Unit SevenProblem solving, Critical thinking, Creativity, and Decision making*

NorCal HIMSS Symposium - March 6, 2009

Learning objectives At the end of this unit, the learner will be able to;Define problem solving, creativity, critical thinking and decision makingDiscuss critical thinking and problem solving.Describe importance of critical thinking for nurses.List the five steps in the decision making process.Describe at least six techniques to increase creativity.Identify at least two decision making tools.

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Problem Solving*

NorCal HIMSS Symposium - March 6, 2009

Problem SolvingIf you have a problem at work, it is a good idea to sort things out. This is called problem solving.**

Problem SolvingBasic intellectual process that has been refined and systemized for the various challenges people face.Problem solving which involves a decision making steps focused on trying to an immediate problems which can be viewed as a gap between what is? and what should be?Problem makes leader better, not bitter*

Problem SolvingIf you think you have a problem at work, there are a number of ways to sort things out Talk to the person you are having a problem with.Talk to your supervisor to help you sort out the problem.Have a meeting with all the people who can help you sort out the problem.**

*Problem Solving*

Why is it important to solve problems at work?People can get cross.Work does not get done.People are unhappy at work.Accidents can happen.Contracts can be lost.People leave work.**

Some Dos of problem solvingDo say what the problem is for you.Do listen to what the problem is for the other person.Do attack the problem, not the person.Do look for solutions that suit you both.**

Some Donts of problem solvingDont call people mean names.Dont put people down.Dont be angry or aggressive.Dont stop listening.**

Approaches of problem solvingTrial and ErrorIntuitionNursing ProcessScientific method/Research processModified Scientific Method*

Problem Solving StepsDefine The ProblemAnalyze The ProblemGenerate Possible SolutionsSelect The Best SolutionPlan For ImplementationImplement And Evaluate The Solution

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Step One : Define The ProblemIdentify the problemDevelop an accurate problem statementComparison against othersMonitor for weak signalsComparison of current performance with objectives or past performanceChecklistsInverse brainstormingListing complaints*

Step Two: Analyze The ProblemDont rush to a wrong solution.Highly critical step.Common mistake to immediately begin generating solutions.Must identify and eliminate root causes of problem.*

Step Two: Analyze The ProblemDiagnostic Tools BrainstormingFlow DiagramsCause and Effect DiagramsPareto ChartsCheck Sheets*

Step Three : Generate Alternative SolutionsHow to Develop Alternatives:Look at the data. What does it tell you?Data will lead to some ideasData may not lead to best idea*

Step Three : Generate Alternative SolutionsQuestion each aspect of situation.What is the job to be done?Why is the job to be done?Who should do the job?Where should the job be done?When should the job be done?How should the job be done?*

Step Three : Generate Alternative Solutions Apply creativity to the situation.Making new waysRearranging old waysForm novel and useful ideasUse all idea sources available.The worker involved.In-house experts.Written materialOutside experts*

Step Three : Generate Alternative SolutionsApply some appropriate actionEliminate (part, reason, job, activity)Combine (parts, forms, jobs, functions)Rearrange (sequence, location)Simplify (foolproof, make obvious, provide interlocks, remove steps, reduce physical effort)Brainstorm for alternative solutions.*

Step Four : Select A SolutionRefer back to original problem statement. Consider:SafetyCostProduct performanceBetter management informationImproved TechnologyTimeQualityAppearance*

Step Four : Select A SolutionSome questions to ask:Will this completely resolve the problem?Will this only satisfy part of the problem?Will this prevent future occurrences?Will this have little or no impact on the problem?Do we have the authority to implement?Do we have the necessary resources?How long will it take to implement?*

Step Five : Plan and Implement SolutionSteps to ensure successful implementation:Work the most powerful forcesPrepare an action plan:What will be done?How will it be done?Where will it be done?Who will do it?When will it be done?*

Step Five : Plan and Implement SolutionDevelop a tracking system:Identify milestones or eventsAssign completion datesIdentify reporting systemsDesign evaluation proceduresImplement the procedures*

Step Six : Evaluate The SolutionMeasure results using procedures established during implementationUse data gathering:Check sheetsControl chartsTime studiesPareto analysis

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Problem Solving StrategiesDo it yourselfInfluence othersAssign someoneDo nothingCombine knowledge

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Problem Solving StrategiesDo it yourselfThe problem solver should evaluate his/her capabilities and expertise and determine whether this is the preferred option*

Problem Solving StrategiesInfluence OthersAllow the person owning the problem to solve itEg. Conflict between 2 employees: The nurse manager may bring the parties together to discuss their issuesInterpersonal skills may be used to assist in conflict resolution, but the employees would be allowed to work out their own solution.

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Problem Solving StrategiesAssign someone Delegation is the transferring to a competent individual the authority to perform a selected nursing task in a selected situation.

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Problem Solving StrategiesDo Nothing Often a problem will subside on its ownThe problem solver should recognize when a problem has the potential to resolve by itself and should consider making a conscious effort not to intervene*

Problem Solving StrategiesCombine knowledgeConsultation, collaboration with an expertTalking through the situation

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Pitfalls in Problem-SolvingFailure to clearly identify the real problemFailure to eliminate preconceived ideas in the identification of solutionsFailure to communicateFailure to follow upFailure to use appropriate resources

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Critical thinking*

NorCal HIMSS Symposium - March 6, 2009

Critical thinkingSuccessful Intelligence depends on 3 thinking skills:

THINKING SKILLScreativeanalyticalpractical*

Critical thinkingCritical: means requiring careful judgment.Thinking: means to have an opinion, to reflect on or ponder, to call to mind or remember to devise a plan, to form a mental picture of (image), to reason *

Critical thinkingAnalytical thinking, purposeful, goal-directed thinking process that strives to problem solve patient care issues through the use of clinical reasoning.Combines logic, intuition, and creativityEssential to nursing practiceIt is manifested when ever a nurse ask why?, what?, and how?.*

Critical thinkingTHINKING Vs CRITICAL THINKINGCritical thinking is controlled, purposeful & more likely to lead to obvious beneficial resultsThinking is basically any mental activity; can be aimless & uncontrolled; it may serve a purpose, but we often arent aware of its benefits; we might not even remember our thoughts at all*

Critical thinkingNo matter which definition you choose, critical thinking involves the use of several concepts, including: exploring, analyzing, prioritizing, explaining, deciding, and evaluating to identify solutions and determine a course of action to solve patient care problems. *

Critical thinking*

Critical thinkingIt is important for manager to assess their staff members to think critically and enhance their knowledge and skill through;Staff development programsCoachingRole modeling *

Critical thinkingCritical thinking is important for;Problem solvingCreativityDecision makingClinical judgment Critical thinking is the concept that link all the above mentioned concepts.*

WHAT IS CRITICAL THINKING IN NURSING?Purposeful, goal-directed thinking aiming to make judgments based on evidence rather than conjecture. It is based on principles of science & the scientific method & develops strategies that maximize human potential & compensates for problems caused by human nature.*

Why do we need to think critically?To make accurate and appropriate clinical decisionsTo solve problems and find solutionsTo plan care for each unique client and client problemTo seek knowledge and use it to make clinical decisions and problem solveTo be able to think creatively when planning care for clients*

CHARACTERISTICS OF CRITICAL THINKINGIt is rational & reflective.It involves healthy, constructive skepticism.It is autonomous.It includes creative thinking.It is fair thinking.It focuses on what to believe & do.*

A Path to Critical/Analytical Thinking*

Components of Critical ThinkingInterpretationAnalysisInferenceExplanationEvaluationSelf-regulation*

Aspects of Critical ThinkingTo develop into an expert critical thinker the nurse needs to use:REFLECTION: purposefully thinking back /recalling. Requires honest reviewLANGUAGE: precise & clear resulting in clear messageINTUITION: inner sensing that something is so*

Levels of Critical ThinkingBasic Critical Thinking: Thinking is concrete and based on book, principles, rules, policies (whatever they can read or hear about). Complex Critical Thinking: the nurse rely less and less on their resource people and think before asking them, come up with the answers themselves. Commitment: The nurse starts anticipating patient needs independently. *

Critical Thinking CompetenciesGeneral critical thinking competencies used by many disciplines, in many everyday situations.Scientific methodProblem solvingDecision making*

Critical Thinking CompetenciesSpecific critical thinking in clinical situations used by physicians, nurses, and other health care professionals.Diagnostic reasoning/ Clinical inferenceClinical decision making*

Critical Thinking CompetenciesSpecific critical thinking competency used in nursing practiceNursing ProcessAssessmentAnalysis (Nursing Diagnosis)PlanningImplementationEvaluation*

Critical Thinking ModelThe model helps to explain how nurses make clinical judgments/ decisions in their clinical practice that result in safe, effective, nursing care. There are 5 components in this model of critical thinking:Knowledge baseExperience in nursingCritical thinking competenciesAttitudes for critical thinkingStandards for critical thinking*

Developing Critical Thinking Attitudes/Skills/Not easyNot either orSelf-assessmentTolerating dissonance and ambiguitySeeking situations where good thinking practicedCreating environments that support critical thinking*

Attitude/skills of critical thinkersThey are:Active thinkers.Knowledgeable of their biases & limitations.Fair-minded.Willing to exert a conscious effort to work in a planful manner.*

Attitude/skills of critical thinkers...Good communicators.Empathetic.Open-minded.Independent thinkers.Curious & insightful.Humble.Proactive.*

Attitude/skills of critical thinkers...Honest with themselves & others, admitting when their thinking may be flawed or requires more thought.Organized & systematic in their approach.Flexible.Cognizant of rules of logicRealisticTeam players.Creative & committed to excellence.*

Standards for Critical ThinkingUniversal Intellectual Standards for Critical Thinking:ClarityAccuracyPrecisionDepthBreadthLogic, applied to clinical reasoning*

Standards for Critical ThinkingIntellectual Standards- 14 intellectual standards (Paul,1993) Nurses use these when using the nursing process:1. Confidence7. Perseverance2. Independence8. Creativity3. Fairness9. Curiosity4. Responsibility10. Integrity5. Risk taking11. Humility6. Discipline

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Standards for Critical ThinkingProfessional standardsSound ethical standardsWhen critically thinking must have a sense of their own values, beliefs, feelings and their clients/ clients familys values, beliefs, feelingsScientifically based practice with standards developed by expertsEvidenced based practiceStandards developed as a result of evidenceThese are minimum requirements that are necessary to give quality effective care*

Creativity *

NorCal HIMSS Symposium - March 6, 2009

Innovation Vs CreativityInnovation is the implementation of new ideas at the individual, group or organizational level.Creativity is the development of ideas about products, practices, services, or procedures that are novel and potentially useful to the organization.*

What Does It Take to Be Creative?TimeHard workMental energy

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Creativity needsCuriosityFlexibilityPassion, inspiration Singleness (following direction)Looking ahead*

Components of creativityCognitive thinking: capacity to work with information and solve problems Approach to personal creativity Emotional & motivationalInterpersonal relations: capacity to participate in creativity process with others *

Characteristics of Creative People*

Creativity EnhancersFocus on intrinsic motivationCreativity goalsDevelopmental feedbackSupportive supervisionHealthy competitionParticipative decision makingAutonomy

Hire creative peopleEnriched, complex jobsProvide resourcesClear organizational goalsInstructions to be creativeRecognize and reward creativityEncourage risk takingNo punishment for failure

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Creativity EnhancersWorkforce diversityInternal and external interactionDiverse teams skilled at working togetherSupportive climateOrganizational culture that promotes innovationFlexible, flat structuresClose interaction and relationships with customers*

Hire creative & diverse workforceDesign complex & challenging jobsSet clear org. goalsRecognize & reward creativitySet creativity goalsUse diverse teamsCreate the rightorg. cultureProvide resourcesesp. timeBe Creative!How Can Organizations Foster Creativity?*

Management Style and CreativityEncourage risk takingProvide autonomyEncourage productivity- sweat equitySupportive supervision, climate, and work groupParticipative leadership*

Organization Design and CreativityFlexibleFlatStructuresInternal &External InteractionClose Contact With CustomersThat promote*

Creativity KillersExcessive focus on extrinsic motivationLimits set by superiorsCritical evaluationClose, controlling supervisionCompetition in a win-lose situationControl of decision makingControl of information*

Creative Thinking TechniquesBrainstorming RulesExpressiveness - Say whatever ideas come to mind without focusing on constraintsNon-evaluation - No criticism allowed; all are valuableQuantity - Produce as many ideas as possibleBuilding - Expand on other peoples ideas*

Creative Thinking TechniquesBrain writing Hybrid of both individual and group brainstormingProduces more ideas than brainstorming

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Creative Thinking TechniquesShift your perspectiveTake a riskSet the stageBe curiousBe spontaneous

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Stages of the creative processWallas modelPreparation:- Define the problem, need, or desire, and gather any information. Set up criteria for verifying the solution's acceptability.Incubation:- Repetition of the same thoughts. No new ideas or interpretations. Reexamine the situation and review the data collected. Last in minutes, weeks, even years.

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Stages of the creative processWallas model3. Illumination/Insight/:- Seeing the entire concept or entity all at once. Very brief, involving a tremendous rush of insights within a few minutes or hours.4. Verification:- Experimentation of solution (succeeded or failed).

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Forms of creativityCombinational: Unfamiliar combination of familiar ideas. Exploratory: Exploration within an established Conceptual space.Transformational: Arises from a deliberate transformation of the conceptual space.*

Barriers to Creative ThinkingResistance to change, rigid mind-set, practice guided by tradition, habit, routinesStereotypical perceptions of clientsFear of making mistakes Unwillingness to take risks or look for alternative strategiesDecision making without sufficient data or supported by rationaleFailure to evaluate effectiveness of nursing actions*

Decision Making*

NorCal HIMSS Symposium - March 6, 2009

Decision MakingIt is a purposeful and goal directed effort that uses a systematic process to choose among two or more options to solve specific problem.Not all decision making begins with a problem situation, instead the hallmark of decision making is the identification and selection of alternatives.

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Decision MakingPoor quality decision is likely if the objectives are not clearly identified or if they are inconsistent with the value of an individual or organization.*

Rational decision making*RationalDecisionMakingProblem isclear andunambiguousSingle, well-defined goalis to be achieved

All alternativesand consequencesare known

Preferencesare clear

Preferencesare constantand stableNo time or costconstraints exist

Final choicewill maximizepayoff

Characteristics of effective decision making processSystematic, comprehensive way of thinking.Predetermined consequences of implemented decision.Much positive outcomes and fewer negative consequences.Based on a goal-oriented" analysis of the situation*

Characteristics of the decisionEffective: Meets the pre-stablished GOALSRealistic: Physically possible, fits circumstancesFeasible: Possible to carry out with*

WHAT ARE THE 3 CONDITIONS IN DECISION MAKING?FreedomRationalityVoluntarity*

WHAT IS CLINICAL DECISION MAKING COMPOSED OF?CueHypothesisKnowledge baseNursing interventionSearchAssumption*

*Decision Making ProcessStep 1: Identify the problemDefining the problem. What is wrong? Where is improvement needed? Begins when the nurse manager perceives a gap between what is actually happening and what should be happening.The nurse manager can identify the problem by analyzing situation.

Decision Making ProcessWhat is the desirable situation? What are the presenting symptoms? What are the discrepancies? Who is involved? When? Where ? How?Develop Feasible hypotheses, and elimination of hypotheses that fail to conform to the facts.*

Decision Making ProcessFeasible hypotheses should be further tested for causal validity.By analyzing available information, manager should begin exploring possible solutions.*

Decision Making ProcessStep 2: Explore alternativesIf situation is not covered by policy, manager must draw on his education and experience, but it may be inadequate.More experienced manager had more alternatives to be suggested for solving a variety of problems.*

Decision Making ProcessStep 2: Explore alternativesHealth care is changing rapidly manager should learn how others are solving similar problems.This can be done through continuing education, professional meetings, review of the literature, and brainstorming with staff.*

Decision Making ProcessStep 3: Choose most desirable alternativeOne alternative is not always clearly superior to all others.Manager must try to balance multiple factors such as pt. safety, staff acceptance, morale, public acceptance, cost, and risk of failure. The following questions may be asked:*

Decision Making ProcessStep 3: Choose most desirable alternative Will this decision accomplish the stated objectives? (yes or no) Dose it maximize effectiveness and efficiency? use available resources before seeking outside assistance.Can the decision be implemented?

If not, it will not solve the problem*

Decision Making ProcessStep 4: Implement decisionThe manager will need to communicate the decision to appropriate staff smoothly to win the cooperation.*

Decision Making ProcessStep 5: Evaluate resultsEvaluate the results of the chosen alternative. Be alert: solutions to old problems sometimes create new problems, so you need additional decisions.*

Decision making modelsThe decision method you used depends on the following circumstances.Is the situation routine, predictable, complex, and uncertain?Is the goal of the decision to make a decision conservatively (just good enough) or optimally? *

Decision making modelsBased on the above assumption there are four decision making model.Normative or Prescriptive DM modelDescriptive/ Behavioral DM modelSatisfying/ Conservative DM modelOptimal DM model*

Decision making modelsNormative or Prescriptive DM modelUsed when the outcome is predictable, the problem/situation is well structured.Information is objective.The decision is already prescribed.Example: if one student get F, the student should take the course again by adding.*

Decision making modelsII. Descriptive/ Behavioral DM modelUsed when the situation is complex, unpredictable, and uncertain.You dont know the outcome.Information is subjective and every person define or interprets into different direction.*

Decision making modelsIII. Satisfying/ Conservative DM modelUsed when information is gathered to meet the minimum requirement for the objective of decision.This model is appropriate when critical, urgent, immediate answer were needed within a short period of time.*

Decision making modelsIV. Optimal DM modelThe solutions/decisions are selected based on optimal requirement for objective decision.Appropriate in the situation that needs time.This model is appropriate when non-critical, urgent, immediate answer were needed within a short period of time.*

Decision making styleThe situation and circumstances should dictate which decision making style is most appropriate.To select an appropriate decision making style, the nurse manager should look at the following decision rules.*

Decision making styleThe importance of the decision quality to the institutional success.The degree to which the manager process the information and skills to decision.The degree to which the followers have the necessary information to generate a quality decision.*

Decision making style4. The degree to which the problem is structured.5. The importance of followers commitment.6. The likelihood that an autocratic would be accepted.7. The strength of followers commitment to institutional goals.8. The likelihood of followers conflict over the final decision. *

Decision making styleBased on the above mentioned rules there are three DM styles. These are;AutocraticDemocraticAnarchic

Based the stated rules characterize them.*

Types of decisionsDecisions made in the nursing service can be categorized depending upon the following criteriaHow much time the manager spends in making decision?What proportion of the organization must be involved in making decision?The organization function/ the nursing functions on which they focus.*

Types of decisions...On the basis of these, there are three classifications:1. Ends -Means2. Administrative-Operational3. Programmed-Non-programmed*

Types of decisions...1. Ends-MeansEnds: deals with the determination of desired individual or organizational results to be achieved.Means: decisions deal with strategic or operational programmes, activities that will accomplish desired results. *

Types of decisions...2. Administrative-OperationalAdministrative: made by senior management, which have significant impact throughout the organization.Operational: are generally made by mid level and first line managers and address day to day operational activities of a particular organizational.*

Types of decisions...3. Programmed-Non-programmedProgrammed:- these are repetitive and routine in nature. Since they can be programmed, procedures, rules and often manuals are formulated to cover those situations.Non-programmed:- unique and non- routine. This can be used in emergency/urgent situation.*

Conditions that initiate decision makingThese are;OpportunityThreat CrisisDeviationImprovement*

Ways of Decision MakingRelying on tradition: based on past decision makingMay appeal to authority: based on suggestions from an expert/a higher level managementPrior reasoning: based on assumptionLogical decision making: is a rational, intelligent and systematic approach*

Factors Influencing Decision Making1. Decision makers attribute Knowledge, experience, and judgment Perception and personality Values and philosophy*

Factors Influencing Decision Making2. The Situation Urgency of solution and time pressures Magnitude and importance Structure and uncertainty and risk Cost benefit*

Factors Influencing Decision Making3. Environmental Constraints External Internal*

Decision Making ToolsThere are many tools. The most common are:Probability theory:- is the likelihood that an event or outcome will actually occur. Decision tree:- are graphic decision making tools used to evaluate decisions containing a series of steps*

Deciding to decide1. Is the problem easy to deal with?Tip: avoid being bogged down in trivial details. Effective managers reserve decision making techniques for problems that require them.2. Might the problem resolve itself.Tip: prioritize and rank problems in order of importance.*

Deciding to decide3. Is it my decision?Tip: the closer to the origin of the problem the decision is the better. Before deciding ask the following questions:Does the issue affect other departments?Will it have a major impact on the superior's area of responsibility?*

Deciding to decideDoes it need further information from higher level?Does it involve serious breach of my departments budget?Is this problem outside my area of responsibility or authority? If the answer to any of these questions is 'YES' pass it to your superior.*

Barriers to Effect Decision-Making1. Easy recall: the more easily can recall the event, the more frequently they believe it occur.2. Easy search: not to put effort to seek information from the appropriate sources.3. Misconception of chance: Most people do not understand the nature of random events.*

Barriers to Effect Decision-Making4. Confirmation gap/bias:bending evidence to fit ones beliefs.5. Relaxed avoidance: the manager decides not to decide or act after noting that the consequences of inaction will not be serious.*

Barriers to Effect Decision-Making6. Defensive avoidance: Faced with a problem and unable to find a good solution based on past experience, this manager seeks a way out.7. Panic: the manager feels pressurized not only by the problem but also time.*

Use of Technology in Decision Making Technology can support, but not take over, the decision-making process.Clinical practitioners should evaluate technology before adopting it.Other staff on which technology will have an impact should have input into decisions on its adoption.*

*The Nurses Role in Patient Decision Making Patients are increasingly knowledgeable about health care and involved in treatment decisions.Nurses must be aware of patients rights in making decisions about their treatments and must assist patients in their decision making.

*The Nurses Role in Patient Decision Making Nurses must recognize when patients are lacking information and implement teaching in such cases.Nurses may need to collaborate with others to determine what information has been shared with the patient and family.

*Strategies to Improve Decision Making Make certain you have all necessary information to make a proper decision.Consider alternatives.Do not be afraid to revise a decision if circumstances change.Anticipate questions and outcomes.

*Strategies to Improve Decision MakingKeep notes and other information for reference.Consider the pros and cons of the decision.Consider how your decision will affect the people involved.Do not get caught up in unnecessary details or issues.

Common Errors in Decision MakingOver-confidence HindsightSelf-servingRandomnessRepresentationAvailabilityFramingConfirmationSelective perceptionAnchoringImmediate gratification*

******Steps in the Problem-Solving Process

Assessment - the existence of a problem must be recognizedData should be collected, compiled, and organizedSteps in the Problem-Solving Process

Analysis problem should be identified and defined clearly

Ask questions: Who? What is the problem? Why do you think that there is a problem?

Determine priority of the problemSteps in the Problem-Solving Process

Develop a list of possible strategiesFocus on a range of solutions before selecting the best oneBe creative!

Steps in the Problem-Solving Process

Outcome Identification clear, concise idea of the desired destinationMeasurablePositive and negative outcomes must be determined

Steps in the Problem-Solving ProcessPlan select the alternative that has the best chance of success and the least undesirable outcome.Know your resources: patients chart, nsg. Texts, medication books, P&P books, individuals with expertise.Identify actions/determine priorityMake decision

Steps in the Problem-Solving Process

Implementation of the chosen solutionIf actions have been delegated to personnel, clear and thorough direction must be given.In addition to delegation, this may require performing nursing actions to achieve the est. goalsSteps in the Problem-Solving ProcessEvaluationChanges may occur in the problem that necessitate immediate revisionsCompare the results obtained with the desired outcome

*Role playing

***********An unforeseen or unexpected or surprising difficulty**Exploring encourages you to identify all the variables within a situation. Analyzing is the process of studying each variable to understand its meaning and its relationship to the other variables. Prioritizing requires you to weigh the relative importance of each variable to the others, at a given point in time. Explaining the variables involves the exercise of amplifying each variable to understand its meaning in the situation and to the involved parties. Deciding means to choose a specific course of action.Evaluating requires the thinker to assess how correct the thinking process was, and if further action is needed.

*****Reflection-Purposely thinking back or recalling a situation to discover its purpose or meaning. Looking back and reflecting on a client situation helps the nurse to have insight and meaning in the situation. Reflection allows the nurse to look at a situation honestly and do some self evaluation of the situation, What was said and how did I respond, How did the patient respond when I did the teaching or the discharge instructions. How did the family reactCaution- Dont over analyze- youll start second quessing everythingThis can be useful when another similar experience is presented to the nurse. When reflecting, important to remain open to new information, knowledge, ways of doing things.

Language-The ability to use language and express yourself is a reflection of the ability to think meaningfully. Nurses must be able to use language effectively (clearly and precisely). When language is not well developed and the spoken word is not clear and distinct it is a sign of sloppy thinking. We must communicate (speak) clearly and distinctly with all of those around us, peers, nurses, patients and families. To critically think you must be able to organize and focus your own thoughts.

Intuition-To be to have an understanding of the particulars in a situation without conscious deliberation. It is an inner sensing about a situation. This ability to have intuition about clients come with time and experience. Book points out that intuition can be the spark that starts the flame of analytical thinking (the nurse seeks more info that will confirm what they have been feeling and concerned about for the patient. Can not use only intuition must use all types of knowledge, cognitive and emotional cues to assess clients and seek more info. Nurses also need to be aware of what they do not know, and seek help appropriately*Basic critical thinking- Here learner is still trusting that the experts have the answer to every problem and situationThinking is concrete and based on book, principles,rules, policies (whatever they can read or hear about). Lots of following the step by step (doing bed bath).At this point there is very limited ability to think critically, resources include instructors, books, other nurses. Caution- Dont let relying on resources limit ability to grow, use experiences, practice, and knowledge to grow to next level of thinking.

Complex Critical thinking-As people grow and become more independent thinkers the level of critical thinking will grow. Slowly will rely less and less on their resource people and think before asking them, come up with the answers themselves. As growth occurs there is a realization that there can be more than one alternative and perhaps solution.As nurses begin to think in more complex ways they look at a problem from many more angles and start weighing the risks vs benefits of each decision/ solution. They start developing the ability to be creative, to think out of the box.

Commitment-The nurse starts anticipating patient needs independently. At this level, the nurse makes a decision based on alternatives and then stands by the decision. The nurse assumes accountability/ responsibility for the decision and evaluates that decision.*Scientfic method= An approach to seeking truth or verifying facts. SM is a formal way to approach a problem plan a solution, test the solution, and come to a conclusion. Science fair. Nurse might identify a problem and seek answers with a formal approach (collecting data,formulating a hypothesis, testing the hypothesis, evaluating the results.

Problem solving- Use problem solving all the time- when problem is identified we seek information about the problem and the information plus knowledge that we already have to find solutions. Effective problem solving means evaluating the solutions and deciding if we need to try other solutions

Decision making-This happens when there are several options or courses of action that one might take to solve a problem or take care of a situation. Decision making is an end point of critical thinking. The pros/ cons or risks/benefits of each option is weighed to make a final decision. If time is taken to weigh each option appropriately then a well informed decision will be the result.*Diagnostic reasoning- It is a process of determining a clients health status after gathering data and making a clinical judgment. Part of the process involves making inferences given data such as s/s, lab data, behaviors (Inference is the process of drawing conclusions given related pieces of information or data)

Clinical decision making- requires careful reasoning so that the options for the best client outcomes are chosen on the basis of the clients condtion and the priority of the problem. Nurse identifies a problem by working with client and then still working with client determines priorities and nursing interventions that will best meet goals of client. The nurse may need to select from a wide range of options to meet goals. See Box 14-3 to see what sorts of things the nurse must do to care for groups of patients. Clinical decision making can be made for individual patients or groups of patients.**Knowledge- depth and extent of knowledge influence the nurses ability to think critically about nursing problemsExperience- Unless nurse has had the opportunity to practice and make decisions about client care, critical thinking skills will not develop. In practice the nurse learns from observing, practicing, talking with clients, families, peers, and reflecting they will stagnate and not grow in their ability to think. Book reminds us that the clinical experience is the laboratory for testing nursing knowledge.Critical thinking competencies- Look at all the general and specific competencies

****It is the ability to generate options or alternative solution ideas.It is the capacity to have new thoughts and to create expressions unlike any other. It is a basic element in many human endeavors, such as art, music, literature, and performance.

**Exicted

******Interest in a building that a tenant earns by contributing to its renovation or maintenance*****Wallas model1. Preparation:- we define the problem, need, or desire, and gather any information the solution or response needs to account for, and set up criteria for verifying the solution's acceptability.2. Incubation:- we step back from the problem and let our minds contemplate and work it through. Repetition of the same thoughts. No new ideas or interpretations. Reexamine the situation and review the data collected. Like preparation, incubation can last minutes, weeks, even years.

*Wallas model3. Illumination/Insight/ :- ideas arise from the mind to provide the basis of a creative response. These ideas can be pieces of the whole or the whole itself, i.e, seeing the entire concept or entity all at once. Unlike the other stages, illumination is often very brief, involving a tremendous rush of insights within a few minutes or hours.4. Verification :- the final stage, one carries out activities to demonstrate whether or not what emerged in illumination satisfies the need and the criteria defined in the preparation stage. Experimentation of solution (succeeded or failed).

**Combinational CreativityUnfamiliar combination of familiar ideas. -Eg. Journalist comparing a politician/terrorist with a deadly animal. -Requires rich store of knowledge. -Valued only if some link is found between them.Exploratory CreativityExploration within an established Conceptual spaceMore likely to arise from a thorough and persistent search of a well-understood space (criterion 3 of Newell and Simon)Transformational CreativityArises from a deliberate transformation of the conceptual spaceTransformational creativity should involve the rejection of some of the constraints that define this space (criterion 2)Some of the assumptions that define the problem itself (criterion 4).It is choosing the best alternative to reach the predetermined objective.

*Example ;Hana comes across a fork of road and found some body on the scen and asked which way shall I take?, a man replied where are you going? Hana replied I dont know finally the man replied it doesnt matter you can follow any one.

*1. Ends-MeansEnds: deals with the determination of desired individual or organizational results to be achieved.Means: decisions deal with strategic or operational programmes, activities that will accomplish desired results. These usually occur during managerial planning processes, strategy and objective formulation processes.

*2. Administrative-OperationalAdministrative: made by senior management, which have significant impact throughout the organization. Usually this type of decision is concerned with policy, resource allocation and utilization.Operational: are generally made by mid level and first line managers and address day to day operational activities of a particular organizational.

*1. Relying on tradition: taking the same decisions that had been undertaken when similar problem arouse in the past.2. May appeal to authority :- make decisions based on suggestions from an expert/a higher level management.3. Prior reasoning: based on assumption4. Logical decision making: is a rational, intelligent and systematic approach to decision making

*There are many tools. The most common are:Probability theory:- is the likelihood that an event or outcome will actually occur and allow decision makers to calculate an expected value for each alternative. Expected Value (EV) = Income it would produce (I) x its probability of making that income (P).Decision tree:- are graphic decision making tools used to evaluate decisions containing a series of steps

*6. Defensive avoidance: Faced with a problem and unable to find a good solution based on past experience, this manager seeks a way out. He/she may let someone else make decisions. This resigned posture may prevent consideration of more viable alternatives.7. Panic: the manager feels pressurized not only by the problem but also time.

*Do not put off decision making out of fear.

*Hindsight-retrospection

Sunk costs

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