Facione (1990) defines Critical Thinking as a purposeful self-regulatory judgment. Halpern (1989) defines it as a purposeful goal directed thinking. Critical Thinking is an essential component of Nursing since a nurse is always, by profession, confronted with complex situations, which demand accurate judgments, clinical decision-making and a continuous learning process.
Thus, a critical thinking involves a big process of reasoning and problem solving where all judgments and clinical decisions are based on evidence. In this process, there is an active ingredient of intuition, emotional intelligence and reflection.
In this process, there is also credibility of the data, scope for investigation and learning. Of course, Critical thinking in nursing is largely influenced by the psychological, physiological and environmental traits like age, level of confidence, bias, skills, fatigue, stress and co-workers.
Various nursing models like T.H.I.N.K. Model (Rubenfeld & Scheffer, 1995), Nursing judgment model (Kataoka-Yahiro & Saylor, 1994), Novice vs. Expert or Struggling vs. Exemplary nurses (Benner, 1984; Beeken, 1997) and Critical Thinking Interaction Model (Miller & Babcock, 1996) highlight the role of critical thinking in nursing practice. Thus, Evidence based nursing practice is an important aspect of Critical Thinking in nursing practice.
Evidence Based Nursing Practice:
Evidence based practice is the conscientious, explicit and judicious use of current best evidence in making decisions about the case of individual patients (Sackett, 1996).
Evidence based practice takes patient's perspective also into account. Hence, evidence based practice involves a big process of question building and this process of question building takes into account clinical findings, aeotiology, diagnosis, prognosis, therapy and prevention of diseases (Baum, 2003).
This question building process gives the idea on the most important question, the question which is encountered very often in practice and the question's relevance very often in practice and the question's relevance to the patient situation.
Evidence based practice is probably best understood as a decision-making framework that facilitates complex decisions across different and sometimes conflicting groups (Sackett, 1996). It involves considering research and other forms of evidence on a routine basis when making health care decisions.
Such decisions include choice of treatment, tests or risk management for individual patients, as well as policy decisions for large groups and populations (Baum, 2003). Of course, the best evidences are based on the conviction that a systematic documenting of a large number of high quality RCTs (Randomized with Concealment, Double blended, complete follow-up, intention to treat analysis) gives the least biased estimate.
Thus, this becomes level 1 evidence and recommendations based on level 1 evidence are Grade A. Various terminologies aid evidence based medical practice such as "Clinical practice guideline" which assists practitioner and patient make decisions about appropriate health care and "Randomized controlled clinical trial" where a group of patients is randomized into an experimental group and a control group. These groups are followed up for the variables and outcomes of interest.According to Judith Green et.al (1998), Qualitative methods can help bridge the gap between scientific evidence and clinical practice, provide rigorous accounts of treatment regimens in everyday contexts, help us understand the barriers to using evidence based medicine, and its limitations in informing decisions about treatment.
Qualitative findings as discussed are often the first type of evidence available relating to innovations and contextual constraints relating to existing practice (David R. Thomas, 2000). Thus, the value of good qualitative data is that it can provide crucial information about context and processes related to health practices and interventions and can be useful in areas for which there is little or no previous research, the use of RCTs or other types of experiments is impossible and to complement quantitative data gathering providing data about unanticipated impacts of interventions.
Qualitative procedures can form information not obtainable using quantitative methods. Qualitative evidence is often the "best available" evidence until quantitative research is carried out (David R. Thomas, 2000).
Lincoln and Guba (1985) suggest that various techniques are necessary for improving and documenting the credibility of data. Having the participants together encourages sharing of views and test for misinformation and understanding amongst the participants, builds trust and good rapport with each other.
Trisha Greenhalgh et.al (2003), view evidence based practice as a sequence of framing a focused question followed by a thorough Search for research derived evidence supported by the appraisal of the evidence for its validity and relevance incorporating the user's values and preferences.
Henderson et.al (2004) have developed an instrument, suggested by Guba's Model of Trustworthiness of Qualitative Research, to evaluate the methodological rigor of qualitative papers expanding Sackett's Rules of Evidence Model for qualitative studies in clinical decision making and have proved that the appraisal instrument and the methodology straightforward, simple to use, and helpful in clinical decision making (Henderson et.al , 2004).
Evidence Based Nursing provides a practice with a strong application of the scientific method. This enables practice to proceed by a process of skeptical questioning rather than by embellishment with rhetoric (Baum, 2003).
Evidence Based Nursing Practice as a practice that helps in developing more transparent working practices to establish guidelines and standards. Evidence Based Nursing can become the basis for thousands of clinical and policy decisions about most aspects of health care, such as tests, treatments, risk factors, screening programs, and other forms of disease management.
Criticisms on evidence-based nursing have been that:
1.Evidence-based practice isn't new and it is what we have been doing for years,
2. Evidence based nursing disregards individualized patient care, and
3. Evidence based nursing lays over-emphasis on randomized controlled trials and systematic reviews. (Alba DiCenso et.al.1998).
Pravikoff et.al (2005) on close examination of nurses' perceptions about their access to tools and the skills to obtain evidence in their practice, using a stratified random sample of 3,000 RNs across the United States, have found that nurses frequently need information for practice on specific tasks but do not understand research nor have received any training in the use of tools that would help them find evidence to base their practice. Deborah J (1999) has also highlighted the theory practice gap that exists in nursing today as a barrier to evidence based nursing.
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Agency San Francisco, Inc.
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Charles L. Berman
Liz Di Bernardo