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Porto Alegre, RS, Brazil. Correspondence addressed to. The aim of this study was to identify the critical thinking skills utilized in the nursing diagnosis process.

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This was an exploratory descriptive study conducted with seven nursing students on the application of a clinical case to identify critical thinking skills, as well as their justifications in the nursing diagnosis process. Content analysis was performed to evaluate descriptive data. Six participants reported that analysis, scientific and technical knowledge and logical reasoning skills are important in identifying priority nursing diagnoses; clinical experience was cited by five participants, knowledge about the patient and application of standards were mentioned by three participants; Furthermore, discernment and contextual perspective were skills noted by two participants.

Based on these results, the use of critical thinking skills related to the steps of the nursing diagnosis process was observed. Therefore, that the application of this process may constitute a strategy that enables the development of critical thinking skills. Descriptors: Thinking; Nursing process; Nursing diagnosis. The nursing diagnosis is defined as the formulation of a clinical judgment regarding the responses of the individual, family or community to actual or potential health problems and to life processes. It provides the basis for selecting interventions to achieve the results for which the nurse is responsible 1.

This diagnosis is designated by a name that is provided by the nurse to guide decisions regarding the phenomenon on which nursing interventions focused 2.

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According to different perspectives, the term diagnosis distinguishes the second phase of the nursing process and corresponds to an analysis of collected data in relation to a client's health; Specifically, a diagnosis refers to a clinical judgment in which the status of the patient is described, to a taxonomy-based diagnostic statement, used to identify a nursing diagnosis that explains the client's health status. Thus, diagnosis represents the result of a diagnostic process, which is defined as a method used to determine the health problem of the client, including an evaluation of the etiologic factors that underlie the problem.

It involves analytical, logical reasoning and non-analytical, intuitive reasoning 3. The nursing diagnosis process, as a form of clinical judgment, involves the recognition of evidence reported by the patient and identified from information relating to a health problem or a life process. After obtaining and verifying the relevant data set, evidence must be interpreted and categorized to produce the diagnostic hypotheses, with to the aim of making decisions regarding the nursing diagnosis that will ultimately shape the nursing interventions This process consists of the collecting and interpretation of data, including the categorization and naming of categor ies.

The collection of information consists of a patient evaluation, which corresponds to the first step of the nursing process, and the interpretation of information based on data analysis. This analytical process consists of the following steps: data collection, wherein the confirmed data are compared with memorized standards and known criteria to devise inferences; the establishment of inferences, the categorization of the data by combining relevant interrelated data into classifications, the establishment of diagnostic hypotheses; and finally, the formal classification, which is based on a nominal category assigned to the result of the clinical judgment process using a taxonomy or classification system 3.

According to an alternate perspective, the nursing diagnosis process involves two phases. The first phase consists of an analysis and synthesis of data to appraise the responses of the individual, family and community to health problems or life processes.

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The analysis phase requires data are separated into constituent parts define their interrelationships, and this phase is characterized by the categorization of data, identification of gaps, and the identification of convergent data. The synthesis of data groups information into patterns that are compared to standards, theories and models, thereby informing the diagnostic hypotheses with their respective causal relationships; the second phase consists of the formulation of the nursing diagnosis.

The naming of a diagnosis, at minimum, requires a title and an indication of the factors that contribute to its occurrence 6. In summary, the diagnosis process is operationalized as the investigation, collection, validation and organization of data, followed by the identification of standards, data registration and interpretation of the data, with the aim of identifying a precise diagnosis 7.

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Furthermore, the diagnosis process is characterized by obtaining and processing data, followed by their interpretation and association. Interpretation of these data requires a knowledge of relevant theories and logical reasoning, which leads to the integration of data with existing theories and ultimately, culminates in the identification of a diagnosis 8. Thus, the decisions that drive the nursing diagnosis involve cognitive and interpersonal skills, as well as professional attitudes 9.

Critical thinking is an essential skill required in the nursing diagnosis process and is defined as an intentional judgment which that results in the interpretation, analysis, evaluation and inference of data, as well as an explanation for evidence upon which the judgment is based Critical thinking also frequires the ability to question knowledge and to respond to questions and these traits, which can be learned and developed, rely on the ability to analyze, synthesize and evaluate information In nursing, critical thinking is considered an essential component of one's professional responsibility and the quality of nursing care.

Critical thinkers have these mental traits: confidence, contextual perspective, creativity, flexibility, curiosity, intellectual integrity, intuition, comprehension, perseverance and reflection. They practice the cognitive skills of analysis, application of standards, discernment, searching for information, logical reasoning, prediction and transformation of knowledge In nursing education, and particularly in relation to the nursing diagnosis process, difficulties may be encountered in the development of critical thinking skills.

Undergraduate nursing course instruct pertains to thenursing diagnosis process is fragmented between disciplines covered in the curriculum, thereby making it difficult to consolidate the theoretical foundations of this process, as well asits formal or informal application in clinical practice. Furthermore, one study 14 highlights that, in the context of teaching the nursing process, there is a dissociation between what is taught in the theoretical lessons and what is routinely observed in of practical training.

This conflict further contributes to a fragmentation between the knowledge and the practice; ultimately, this conflict indicates a detachment from critical appraisal, reflection and articulation of the information provided by the different disciplines that make up the undergraduate nursing course curriculum. As a result of these gaps in the teaching of the nursing diagnosis process, students present with difficulties in exercising critical thinking, and therefore they tend to rely on the use of taxonomies. This focus, disregard the context of the clinical practice and especially the needs of the patient, which are often not expressed by selected given nursing diagnosis.

The interpretation and grouping of data required, by the nursing diagnosis process represents a teaching challenge due to the need for data evaluation the coherent relationships linking data, and the gathering of evidence used to identify the nursing diagnosis. Thus, it becomes essential to better understand critical thinking in the nursing context to ascertain the primary cognitive difficulties encountered by students during the application of the nursing diagnosis process. The current study was guided by the following question: What critical thinking skills are used by nursing students in the application of the nursing diagnosis process?

Therefore, this study was conceived to identify critical thinking skills involved in the nursing diagnosis process. This was an exploratory study utilizing a qualitative approach. A validated case study 15 was presented to the nursing students to identify a priority nursing diagnosis, based on the taxonomy of Nanda-I 1 , and to identify the critical thinking skills used, and the justifications for their use in the nursing diagnosis process.

The case study design was justified as it is emphasized by the nursing literature as an important tool for identifying relevant clinical data and, consequently, for guidance in teaching the nursing diagnosis process. The formulation of diagnoses in actual clinical cases is extremely complex because it is not feasible to fully portray these situations in clinical simulations, thereby limiting their description. However, it is considered an appropriate compromise to limit the complexity of simulations to the intellectual domain, by using case studies, particularly if the focus is the identification of a diagnosis or to improve diagnostic reasoning 9.

Seven nursing students were selected, by invitation, in accordance with the following inclusion criteria: current status as a nursing student agreement to participate in the study by signing the Terms of Free Prior Informed Consent TFPIC , attendance in the 9th semester of the UFPB undergraduate nursing course, these students were approaching the conclusion of the course and had practically applied the nursing diagnosis during different internships; and performance of theoretical and practical educational activities, in units at the Lauro Wanderley University Hospital HULW incorporatingnursing diagnoses.

Data collection derived from the case study was executed with the participants. A clinical case was presented, and the identification of the relevant objective and subjective data was requested following an interpretation of the data, data grouping was suggested to establish different nursing diagnoses. Finally, the identification of a priority nursing diagnosis was articulated. Based on the resolution of the clinical case, the study participants exercised critical thinking based on self-reflection.

To facilitate this exercise, the following question was developed by the researcher: What critical thinking skills did you use to follow the steps of the nursing diagnosis process and why did you use them? Participants were asked to endorse items related to critical thinking skills that, in their perception, were used in the nursing diagnosis process. Immunotherapy and next-generation sequencing guided therapy for precision oncology: what have we learnt and what does the future hold? Yohe S, Thyagarajan B.

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