评判性思维在护理工作中的应用（Application of critical thinking in nursing work）

评判性思维在护理工作中的应用Application of critical thinking in nursing workApplication of critical thinking in nursing workPreface Liu Huaping (195, 8-), female, Beijing people, doctor, associate professor, School of nursing, Peking Union Medical College, main research fields: clinical nursing and nursing management. In twenty-first Century, the era of rapid development of science and technology, knowledge update rapidly, medical and health knowledge level is constantly improving. According to statistics, the renewal rate of medical knowledge can reach 50% within five years, and the knowledge taught by textbooks in medical schools has far failed to meet the clinical needs. Nursing is an important part of the medical and health system. The nursing profession in our country has developed rapidly in an unprecedented situation. At the same time, it is also facing the opportunities and challenges brought about by the renewal of medical knowledge. At present, the total number of nurses in our country has reached 1 million 300 thousand, and the level of clinical nursing technology has been greatly improved. It plays an important role in the critically ill, acute and difficult diseases and the treatment of patients with infectious diseases. With the accelerated trend of population aging in our country, nursing has shown a variety of trends, such as community, family care, day ward, hospice care and so on. It has effectively guaranteed and improved the peoples health level. At present, accelerating economic and social development in our country, the key period of building a well-off society, peoples growing demand for health care has put forward higher request to the general nursing worker, so care professionals must strive to strengthen their own learning, improve occupation skills, to keep pace with the times, keep pace with the times. In order to develop nursing team and improve the overall quality better, bring to meet the social and economic development, the renewal of knowledge and the challenges of population aging, we must establish a formal system of nursing professional continuing medical education system, to promote the new knowledge, new business learning, improve professional skills and ability to work. This textbook is designed to provide knowledge support for continuing education of nursing professionals, the establishment of continuing education exchange platform, to expand the nursing professional perspective, the spread of new knowledge and information, so that nursing professionals to understand and grasp the knowledge frontier. This material condenses many editors believe that this effort, the publication of teaching materials of nursing continuing education project will play a positive role in promoting.Since 1980s, the international nursing community has confirmed the importance of critical thinking in nursing education, clinical practice and nursing research by a large number of studies. As early as 1989, the American Association for critical care considered critical thinking skills as a mandatory standard for assessing the quality of undergraduate education and higher levels of education, 1 4. In China, more and more nursing education experts begin to realize the importance and urgency of the critical thinking training of nurses and nursing students, 5, 6. This article mainly introduces the basic concept of critical thinking, the relationship with nursing procedure, and its application and training in nursing, so as to highlight its practicality and importance, and look forward to its further development. 1 critical thinking introduction 1.1 critical thinking concept critical thinking (CriticalThinking) and some scholars translate critical thinking. The concept originated from philosophy, which was put forward by scholars of Frankfurt school in Germany in 1930s as a critical theory and mode of thinking.The earlier explanations were proposed by Watson and Glaser1964, who argue that critical thinking is the synthesis of attitudes, knowledge, and skills 7. Report of the Delphi group in 1990 gives a basic definition of the professional consensus: critical thinking is a kind of objective judgment process and self adjustment, including elaboration, analysis, evaluation, reasoning and standard of evidence, concept, method, explanation, or to judge the situation on the basis of considering all 8. Kataoko, Yahiro and so on think that critical thinking in nursing discipline is the reflection and reasoning process of nursing problem solving method. It includes 5 parts, such as the attitude, skills, professional knowledge, experience and standard of caregivers, 9. Some people think that in a specific situation, the analysis, reasoning, hypothesis, summary of rules, statements, beliefs and behaviors by exploratory attitude are the reflection of critical thinking in nursing. The characteristics of 1.2 critical thinking 1.2.1 initiative: in critical thinking, we are not passively waiting, more than the negative stimuli, but to actively participate in to the corresponding activities; not passively wait for instructions, but constructive thinking, critical thinking in nursing by UsingCriticalThinkinginNursing Liu Huaping Zhao Qinqin (Nursing College of Peking Union Medical College, Beijing, 100730) LIU Hua-ping ZHAO Qin-qin to make their own judgment. 1.2.2 independence: critical thinking than others, with re elaborates not self thinking, but thinking of themselves and others thinking as an individual and independent. In other words, have your own insight. When we believe in something, accept some ideas, not indiscriminately, all of them according to income, but the critical thinking of specific analysis, make their own independent judgment, and then decided to adopt or reject. 1.2.3 reflection: critical thinking is not a rational processing activity. It aims at innovation, and it is a re thinking of thinking. When we ourselves or others have some views and ideas, we use the review of critical thinking, the fact whether the interpretation is reasonable or not, according to the full or not, and whether the comprehensive analysis, comprehensive evaluation is appropriate or not, such as composition, the evaluation of the objective or not, and the standard reasonable or not, there is no value, and how to use, etc. This kind of reflection on thinking is of great significance for decision making, clear thinking and correct reasoning. 1.2.4 comprehensive review: when we reflect on their own and others thinking, not to seize the leaves Festival and must look to make a fuss, multi angle reflection is full, and even other evaluation subject evaluation. To choose personal hobbies interpret out of context, critical thinking is taboo. A thorough examination will enable our critical thinking to be judged. 1.2.5 has a persuasive judgment: critical thinking is not just about giving personal opinions, but more importantly, there are good reasons and grounds to judge 10. In a word, critical thinking is an autonomous thinking, with unlimited potential, and critical thinking is not passive to accept the opinions of others,After analyzing and determining what kind of opinion authority is credible, they accept their own ideas. They are not easily manipulated and are not blindly led by the people around them. 1.3, the composition of critical thinking, although western scholars understanding of critical thinking in various forms, but almost all definitions are from cognitive skills and emotional expression in two areas. Liu Huaping (1958-), female, Beijing people, doctor, associate professor, Dean of Nursing School of Peking Union Medical College, main research field: clinical nursing and nursing management.The W.OxmanMichelli on 1992, critical thinking skills (including cognitive skills and emotional expression (Intelligence) evaluation of two aspects of spirit). He pointed out that the spirit of judgment refers to attitudes and tendencies, including: independent awareness, open-minded, whole body, intellectual level, respect for others, 11. Kneedler believes that the cognitive skills of critical thinking includes: (1) to identify the central issues and problems; (2) comparison of similarities and differences; (3) to determine what information is relevant; (4) the formation of appropriate questions; (5) the difference between facts and opinions and reasonable judgement; (6) check consistency between the lines; (7) recognition hypothesis; (8) recognition prototype and jargon (9); recognition bias, emotional factors, publicity and semantic orientation; (10) identify different value system and ideology; (11) the proper identification of materials; (12) to predict the possible consequences of 12. 1.4, the significance of critical thinking, critical thinking is often associated with reflection, questioning, negation and other cognitive links, but this does not mean that critical thinking has only a purely negative meaning. In fact, critical thinking is closely related to creative thinking: without the challenge and judgment of the existing knowledge, without the analysis and demonstration of new ideas and viewpoints, there can be no innovation. In this respect, critical thinking is not only the premise of creative thinking, but also an indispensable thinking character in the whole process of creative thinking 13. The application of critical thinking in nursing work, can better evaluate and use the information obtained, choose effective methods to solve the problems, improve their social skills, improve the quality of nursing work, promote the development of nursing specialty. The relationship between critical thinking and nursing program of 2 nursing program is a systematic approach to solve the problem in clinical care, the interrelated and interdependent relationship between critical thinking and nursing procedures, both of which contain the processing problems, make decisions and creative thinking of the three heart activity, but they are not exactly the same. Nursing procedures are essentially a solution to the problem, and nurses use cognitive skills in critical thinking at all stages of the use of nursing procedures to solve problems. Watson and Glaser pointed out in 1964 that critical thinking is often associated with nursing procedures and runs through all aspects of the nursing process, 7. The 2.1 stage: nursing assessment of nurses need reliable observation and analysis, to identify whether a patient information related to health problems, to determine whether an important, sort and organize data, verify the information, and according to the conceptual framework of nursing or nursing concepts related to the theory of correct classification, these activities are required to use critical thinking skills. Two2 nursing diagnosis stage: nurses need to find out the relation between the categories of clues and clues, and then form inferences based on these clues. The formation of a diagnosis after diagnosis has been proved, and the process of forming the diagnosis is actually a critical thinking process. The 2.3 stage: nursing care plan as a critical thinking is very cautious when making decisions, which is why nurses can according to the knowledge and experience, according to the patients condition, will make nursing diagnosis possible or dangerous, and the reasonable choice of the order of priority, target for patients, the nursing effect evaluation standard, analyzing related factors, formulate nursing measures according to the related factors. The evaluation criteria, selection, interpretation and assumption of the selected nursing measures can solve the patients problems and use interdisciplinary knowledge and other thinking activities are critical thinking skills. The 2.4 stage: nursing nurses use knowledge and nursing principle and related disciplines to solve the problem for the patient, use is not a simple memory knowledge and principle thinking process, it is also the critical thinking process. The 2.5 stage: nursing evaluation of nurses through observation and other methods of data collection, and data collection and evaluation criteria, to determine the expected goal is achieved, the method is also a criterion to evaluate the critical thinking process 14. At each stage of the nursing process, from evaluation to evaluation, nursing staff should always make clinical judgments and inferences. It can be said that critical thinking is the engine that drives the nursing program 15. 3 the application of critical thinking in nursing work. Following the nursing process at each stage, to analyze the specific application of critical thinking in nursing work. 3.1 in the evaluation phase of the application, in the collection of information, nurses will find possible problems of patients, from the discovery or identification of the problem to make a preliminary conclusion, that is, hypothetical reasoning. For example, after an abdominal operation, the patients blood pressure is 80/50mmHg. Low blood pressure is a major problem for the patient, and the nurses initial reasoning may be that the patient is suffering from shock. A nurses reasoning ability is influenced by knowledge, experience, and values. But before making a decision, the nurse will further confirm the information. Nurses must collect more data to verify the accuracy of the data already available. The method of verification consisted of looking at symptoms and crises with or without shock, comparing past blood pressure, re measuring blood pressure, or asking another more experienced nurse to measure 16. Nurses should consider what factors affect the accuracy of the data obtained, and whether subjective data is consistent with objective data. In the analysis of data, to classify data, to consider whether the subjective impact of nurses, the adequacy of information, comprehensive, but also to supplement what information in order to make accurate judgments on the problem 15. When analyzing the data, the data should be compared with the normal value or reference value and the patients previous situation, so as to lay the foundation for correct nursing diagnosis. 3.2 in the application of nursing diagnosis stage, nurses should use critical thinking in the process of nursing diagnosis based on the analysis of data. According to the data collected by the nurses, the nurses should consider the existing problems of the patients and what potential health problems the patients have,What problems need nurses to deal with? What are the problems associated with the care and cooperation of doctors and nurses? What are the factors that lead to patient problems?. For example, a patient, a woman, has a temperature of 39.4. C; dry skin and flushing; less frequent urination and decreased urine output. According to these data, the nurses initial impression is that the patient may have problems with nutrition, metabolism, function, or excretory function. In order to obtain the correct nursing diagnosis, nurses should continue to collect data within the two functional health categories. In the continuing data, the nurse found that the patient had been vomiting since he had a cold two days earlier and had less water. In addition, palpation of the bladder revealed no swelling. These data show that the patient has no excretory dysfunction. So the nurses decision to reduce urine, raise body temperature and dry and flush skin may be due to inadequate intake of water, 16. 3.3 in the formulation of the application stage of nursing planning, when nurses formulate nursing plans for patients, it is necessary to find out the countermeasures or measures that can prevent, control or eliminate the identified patient problems. This process can be used for inductive, associative, and predictive thinking strategies. For example, a nurse assessment because of traumatic brain injury and coma are using ventilator patients, found that the upper lobe of the left lung Youluo. Nursing diagnosis for the nurses of the patient is ineffective airway clearance with the patients state of consciousness, change, not to cough up sputum intubation induced respiratory tract secretion and immobility caused by sputum deposition on. When choosing a measure, the nurse will think of suctioning, turning over, and so on. But when predicting possible outcomes, nurses will find that these two measures have increased the risk of increased intracranial pressure, according to research literature. If this measure is not taken, the sputum may cause bronchial obstruction and hypoxemia and hypoxemia may increase intracranial pressure. In order to reduce these risks, the nurses use bowls in the patient when turning, and plans in the sputum for patients before and after oxygen inhalation for several minutes, and as far as possible to shorten the sputum suction time 16. In the planning process to nurse each measure according to whether the patient safety, feasibility, application of existing resources, is in accordance with the patients values or beliefs, and other treatment plan is consistent with the 15. In the formulation of the plan, we should also consider the proposed nursing diagnosis, according to primary and secondary points, headed by the top, middle and sub sub priorities, sorting out priorities. The nurse also proposes care goals to guide care during the planning process, which is also the basis for the evaluation of nursing interventions. When setting goals, consider whether the goals are appropriate, whether the goals are consistent with the treatment plan, and whether the goals are realistic. 3.4 in the implementation phase of nursing, nurses should judge patients needs, observe the patients reaction and judge whether they are moving towards the expected direction when implementing the measures. Decide if you need to adjust the plan. As mentioned in the example, the nurse in sputum to brain trauma patients, close observation of changes in the patients breathing, oxygen saturation, pulse, blood pressure, if there are signs of increased intracranial pressure, should immediately stop the operation, the patient inhale oxygen and then observe the patients reaction 16. In this process, nurses should pay attention to the core issues are: (1) after the implementation of planning measures, the patients situation has changed, measures are appropriate;(2) nurses have enough knowledge and technology to deal with the patients condition; (3) in the implementation of each measure, when to check the patients reaction; (4) whether to ignore the principle of safety; (5) are not in accordance with the patients age, value and general health measures to adjust the 15. 3.5 in the evaluation phase of nursing evaluation, nurses should collect data related to patients to determine whether the goal of nursing is achieved or achieved. The critical thinking skills used to collect data are the same as those in the evaluation phase. The conclusion, however, is whether or not the care measures are up to expectations and whether or not the care measures can be terminated or need to be modified. In the nursing work, nurses can not only focus on the operation process, but also should collect and analyze the relevant data carefully, and exercise their thinking process 16. Therefore, in the evaluation of nurses, application of critical thinking should be as follows: (1) on the data is to achieve the desired effect, patients and their families are also considered to achieve goals; (2) think in the implementation of the nursing measures, which can still be improved; (3) if the patients results do not meet expectations that must be considered: the basic data is not accurate? Is the nursing diagnosis correct? Is the expected target feasible or measurable? Is the choice of nursing measures correct? Is it implemented as planned? 15 critical thinking training, the research of critical