Journal of Nursing Education

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EDITORIAL 

Critical Thinking: Beyond Nursing Process

Christine A Tanner, PhD, RN, FAAN

Abstract

I've been on a mission for several years now about the nursing process. It seems to me that nursing faculty throughout the western world have both reified and deified the nursing process. Indeed, when I was a young faculty member in the 1970s, the nursing process was an enormous help to me in guiding students to THINK about what they were doing in practice, to recognize that nursing action was purposeful, goal-directed, and not merely execution of doctor's orders. But I soon found that not everything fit within the framework we called nursing process, or the related diagnosis-treatment model of nursing practice.

Virginia Henderson through her writings helped me to see the light. In a now classic article, "The Nursing Process- Is the Title Right?" published in 1982 and in later editorials (1987a, 1987b), Henderson traced the origins of nursing process. She pointed out that it was originally used to refer to aspects of the nurse-patient relationship, but that in contemporary usage, the relational aspects were largely missing. Instead, as used through the 70s and 80s, nursing process was focused on scientific problem-solving. Henderson was most disturbed that nursing process had become largely synonymous with nursing practice. She commented that the nursing process was neither THE nursing process, meaning the only process nurses use, nor the NURSING process, meaning that only nurses use a scientific problem-solving process. She astutely pointed out that nursing process overplays the importance of science in nursing judgment, downplays other ways of thinking, such as intuition, and interferes with effective interdisciplinary collaboration. To make her point about the multiple meanings of nursing process she wrote about an incident described to her by a nursing student in Texas. The student was sporting a T-shirt that had boldly printed across the front "And on the 8th day, God created the nursing process. Therein ended life as we know it." A woman approached the student, carefully read her T-shirt, then announced, "Honey, I know just what you mean! I had 7 children, nursed them all and had absolutely no life!!"

During the 1980s, nursing process gradually became synonymous with clinical decision-making and clinical judgment. Nursing faculty relied on the nursing care plan, with its nursing process underpinnings as the primary method for teaching students clinical decision-making (Tanner, 1986). However, there is now ample research pointing out that the nursing process fails to capture the thought processes used by either beginner or experienced nurses as they go about making decisions in their practice (see reviews by Fonteyn, 1994 and Tanner, 1998).

So now, here we are in the new millenium. And we find that nursing faculty see nursing process as synonymous with critical thinking! In her study reported in this issue of JNE, Joanne Gordon surveyed faculty in the Midwest to explore their definition of critical thinking and to examine the extent to which they agreed with non-nurse critical thinking experts. She reports that "nurse educators are more likely to identify researching, problem-solving, decision-making, and planning as critical thinking"; more than half the respondents agreed with the statement that nursing process and critical thinking are synonymous. This is troubling to me in considering both what might be included in instruction on critical thinking, but more importantly for what might be left out.

It goes without saying that these are troubling times in health care. We obviously need nurses who are skilled in clinical judgment. Nurses who practice in hospitals, home care, physicians offices, and long-term care are caring for increasingly fragile and acutely ill patients; it is no exaggeration to say that these patients' lives hang in the balance of…

I've been on a mission for several years now about the nursing process. It seems to me that nursing faculty throughout the western world have both reified and deified the nursing process. Indeed, when I was a young faculty member in the 1970s, the nursing process was an enormous help to me in guiding students to THINK about what they were doing in practice, to recognize that nursing action was purposeful, goal-directed, and not merely execution of doctor's orders. But I soon found that not everything fit within the framework we called nursing process, or the related diagnosis-treatment model of nursing practice.

Virginia Henderson through her writings helped me to see the light. In a now classic article, "The Nursing Process- Is the Title Right?" published in 1982 and in later editorials (1987a, 1987b), Henderson traced the origins of nursing process. She pointed out that it was originally used to refer to aspects of the nurse-patient relationship, but that in contemporary usage, the relational aspects were largely missing. Instead, as used through the 70s and 80s, nursing process was focused on scientific problem-solving. Henderson was most disturbed that nursing process had become largely synonymous with nursing practice. She commented that the nursing process was neither THE nursing process, meaning the only process nurses use, nor the NURSING process, meaning that only nurses use a scientific problem-solving process. She astutely pointed out that nursing process overplays the importance of science in nursing judgment, downplays other ways of thinking, such as intuition, and interferes with effective interdisciplinary collaboration. To make her point about the multiple meanings of nursing process she wrote about an incident described to her by a nursing student in Texas. The student was sporting a T-shirt that had boldly printed across the front "And on the 8th day, God created the nursing process. Therein ended life as we know it." A woman approached the student, carefully read her T-shirt, then announced, "Honey, I know just what you mean! I had 7 children, nursed them all and had absolutely no life!!"

During the 1980s, nursing process gradually became synonymous with clinical decision-making and clinical judgment. Nursing faculty relied on the nursing care plan, with its nursing process underpinnings as the primary method for teaching students clinical decision-making (Tanner, 1986). However, there is now ample research pointing out that the nursing process fails to capture the thought processes used by either beginner or experienced nurses as they go about making decisions in their practice (see reviews by Fonteyn, 1994 and Tanner, 1998).

So now, here we are in the new millenium. And we find that nursing faculty see nursing process as synonymous with critical thinking! In her study reported in this issue of JNE, Joanne Gordon surveyed faculty in the Midwest to explore their definition of critical thinking and to examine the extent to which they agreed with non-nurse critical thinking experts. She reports that "nurse educators are more likely to identify researching, problem-solving, decision-making, and planning as critical thinking"; more than half the respondents agreed with the statement that nursing process and critical thinking are synonymous. This is troubling to me in considering both what might be included in instruction on critical thinking, but more importantly for what might be left out.

It goes without saying that these are troubling times in health care. We obviously need nurses who are skilled in clinical judgment. Nurses who practice in hospitals, home care, physicians offices, and long-term care are caring for increasingly fragile and acutely ill patients; it is no exaggeration to say that these patients' lives hang in the balance of skilled nursing judgment. Yet we also know that these same nurses are practicing in unsafe environments.

The recent series published by the Chicago Tribune sadly blamed nurses for fatal medical errors that are the direct result of staffing issues. More than ever before we need professional nurses who can act as informed citizens, be advocates for public health, have access to care for the uninsured, and who can recognize big system problems and take action to resolve them. This is what critical thinking is all about!

This view is supported by the experts who were respondents to the Delphi survey conducted by Barbara Scheffer and Gaie Rubenfeld, reported in this issue. They present a proposed definition of critical thinking that embraces both habits of mind and cognitive skills. As nursing faculty, we will continue to struggle with critical thinking: what it means and how to teach it. But Scheffer's and Rubenfeld's work helps us move our conception of it beyond the narrowly circumscribed nursing process.

REFERENCES

  • Fonteyn, M.E., & Cooper, L.F. (1994). The written nursing process: Is it still useful to nursing education? Journal of Advanced Nursing, J9(2):315-319.
  • Henderson, V. (1987a). The nursing process in perspective. Journal of Advanced Nursing, I2(6):657-658.
  • Henderson, V. (1987b). Nursing process- a critique. Holistic Nursing Practice, i(3):7-18.
  • Henderson, V. (1982). The nursing process- is the title right? Journal of Advanced Nursing, 7:103-109.
  • Tanner, CA. (1986). The nursing care plan as a teaching method: Reason or ritual? Nurse Educator, IZ(4):8-10.
  • Tanner, CA (1998). Clinical judgment and evidence-based practice: Conclusions and controversies. 31st Annual Communicating Nursing Research Conference/12th Annual WIN Assembly, "Quality Research for Quality Practice," May 1998, Phoenix, Arizona. Communicating Nursing Research, 31:19-35.
  • Tanner, CA (1993). More thinking about critical thinking and clinical decision making. Journal of Nursing Education, 32(9):387.

10.3928/0148-4834-20001101-04

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