Milestones of critical thinking: a developmental model for medicine and nursing.

Critical thinking is essential to a health professional's competence to assess, diagnose, and care for patients. Defined as the ability to apply higher-order cognitive skills (conceptualization, analysis, evaluation) and the disposition to be deliberate about thinking (being open-minded or intellectually honest) that lead to action that is logical and appropriate, critical thinking represents a "meta-competency" that transcends other knowledge, skills, abilities, and behaviors required in health care professions. Despite its importance, the developmental stages of critical thinking have not been delineated for nurses and physicians. As part of a task force of educators who considered different developmental stage theories, the authors have iteratively refined and proposed milestones in critical thinking. The attributes associated with unreflective, beginning, practicing, advanced, accomplished, and challenged critical thinkers are conceived as independent of an individual's level of training. Depending on circumstances and environmental factors, even the most experienced clinician may demonstrate attributes associated with a challenged thinker. The authors use the illustrative case of a patient with abdominal pain to demonstrate how critical thinking may manifest in learners at different stages of development, analyzing how the learner at each stage applies information obtained in the patient interaction to arrive at a differential diagnosis and plan for evaluation. The authors share important considerations and provide this work as a foundation for the development of effective approaches to teaching and promoting critical thinking and to establishing expectations for learners in this essential meta-competency.

An ethnography of pain assessment and the role of social context on two postoperative units.

AIM: This paper is a report of a study to examine nursing assessment of pain across two postoperative units. BACKGROUND: Postoperative pain management remains problematic. While the nursing unit, as the context, has been described as influencing pain assessment practice, the nature of this influence remains unexplored. METHOD: The study was conducted in the United States of America on two postoperative units of one teaching hospital in 2003-2004. Bourdieu's approach to ethnography was used. This applies traditional ethnographic techniques in sequential phases designed to illuminate: (1) relative positions of agents in a field of practice, (2) social capital in the field, and (3) the habitus of agents. Multiple data collection techniques appropriate to each phase were employed, including participant observation and individual interviews. FINDINGS: A predominant pattern of pain assessment existed on each unit. Nurses used assessment criteria from three spheres, i.e. the client's narrative, evident criteria and a reference typology of assessment findings. Nurses used a single sphere as a primary filter through which data were processed. This filter was distinctive for each unit, and consistent with the unique pattern of nursing pain assessment on each unit. CONCLUSION: Nurses' pain assessment practice is profoundly shaped by the social context of the unit on which practice occurs. Bourdieu's' theory of practice is a useful lens through which to examine the social context of pain assessment practice.