Critical thinking and accuracy of nurses' diagnoses. Part I: risk of low accuracy diagnoses and new views of critical thinking

Pensamiento crítico y precisión de los diagnósticos de enfermería. I Parte: riesgo de diagnósticos de baja precisión y nuevas perspectivas del pensamiento crítico

Pensamento crítico e acurácia dos diagnósticos de enfermagem. Parte I: risco de diagnósticos de baixa acurácia e novas visões do pensamento crítico

Critical thinking and accuracy of nurses' diagnoses. Part I: risk of low accuracy diagnoses and new views of critical thinking^*

Pensamento crítico e acurácia dos diagnósticos de enfermagem. Parte I: Risco de diagnósticos de baixa acurácia e novas visões do pensamento crítico

Pensamiento crítico y precisión de los diagnósticos de enfermería. I Parte: Riesgo de diagnósticos de baja precisión y nuevas perspectivas del pensamiento crítico

Margaret Lunney

Professor Department of Nursing College of Staten Island, The City University of New York (CUNY). [e-mail]

ABSTRACT

Interpretations of patient data are complex and diverse, contributing to a risk of low accuracy nursing diagnoses. This risk is confirmed in research findings that accuracy of nurses' diagnoses varied widely from high to low. Highly accurate diagnoses are essential, however, to guide nursing interventions for the achievement of positive health outcomes. Development of critical thinking abilities is likely to improve accuracy of nurses' diagnoses. Newer views of critical thinking serve as a basis for critical thinking in nursing. Seven cognitive skills and ten habits of mind are identified as dimensions of critical thinking for use in the diagnostic process.

Keywords: Critical Thinking. Nursing Diagnosis. Accuracy.

RESUMO

A diversidade e complexidade na interpretação dos dados dos pacientes contribuem para o risco de menor acurácia dos diagnósticos de enfermagem. Embora os achados em pesquisa confirmem esse risco pela enorme variação na acurácia, diagnósticos precisos são essenciais para direcionar as intervenções de enfermagem para o alcance de resultados positivos na saúde. É provável que o desenvolvimento de habilidades de pensamento crítico melhore a acurácia dos diagnósticos feitos pelas enfermeiras. Novas visões do pensamento crítico servem de base para o pensamento crítico em enfermagem. Sete habilidades cognitivas e dez formas de pensar são identificadas como dimensões do pensamento crítico no uso do processo diagnóstico.

Palavras-chave: Pensamento crítico. Diagnóstico de enfermagem. Acurácia.

RESUMEN

La diversidad y complejidad en la interpretación de los datos de los pacientes contribuyen al riesgo de que los diagnósticos de enfermería sean menos precisos. Pese a que los hallazgos en investigación confirmen este riesgo, debido a la enorme variación en la precisión, son esenciales diagnósticos exactos para orientar las intervenciones de enfermería en el logro de resultados positivos en la asistencia a la salud. Desarrollar habilidades para el pensamiento crítico es mejorar la precisión de esos diagnósticos. Las nuevas perspectivas del pensamiento crítico ofrecen una base para el alcance de este objetivo. Fueron identificadas siete habilidades cognitivas y diez formas de pensar como dimensiones del pensamiento crítico en el uso del proceso de diagnóstico.

Palabras-clave: Pensamiento crítico. Diagnóstico de enfermería. Precisión.

Classifications of nursing diagnoses are widely used in health care settings throughout the world ⁽¹⁾, but even widespread use of nursing diagnoses has not generated sufficient attention to diagnostic accuracy ^{(2- 3)}. Accuracy should be a major goal of the diagnostic process since diagnoses are probabilistic clinical judgments and, as such, are always at risk of being inaccurate. In the near future, with implementation of electronic health records ^(4-5), diagnostic accuracy will be even more important because only standard terms such as these will be used to represent diagnoses of patient data and these terms will be aggregated to produce epidemiological descriptions of patient populations. Epidemiological descriptions of human responses will be seriously flawed unless greater efforts are made to achieve accuracy of nurses' diagnoses. One of the ways that nurses can achieve higher rates of accuracy is to improve the use of critical thinking in the diagnostic reasoning process. The purpose of this two-part paper is to explain the importance of critical thinking (CT) to achieve accuracy of diagnoses, explain new views of CT, apply CT in the diagnostic process with a case study, and describe ten strategies for self-development of CT abilities.

CT and Diagnostic Accuracy

Development of CT abilities for diagnostic accuracy is important because: (1) accurate interpretation of patient data is a challenging task that requires high levels of thinking abilities and intelligence; (2) the thinking abilities of nurses, like other adults, vary from high to low and can be improved; and (3) optimum use of CT abilities supports the validity of diagnoses made from data. Interpreting patient data is challenging because the signs and symptoms of nursing diagnoses overlap with one another; the responses of human beings are holistic, complex, and unique; and incorrect inferences may form the bases for nurses' diagnoses. Table 1 shows three examples of the overlap of signs and symptoms of nursing diagnoses. Such overlap can easily lead to diagnostic errors and, since diagnoses are the basis for nursing interventions, low accuracy leads to undesired patient outcomes.

Table 2 shows three case study examples of harm to patients that occurred by misinterpreting the meaning of cues to these overlapping diagnoses⁽⁶⁾. The holistic and complex responses of human beings are influenced by many variables such as culture. Since human beings are unique, nurses cannot know the responses of persons in their care until such persons reveal who they are⁽⁷⁾. Accuracy, then, depends on efforts to know people through listening. Usually patients are the best sources of data and data interpretation in relation to themselves. Nurses can only know the persons in their care if they listen carefully and validate data interpretations.

Nurses continuously interpret patient data based on the limits of short-term memory. Humans hold 7 ± 2 bits of information in short term memory ⁽⁸⁾, so data are continuously changed to inferences that summarize large amounts of data, e.g., inferences are made that people are male or female based on body type, hair style, name, type of clothing, and many other data. Inferences are the personal meanings that people derive from data (see example in Table 3). Diagnostic decisions, however, are at higher levels of abstraction and may include many inferences made from data, some of which may be incorrect.

In a systematic review of research findings on interpretations of patient data ⁽³⁾, showed that nurses' interpretations, and thus accuracy, varied widely. In these studies, researchers used written or computer case simulations to measure data interpretation, which helps to maintain consistency of patient data for all subjects. It is expected that these findings probably reflect what occurs with actual clinical cases, especially since the diagnostic process is more complex with real cases. A clinical study was conducted to measure the accuracy of 62 staff nurse volunteers in three New York/New Jersey area hospitals ^{(3, 9)}. This study demonstrated that accuracy of nurses' diagnoses of patients' psychosocial responses varied from high to low with 153 newly admitted patients in the three hospitals. Each nurse diagnosed one to four patients within 36 hours of admission. Two clinical experts identified the highest accuracy diagnosis for each patient in collaboration with the patients and each other. For each clinical case, the same two clinical experts independently judged the accuracy of the staff nurse's diagnosis. On a seven-point scale of accuracy, from -1 to +5, only 66.2% of the diagnoses were rated as +3 level of accuracy or above, i.e., the diagnostic statements generally reflected the high relevance cues for psychosocial problems. These were nurses that were confident enough in their diagnostic ability to volunteer to be judged for accuracy. The diagnostic accuracy of nurses with low confidence in their diagnostic ability has not been studied.

The challenge of achieving accuracy of nursing diagnosis can be noted in the case study of MH, a 16 year old girl who was admitted to the hospital for diabetic ketoacidosis (see Table 4). The nurse focused on diagnosing behaviors of MH that contributed to this diabetic complication in order to prevent similar crises in the future. A nursing diagnosis of Ineffective Management of Therapeutic Regimen was identified and validated with MH but the task of identifying related factor(s) as a basis of nursing interventions was more challenging. The data revealed that MH had not communicated with her mother about following her diabetic diet at home, which led to poor dietary habits at home even though she followed her diet at school. The data from this case study were given to 80 experienced nurses at a conference on nursing diagnosis and the results were 46 different interpretations (Table 5) that met the criteria for seven levels of accuracy.

Nurses vary in CT abilities, as do all adults. Even adults who achieve similar accomplishments, e.g., airline pilots, registered professional nurses with bachelor's degree preparation, vary in thinking abilities⁽¹⁰⁾. For decades, cognitive psychologists who studied many different kinds of thinking abilities verified that the thinking abilities of adults vary widely, e.g., Guilford and colleagues studied thinking abilities associated with the Guilford Structure of Intellect Model^(10-11). In Lunney's study of nurses basic thinking abilities, the range of scores on cognitive fluency was 6 to 41.5, on cognitive flexibility was 0 to 27.5, and on cognitive elaboration was 7 to 30.5⁽³⁾. The wide differences in these scores indicate that thinking abilities of these nurses varied from very low to high. Cognitive fluency, flexibility, and elaboration, however, are important thinking abilities to identify possible data to collect and diagnoses to consider. They are dimensions of intelligence needed to function in nursing practice. These and other thinking abilities can be improved through metacognition, i.e., thinking about thinking, increased effort, and other strategies.

Newer views of intelligence are that intelligence can continuously grow and improve^(12-13). Intelligence is "the purposive adaptation to, selection of, and shaping of environments relevant to one's life and abilities." (1988, p. 65). Intelligence develops as an interaction of the internal world, the external world, and the person's experiences of these interactions. The internal world of the individual consists of: metacomponents, knowledge acquisition components, and performance components. Metacomponents are thinking processes to plan, monitor, and evaluate problem solving. Knowledge acquisition components are thinking processes to obtain information for problem solving. Performance components are thinking processes used for problem solving. The external world of the individual consists of environments at home, work, play, and so forth. The internal world interacts with the external world through experiences. The goal of interactions and experiences are to adapt to existing environments, select new environments, or shape existing environments to new environments. For example, experiences of internal/external interactions vary from novel to routine and automatic. With increased experience, people develop ease in planning for task completion and handling complex interactions.

The experience of thinking for nursing practice situations can be further developed by thinking about thinking and making efforts to develop thinking abilities. Improved use of CT enables nurses to better evaluate the relevance of cues, recognize the relationship between cues and possible diagnoses, consider greater numbers and types of possible diagnoses, and make decisions regarding which diagnoses are best supported by the data.

Newer Views of CT

Newer views of CT are more consistent with the postmodern approach to science⁽¹⁴⁾ than older views, i.e., newer views on CT acknowledge the interactive nature of CT of the person and environment (e.g., Brookfield⁽¹⁵⁾, Facione⁽¹⁶⁾, Scheffer, Rubenfeld⁽¹⁷⁾). Older views are incorporated into newer views but, with newer views, there is less emphasis on the objective nature of thinking. Older views included abilities to (a) discriminate between good and bad arguments, (b) conduct inductive and deductive reasoning, (c) clarify assumptions, (d) weigh evidence, (e) evaluate conclusions, and (f) justify facts and values. Newer views relate these and other internal processes to external environments, thus they are broader and more inclusive of human-environment interaction. For example, Brookfield⁽¹⁵⁾ defined CT as "a productive and positive process stimulated by positive and negative events with manifestations that vary according to the context." The contextual nature of thinking and intelligence characterizes newer views.

An important research study that influenced newer views of critical thinking was Women's ways of knowing⁽¹⁸⁾. The findings of this study of 135 women from colleges and social services agencies were that the thinking processes of women develop through relationships with others. Women's perspectives on "knowing" varied according to relationships and community-based experiences. The researchers identified five phases of development in women's ways of knowing (see Summary, Table 6). This study verified that intuition is a legitimate thinking strategy for knowing.

Many views of CT had been described by philosophers and psychologists, but, until recently no studies were done to identify the dimensions of CT that are needed for nursing practice. Scheffer and Rubenfeld⁽¹⁷⁾ conducted a Delphi study with 55 nurses who had published on the topic of critical thinking. The result was a definition of CT for nursing that includes seven cognitive skills and ten habits of mind. In Part II of this article, these seven cognitive skills will be applied to the case study of MH.

Recebido: 17/02/2003

Aprovado: 12/06/2003

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*

This article was adapted from a course presented in March 2003 at the University of Sao Paulo.

The author thanks Dra. Dina A. Lopes Monteiro da Cruz for her contributions to course development.

Publication Dates

• Publication in this collection
  04 Dec 2008
• Date of issue
  June 2003

History

• Received
  17 Feb 2003
• Accepted
  12 June 2003