Essential Competencies of Preceptors: A Focus on Working with APRN Students

Module 4: Facilitating Critical Thinking and Clinical Decision-Making

Introduction

Critical thinking in nursing education and clinical practice has been of significant interest. The use of critical thinking is often explored when a student makes an error in practice. This error may well have originated from a lack of knowledge rather than critical thinking ability. As has been discussed in previous modules, it is important that the preceptor assess the student's current knowledge about a specific patient presentation, disease process, procedure, medication, etc. prior to making assumptions about the student's critical thinking skills. It is impractical to "critically think" about a problem or situation when there is a clear lack of understanding and knowledge.

While there are many definitions of critical thinking, the desired outcome of critical thinking is safe, quality nursing care. The process of critical thinking is based on objective evidence rather than subjective assumptions. This includes the ability to recognize the clinical presentation of the patient, correlate the clinical presentation to the underlying pathophysiology, develop a differential diagnosis and most importantly develop a treatment plan based upon a sound understanding of the rationale.

There are many definitions of critical thinking.

Table 1 – Definitions of Critical Thinking

American Philosophical Association (1990)	"Critical thinking is the process of purposeful, self-regulatory judgment. This process gives reasoned consideration to evidence, context, conceptualization, methods, and criteria" (APA, p. 9).
Alfaro-LeFevre (2009)	"Critical thinking is purposeful, goal-directed thinking that aims to make judgments based on evidence (fact), rather than conjecture (guesswork). Based on principles of science and the scientific method (e.g. maintaining a questioning attitude, following an organized approach to discovery, and making sure information is reliable), critical thinking requires developing strategies that maximize human potential (e.g. tapping on individual strengths), and compensate for problems caused by human nature (e.g. the powerful influence of personal perceptions, values, and beliefs)" (p. 9).
Chafee (1994)	"Critical thinking is an active, purposeful, organized cognitive process we use to carefully examine our thinking and the thinking of others, in order to clarify and improve our understanding" (p. 51).
Ennis (1985)	"Critical thinking is reflective and reasonable thinking that is focused on deciding what to believe or do" (p. 24).
Paul (1993)	"Critical thinking is that mode of thinking about any subject, content, or problem in which the thinker improves the quality of his or her thinking by skillfully analyzing, assessing, and reconstructing it. Critical thinking is self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposes assent to rigorous standards of excellence and mindful command of their use. It entails effective communication and problem-solving abilities, as well as a commitment to overcome our native egocentrism and sociocentrism." (p. 24).
Turner (2005)	"Critical thinking is a purposeful, self-regulatory judgment associated in some way with clinical decision making, diagnostic reasoning, the nursing process, clinical judgment, and problem solving. It is characterized by analysis, reasoning, inference, interpretation, knowledge, and open-mindedness. It requires knowledge of the area about which one is thinking and results in safe, competent practice and improved decision making, clinical judgments, and problem-solving" (p. 276).

Jackson (2006) describes three themes found in all definitions of critical thinking,

• "the importance of a good foundation of knowledge, including formal and informal logic;
• the willingness to ask questions; and
• the ability to recognize new answers, even when they are not the norm and not in agreement with pre-existing attitudes" (p, 4).

Whether the preferred terminology is critical thinking, clinical reasoning, or clinical judgment, it is vital that registered nurses make sound clinical decisions. The focus of this module is to provide specific strategies that can be used by the preceptor in the clinical setting to facilitate clinical decision making. These strategies include pre-planning of clinical learning experiences and patient assignments, clinical rounds, questioning, role modeling, and debriefing.

The focus of this module is to provide specific strategies that can be used by the preceptor in the clinical setting to facilitate student clinical decision making. The One-Minute Preceptor model will be reviewed as a popular method for teaching APRN students. This strategy includes getting a commitment, probing for supporting evidence, teaching general rules, reinforcing what was done well and correcting errors.

Objectives

At the conclusion of this module, the learner will be able to:

• Describe strategies that facilitate critical thinking and clinical decision making.
• Implement methods to evaluate clinical decision making of APRN students in the clinical setting.
• Demonstrate mastery of "One Minute Preceptor" technique to encourage effective learning