated content on pharmacology, nutrition, and diagnostic/lab tests to encourage you to think critically about all aspects of care. This fourth edition also features highlighted prioritization content to help you prepare for success on the NCLEX? examination and provide quality patient care....more

Paperback, 705 pages

Published June 1st 2008 by Mosby (first published June 4th 2004)


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