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Reflective Practice Nursing Definition Of Critical Thinking

(Penny Heaslip, 1993, Revised 2008 Thompson Rivers University, Box 3010, 900 McGill Road, Kamloops, BC Canada, V2C 5N3 pheaslip@tru.ca )

To become a professional nurse requires that you learn to think like a nurse. What makes the thinking of a nurse different from a doctor, a dentist or an engineer?  It is how we view the client and the type of problems we deal with in practice when we engage in client care. To think like a nurse requires that we learn the content of nursing; the ideas, concepts and theories of nursing and develop our intellectual capacities and skills so that we become disciplined, self-directed, critical thinkers.


Critical thinking is the disciplined, intellectual process of applying skilful reasoning as a guide to belief or action (Paul, Ennis & Norris). In nursing, critical thinking for clinical decision-making is the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care (Heaslip). Critical thinking when developed in the practitioner includes adherence to intellectual standards, proficiency in using reasoning, a commitment to develop and maintain intellectual traits of the mind and habits of thought and the competent use of thinking skills and abilities for sound clinical judgments and safe decision-making.

Intellectual Standards for Reasoning

Practitioners in nursing who are critical thinkers value and adhere to intellectual standards. Critical thinkers strive to be clear, accurate, precise, logical complete, significant and fair when they listen, speak, read and write. Critical thinkers think deeply and broadly. Their thinking is adequate for their intended purpose (Paul, Scriven, Norris & Ennis). All thinking can be examined in light of these standards and as we reflect on the quality of our thinking we begin to recognize when we are being unclear, imprecise, vague or inaccurate. As nurses, we want to eliminate irrelevant, inconsistent and illogical thoughts as we reason about client care. Nurses use language to clearly communicate in-depth information that is significant to nursing care. Nurses are not focused on the trivial or irrelevant.

Nurses who are critical thinkers hold all their views and reasoning to these standards as well as, the claims of others such that the quality of nurse's thinking improves over time thus eliminating confusion and ambiguity in the presentation and understanding of thoughts and ideas.


Elements of Reasoned Thinking

Reasoning in nursing involves eight elements of thought. Critical thinking involves trying to figure out something; a problem, an issue, the views of another person, a theory or an idea. To figure things out we need to enter into the thinking of the other person and then to comprehend as best we can the structure of their thinking. This also applies to our own thinking as well. When I read an author I'm trying to figure out what the author is saying; what problem or issue the author is addressing, what point of view or frame of reference he is coming from, what the goal or purpose is of this piece of writing, what evidence, data or facts are being used and what theories, concepts, principles or ideas are involved. I want to understand the interpretations and claims the author is making and the assumptions that underlie his thinking. I need to be able to follow the author's lines of formulated thought and the inferences which lead to a particular conclusion. I need to understand the implications and consequences of the author's thinking. As I come to understand the author in-depth I will also begin to recognize the strength and weakness of his reasoning. I will be able to offer my perspective on the subject at hand with a clear understanding of how the author would respond to my ideas on the subject.


The Elements of Thought

All thinking, if it is purposeful, includes the following elements of thought (Paul, 1990).

  1. The problem, question, concern or issue being discussed or thought about by the thinker. What the thinker is attempting to figure out.
  2. The purpose or goal of the thinking. Why we are attempting to figure something out and to what end. What do we hope to accomplish.
  3. The frame of reference, points of view or even world view that we hold about the issue or problem.
  4. The assumptions that we hold to be true about the issue upon which we base our claims or beliefs.
  5. The central concepts, ideas, principles and theories that we use in reasoning about the problem.
  6. The evidence, data or information provided to support the claims we make about the issue or problem.
  7. The interpretations, inferences, reasoning, and lines of formulated thought that lead to our conclusions.
  8. The implications and consequences that follow from the positions we hold on the issue or problem.

When nurses reason they use these elements of thought to figure out difficult questions and recognize that their thinking could be flawed or limited by lack of in-depth understanding of the problem at issue therefore, they critically monitor their thinking to ensure that their thinking meets the standards for intellectual thought.

In summary, as a critical thinker, I am able to figure out by reading or listening critically what nurse scholars believe about nursing and on what basis nurses act as they practice nursing. To do this I must clearly comprehend the thinking of another person by figuring out the logic of their thinking. I must comprehend clearly the thinking of myself by figuring out my own thoughts on the subject at hand. Finally, I must use intellectual standards to evaluate my thinking and the thinking of others on a given problem such that I can come to a defensible, well reasoned view of the problem and therefore, know what to believe or do in a given circumstance. To do this I must be committed to developing my mind as a self-directed, independent critical thinker. I must value above all else the intellectual traits and habits of thought that critical thinkers possess.

Intellectual Traits and Habits of Thought

To develop as a critical thinker one must be motivated to develop the attitudes and dispositions of a fair-minded thinker. That is, one must be willing to suspend judgments until one truly understands another point of view and can articulate the position that another person holds on an issue. Nurses come to reasoned judgments so that they can act competently in practice. They continually monitor their thinking; questioning and reflecting on the quality of thinking occurring in how they reason about nursing practice. Sloppy, superficial thinking leads to poor practice.

Critical inquiry is an important quality for safe practice. Nurses must pose questions about practice and be willing to attempt to seek answers about practice. Nurses must be willing to attempt to seek answers to the difficult questions inherent in practice, as well as the obvious. Question posing presupposes intellectual humility and a willingness to admit to one's areas of ignorance as well as, intellectual curiosity and perseverance and willingness to seek answers. Critical thinkers in nursing are truth seekers and demonstrate open-mindedness and tolerance for others' views with constant sensitivity to the possibility of their own bias.

Nurse's who are critical thinkers value intellectually challenging situations and are self-confident in their well reasoned thoughts. To reason effectively, nurses have developed skills and abilities essential for sound reasoning.


Critical Thinking Skills and Abilities

Critical thinkers in nursing are skilful in applying intellectual skills for sound reasoning. These skills have been defined as information gathering, focusing, remembering, organizing, analyzing, generating, integrating and evaluating (Registered Nurse's Association of British Columbia, 1990). The focus of classroom and clinical activities is to develop the nurse's understanding of scholarly, academic work through the effective use of intellectual abilities and skills. As you encounter increasingly more complex practice situations you will be required to think through and reason about nursing in greater depth and draw on deeper, more sophisticated comprehension of what it means to be a nurse in clinical practice. Nursing is never a superficial, meaningless activity. All acts in nursing are deeply significant and require of the nurse a mind fully engaged in the practice of nursing. This is the challenge of nursing; critical, reflective practice based on the sound reasoning of intelligent minds committed to safe, effective client care.


To accomplish this goal, students will be required to reason about nursing by reading, writing, listening and speaking critically. By doing so you will be thinking critically about nursing and ensuring that you gain in-depth knowledge about nursing as a practice profession.

Critical Thinking...a Holistic Approach

Critical Listening: A mode of monitoring how we are listening so as to maximize our accurate understanding of what another person is saying. By understanding the logic of human communication - that everything spoken expresses point of view, uses some ideas and not others, has implications, etc., critical thinkers can listen so as to enter empathetically and analytically into the perspective of others.

Critical Thinking: 1) Disciplined, self-directed thinking which implies the perfection of thinking appropriate to a particular mode or domain of thinking. 2) Thinking that displays master of intellectual skills and abilities. 3) The art of thinking about your thinking while you are thinking in order to make your thinking better: more clear, more accurate, or more defensible.

Critical Writing: To express oneself in languages required that one arrange ideas in some relationships to each other. When accuracy and truth are at issue, then we must understand what our thesis is, how we can support it, how we can elaborate it to make it intelligible to others, what objections can be raised to it from other points of view, what the limitations are to our point of view, and so forth. Disciplined writing requires disciplined thinking; disciplined thinking is achieved through disciplined writing.


Critical Reading: Critical reading is an active, intellectually engaged process in which the reader participates in an inner dialogue with the writer. Most people read uncritically and so miss some part of what is expressed while distorting other parts. A critical reader realizes the way in which reading, by its very nature, means entering into a point of view other than our own, the point of view of the writer. A critical reader actively looks for assumptions, key concepts and ideas, reasons and justifications, supporting examples, parallel experiences, implications and consequences, and any other structural features of the written text to interpret and assess it accurately and fairly. ( Paul, 1990, pp 554 & 545 )

Critical Speaking: Critical speaking is an active process of expressing verbally a point of view, ideas and thoughts such that others attain an in-depth understanding of the speaker's personal perspective on an issue. Monitoring how we express ourselves verbally will ensure that we maximize accurate understanding of what we mean through active dialogue and openness to feedback on our views. (Heaslip, 1993).


References:

Paul, R.W. (1990). Critical Thinking: What Every Person Needs to Survive in a Rapidly Changing World. Rohnert Park, California: Center for Critical Thinking and Moral Critique

Norris, S. P. & Ennis, R.H. (1989). Evaluating critical thinking. Pacific Grove, CA: Midwest Publications, Critical Thinking Press

Reflective leadership is a way of approaching the work of being a leader by leading one’s life with presence and personal mastery. Learning to be present, to be aware and attentive to our experience with people throughout the day is the focus of reflective leadership. It approaches the study and practice of leadership from the perspective of human experience. Based upon the science of phenomenology, reflective leadership begins with self-awareness and reflection on one’s own experience and the experience of others, and results in improved communication that enlivens and changes nursing practice.

Why cultivate reflective thinking?

Reflective thinking is both an internal and external process that promotes self-understanding and improved critical thinking skills. It is essentially a form of inner work that results in the energy for engaging in outer work. It is also a meaningful and necessary activity for knowing what is important to oneself and in one’s practice or organization. Therefore, it is important to be aware of one’s thinking in order to understand oneself, and to make informed and logical decisions when working with others. In turn, attending to the thoughts, feelings, and behaviors of others facilitates progress toward achieving professional and organizational goals. Therefore, this article will begin with a focus on becoming a reflective thinker as a means to becoming a reflective leader. By thinking about one’s experience, we develop a fuller understanding about what is known and increase our potential for leadership capacity (Horton-Deutsch & Sherwood, 2008; Sherwood & Horton-Deutsch, 2012).

As an initial step to becoming a more reflective thinker, and ultimately a reflective leader, I encourage you to thoughtfully consider the following questions and responses: What steps do I take to become a reflective thinker? What tools, resources, and models can help me to become more self-aware and reflective? What does reflective leadership mean to me? How do reflective leaders positively impact nursing practice and develop future reflective leaders? What reflective leadership processes augment leaders’ strengths and build success in others?

What steps do I take to become a reflective thinker?

Taggart and Wilson (2005) developed a reflective thinking model that illustrates the reflective thinking process. One of the first steps to reflective thinking involves identifying a problem, challenge, or dilemma. Next, step back from the problem and look at the situation from a third person perspective in order to frame or reframe the problem. Ask yourself: How might an outsider view this situation? This second step involves observation, data gathering, reflection, and consideration of moral principles. These aspects help to provide a mental picture of your thinking in an attempt to define the context of the situation. The situation may be likened to past events in an attempt to make sense of the problem and to search for possible solutions within your repertoire. Ask yourself: What has worked for me in similar situations I have encountered in the past, and how is this situation different? Once you have searched for routine approaches or identified possible approaches based on reasoning through similar past experiences, predictions are made and a number of possible approaches created. The approaches are then systematically tested with subsequent observation and further testing. The final stage involves reviewing the actions taken and the consequences. Ask yourself and others involved: Do I (you) feel this situation has been successfully resolved? If the approach was successful, the instance is stored for future retrieval in similar situations. If the approach was not successful, the problem may be reframed and the process repeated.

What tools, resources, and strategies can help me to become more self-aware and reflective?

Communication occurs within the context of awareness. To effectively communicate what you are thinking, you must be aware of what you are thinking. The Awareness Wheel as described by Miller, Sherod, and Phyllis provides a tool for tuning into yourself and becoming more self-aware. For example, in my own experience of working toward being a more reflective person, I have learned to see conflict as an opportunity to discover something new/more about myself and the other person. I use the Awareness Wheel to help reflect and process the situation.

Ask yourself: What am I sensing? What am I feeling? What am I thinking? What am I willing to do? What am I unwilling to do? It is important to take the time necessary to ask yourself these questions. Sometimes it takes days to get to genuine answers. You may have to keep asking the questions until you can move past strong emotions such as anger or resentment. Emotions are valuable tools that guide us to what we are thinking. Once you have reflected on and are able to honestly and fully answer these questions, share your concerns and responses to the above questions with the other person(s) in a direct and nonthreatening way. Use of the language in the questions above encourages balanced ownership and enhances connection. The Awareness Wheel provides a tool for monitoring your own self-awareness, expanding your thoughts, and listening attentively to others for resolving problem situations.


Another prerequisite to working effectively with others is to know your own unique gifts and talents. This involves personal exploration. Strengths Finder is an assessment that helps you to identify your talents and provides hundreds of strategies for building them into strengths. The book can be read in one sitting and the test can be taken online in 30 minutes. The approach emphasizes how to apply, practice, and refine your strengths as well as those around you. This personalized development guide helps you to align your job and goals with your natural talents.

Another resource is a paper from the Sigma Theta Tau International Scholarship of Reflective Practice Task Force. It includes recommendations and guidelines related to reflective practice that are useful to individual clinicians, nursing leaders, healthcare organizations, institutions, educators, and health care consumers. It includes a comprehensive bibliography of resources on the scholarship of reflective practice. This resource paper describes definitions of reflection and reflective practice and their historical context, methods, processes, applications, benefits, and limitations. Recommendations are made to promote reflective practices in nursing worldwide.

What does reflective leadership mean to me?

Reflective leadership involves a commitment to the ongoing process of continual and sustained critical self-awareness and development, as well as facilitating this complex process in others. So, how do you do this? As a reflective leader, share your reflective thoughts with others and invite them to consider things as well. Enter into relationships with others without presenting a front or pretense, but instead being self-aware. I use the feelings that are available to me, allow myself to experience these feelings, and communicate them when appropriate. This type of real and genuine approach supports an even playing field and conveys that I value other persons and their contributions. I think of it as a way to encourage others through my own supported reflective practice.

Reflective leadership involves listening in order to learn from others. This listening necessitates an openness to others that is vital to human understanding and response. Listening fully and reflectively is not obtained without effort; it is a skill and art that must be practiced, discussed, and refined. Reflective leaders listen to stories from nurses and patients, and they discuss and reflect on how these stories can enhance and transform nursing practice and health care. A story invites us to search for significance. Stories provide information about what works and what does not work. Discussing and reflecting on stories enhances, transforms, and enables us to incorporate changes into our practice.

How do reflective leaders positively impact nursing practice and develop future reflective leaders?

Over the years, I have found this process allows me to not only share my concerns, but often brings underlying and hidden issues to the surface for both me and others involved. It provides an opportunity for me and the other person(s) to genuinely reflect on each other’s perspective, which creates a kind of catharsis. Then, each of us develops a broader perspective, a greater sense of understanding, and a renewed appreciation for each other.

Reflective practice is a transformative process. Once this healing has occurred, you and the other person are able to move forward in a more unified manner. You are then able to set mutually agreed-upon goals and guidelines that help to prevent future conflict. Activities such as informal times to connect (checking in) with one another and regular meetings that encourage reflective practice processes and open channels of communication support reflective leadership. Reflective leaders value these meetings and view them as a way to become more effective in professional collaborative work. It supports the development of a strong sense of collegiality within working relationships.

As a reflective leader it is important to be open and permit testing of assumptions and learning about one’s effectiveness. To ensure the effectiveness of your approach you will need to confront problems such as your own defensiveness, the defensiveness of others, and the ineffectiveness of your working group. Though addressing defensiveness with others risks weakening the relationships of members of the group, not testing assumptions risks the working group closing off.

Reflective leaders create a community in which reflection is an acceptable form of learning and support. That is, when issues arise you create a safe environment for personal expression in a thoughtful manner. Reflective leaders set goals, provide feedback, encourage and inspire, and promote self-monitoring. They draw upon individual strengths, offer others a variety of approaches to accomplish their work, and continually clarify or extend ideas and put problems into perspective. Aspiring to this vision is essential to helping to define and redefine goals.

What reflective leadership processes augment leaders’ strengths and build success in others?

Reflective leaders seek out other reflective leaders for peer reflection. This helps challenge assumptions, which may not be consistent with theory. Peers help us to clarify our values so that they match our behavior. This enables us to build each other’s strengths, compensate for each other’s weaknesses, and explore more creative problem-solving approaches.

Effective leaders achieve the task, build and maintain the team, and develop individuals along the way. These aspirations are best achieved when leaders are able to function in a collaborative and collegial way through practices of reflectivity that begin the process of perspective transformation. Reflective leadership is transformative in that it is about being successful and building success in others by reducing obstacles to leadership. Any obstacles are identified through reflection. Obstacles are intrinsic to our usual human ego-strivings to accomplish, to succeed, to control our surroundings and/or situation, and to compensate for our insecurities. We reduce the obstacles to leadership by consciously responding to whatever challenges us as a leader.

Reflective leaders foster a preferred way of being. They respond to daily leadership challenges by having an in-depth and comprehensive awareness of what kind of leader they want to be, what kind of human being they want to be, and what kind of legacy they want to leave. These questions direct a leader in the way he or she takes up daily leadership. How a leader goes about their day will determine, at the end of the day, if the leader feels successful and rests with integrity and peace of mind.

One of the greatest challenges for leaders of our era is the rapid rate of change. Another is the need for a new framework for the provision of health care services. These challenges require a leader who can bring everyone to the table to shape the future through collective dialogue and concerted action. Reflective leaders model an adaptive capacity, manage conflict, and know how to establish and maintain relationships. Reflective leaders are the co-creators of change. They recognize that no one person or situation can take away their personal peace or sense of competence. They transmit these feelings to others in a way that encourages and enables them to embrace the future and share in the creation of it. Finally, reflective leaders act as a model for others in their own search for meaning and value what they do. Through a commitment to ongoing reflective practice they exhibit self-awareness and personal growth.

On the path to becoming a reflective leader

Becoming a reflective leader begins by being reflective in your own practice. Start by being more fully present in each activity during your day. While interacting with others, attend to both verbal and nonverbal communication. Be sure to ask questions and clarify concerns. Be an active listener. Consider your own experience, the other person’s experience, and assumptions of each before drawing conclusions. Check in with others to ensure they feel heard. These practices will build relationships and a sense of mutual respect. In time, you will find others are drawn to you and seek your thoughtful consideration regarding problems at work. Through this transformative process you will walk the path to becoming a reflective leader!

Sara Horton-Deutsch is an associate professor in the Indiana UniversitySchool of Nursing in Indianapolis.

Selected references

Bilotta V, Bilotta G. A Conversation with the Co-Founders of the Institute of Reflective Leadership. March 2007. http://www.reflectiveleadership.com. Accessed December 17, 2012

Buckingham M, Clifton, D. Now, Discover Your Strengths. The Free Press: New York; 2001.

Freshwater D, Horton-Deutsch S, Sherwood G, Taylor B. (2005). Resource Paper on the Scholarship of Reflective Practice, Sigma Theta Tau International. Available through Sigma Theta Tau International website. http://www.nursingsociety.org/Pages/SearchResultsPrimary.aspx?k=reflective%20practice%20paper&cs=This%20Site&u=http%3A%2F%2Fwww.nursingsociety.org

Horton-Deutsch S, Sherwood G. Reflection: An educational strategy to develop emotionally competent nurse leaders. J Nurs Manage. 2008;16(8):946-954.

McCormack B, Hopkins E. The development of clinical leadership through supported reflective practice. J Clin Nurs.1995;4(3):161-168.

Mezirow J. A critical theory of adult learning and education. Adult Education. 1981;32(1):3-24.

Miller Sherod, Phyllis. http://www.primarygoals.org/models/awareness-wheel/Connecting with Self and Others. Accessed December 20, 2012.

Porter-O’Grady T, Malloch K. Quantum Leadership: A Resource for Health Care Innovation. 2nd ed. Sudbury, MA: Jones and Bartlett; 2007.

Rapp T. Now Discover Your Strengths: Strengths Finder 2.0. The Gallup Organization. New York: Gallup Press; 2007.

Shermis S. Reflective thought, critical thinking. http://www.learn2study.org/teachers/reflective.htm. Accessed December 20, 2012.

Sherwood, G. & Horton-Deutsch, S. Reflective Practice: Transforming education and improving outcomes. Indianapolis: Sigma Theta Tau International Honor Society of Nursing; 2012.

Swenson M, Sims S. Listening to learn. In Diekelman NL (eds), Teaching the Practitioners of Care: New Pedagogies for the Health Professions. Madison, WI: University of Wisconsin Press; 2003.

Taggart GL, Wilson AP. Promoting Reflective Thinking in Teachers. 2nd ed. Thousand Oaks, CA: Corwin Press; 2005.

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