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1、,第七章 评判性思维和护理临床决策,Critical Thinking and Decision-making in Nursing,Nursing School of Second Military Medical University,Main Topics:,Why and which thinking is important to nurse? What is the definition and components of critical thinking and why it is important? How to improve the nurses critical th
2、inking ability? Whats clinical decision making and how to make clinical decisions?,Significance of Nursing Thinking,思维形态,动作思维 形象思维（直观思维） 抽象思维（逻辑思维）,思维探索答案方向,求异思维（发散思维） 求同思维（聚合思维）,思维是否具有新颖性、独创性,再生性思维 创造性思维,Everybody thinks all the day and all the time.,思维的类型,Scenario ：Its Tuesday. Youre on the way to
3、 classroom and these thoughts are going though your mind: “I have so much to doanatomy(解剖) test on Wednesday, Physiology(生理学) paper due on Thursday.I really wanted to get a hair cut.Do I really have to shop tomorrow?Hey, what an interesting looking man that is on the corner.Im starvingWhat can I eat
4、?”,Aimless thinking,Think,Purposefully,Dialectically,Dynamically,Critically,Initiatively,评判性思维（critical thinking）,20世纪30年代德国法兰克福学派创立 一种批判理论和思维方式 70年代开始运用于教学 本质是反思能力和建设性批判精神,History,80年代初，被引入护理 护理科学的理论基础和哲学基础 1992年，美国护理联盟（the National League for Nursing，NLN）把评判性 思维列入评审护理学院的必须标准。,护理科学的理论基础和哲学基础,评判性思维（
5、critical thinking）,History,One of the core competencies One of the hot topics,Bandman(1988):“the rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs, and actions. ”,评判性思维（critical thinking）,Definitions,“对思想、推理、假设、原则、争议、结论、问题、说明、信念和行
6、动的理性检验。”,Kozier et al（2000）: Critical: not “eager to find fault” but “capable of judging carefully and accurately.” Thinking: to have an opinion, to reflect on, to call to mind, to devise by thinking, to form a mental picture of (image), to reason.,评判性思维（critical thinking）,Definitions,“评判性的”不是指“急于发现
7、问题”，而是指“仔细地、正确地判断能力”； “思维”是指有思想、有反思、有回忆、有设计发明、有想象和有推理。,Kozier et al（2000）: Critical thinking: “a purposeful mental activity in which ideas are produced and evaluated, plans made, and desired conclusions determined.”,评判性思维（critical thinking）,Definitions,“一个有目的的、产生思想并对其进行评价，制定计划和确定理想结论的智力活动过程。”,Alfaro
8、-LeFevre(1999) : Entails purposeful ,outcome-directed (results-oriented) thinking. Is driven by patient, family, and community needs. Is based on principles of nursing process and scientific method. Requires knowledge, skills and experience.,评判性思维（critical thinking）,Definitions,必须是有目的的、结果导向的思维；受患者、家
9、庭、社区需要的驱动；以护理程序和科学方法原则为基础；需要知识、技能和经验；,Alfaro-LeFevre(1999) : Is guided by professional standards and ethics codes. Requires strategies that maximize human potential and compensate for problems created by human nature. Is constantly reevaluating, self-correcting, and striving to improve.,评判性思维（critic
10、al thinking）,Definitions,受职业标准和伦理规范的指导；需要一定的策略，如：运用个人力量来发挥人类最大潜能的策略，弥补人性弱点的策略；需要不断地再评估、自我修正并努力改进。,评判性思维首先是一种理性思维，护理运用强调的是一种观念、一种意识 评判性思维理论是一个完整体系 反思（Reflection）和推理（rational reasoning）是评判性思维的实质过程 临床决策是护理评判性思维的核心目的 护理程序是评判性思维的应用工具,评判性思维（critical thinking）,Definitions,General critical thinking Critical
11、 thinking in clinical situations Specific critical thinking in nursing,评判性思维（critical thinking）,Types,Specific Knowledge Base(专业基础知识) Experience （经验） Skills in Critical Thinking （思维技能） Attitudes for Critical Thinking(态度倾向),Critical thinking in nursing,Components,Skills in Critical Thinking,Is the co
12、re component. Critical analysis Inductive reasoning Deductive reasoning,Critical thinking in nursing-Components,Case：With the caring experience of 35 children undergoing maxillary surgery, several conclusions of peri-operational interventions for maxillary surgery patients are drawn as follows:123,归
13、纳法（induction）,Case：A patient underwent a partial gastrectomy operation this morning. The surgeon prescribed as follows: 1. Following nursing interventions for the patients undergoing general anesthesia 2.,演绎法 （deduction）,Skills in Critical Thinking,Six critical thinking cognitive skills： interpretat
14、ion, analysis, evaluation, inference, explanation and self-regulation,American Philosophical Association (APA,1990),Critical thinking in nursing-Components,1.Confidence. 2. Independence of thought. 3.Fairness. 4.Integrity. 5.Responsibility and Accountability. 6. Curiosity. 7.Risk Taking and courage.
15、 8.Creativity. 9.Perseverance. 10.Humility.,Attitudes for Critical Thinking,Critical thinking in nursing-Components,Commitment Level Complex Level Basic Level,Levels of Critical Thinking in Nursing,尽职层次 复杂层次 基础层次,Strader (1992): “the process of establishing criteria by which alternative courses of a
16、ction are developed and selected.”,Definitions,Clinical decision making in nursing,Smith H. and Donald (2002): A problem solving activity that focuses on defining client problems and selecting appropriate treatment interventions.,Roche (2002): A complex process in which nurses combine theoretical kn
17、owledge with practical experience to make judgments regarding client care.,Definitions,Clinical decision making in nursing,Kozier et al (2000) : A critical thinking process for choosing the best actions to meet a desired goal.,护理临床决策就是护士在临床护理实践过程中，对面临的现象或问题，从所拟定的若干个可供选择的方案中做出决断并付诸实施的过程。,Definitions,
18、Clinical decision making in nursing,Ethical decision making 护理伦理决策 Clinical decision making 护理临床决策 Managerial decision making in nursing 护理管理决策,Classifications,Decision making in nursing,The classification is not absolutely!,Identify/Define the Problem 确定问题 State the Goals/Identify the Objectives 陈述
19、目标 Seek Alternatives and Make Choices 寻求备择方案并做出决策 Implement the Solutions 实施方案 Evaluate and Feedback 评价和反馈,Process steps,Decision making in nursing,Personal Factors/Individual Factors,Influencing Factors,Clinical Decision making in nursing,Values Past Experience Knowledge Base Individual Preference
20、and Risk Way of Thinking Emotional Intelligence Personal Characteristics,Environmental Factors,Influencing Factors,Clinical Decision making in nursing,The physical environmental factors The social environmental factors,Situational Factors,Influencing Factors,Clinical Decision making in nursing,Anxie
21、ty, Stress, Fatigue Freedom, Rationality, and Voluntarily Related Information Risks Involved Time Limitations Complexity of Decision Making Task,What major outcomes/results do I hope to achieve? What problems or issues must be addressed to achieve the major outcomes? What are the circumstances (what
22、 is the context)? What knowledge is required? How much room is there for error? How much time do I/we have? What resources can help? Whose perspectives must be considered? What is influencing thinking?,Strategies promoting critical thinking and clinical decision making,学而不思则罔 思而不学则殆,知识,实践,思维,专业成长,Developing Thinking Abilities,千 里 之 行,知识,实践,思维,Developing Thinking Abilities,始 于 足 下,Have a break！,