Learn — Thinking, intelligence, personality & their assessment

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Thinking, reasoning and problem solving

Thinking is the mental manipulation of images, concepts, words and symbols to reach a conclusion, solve a problem or make a decision without acting on the world first, and it is the cognitive process the nurse uses in every clinical judgement and the patient uses in deciding whether to follow advice. Its tools — concepts, reasoning, problem solving and creativity — and its errors — rigidity, set and the thinking disorders of illness — are asked in the applied psychology paper and met on the ward.

The building blocks are images (mental pictures), concepts (categories formed by abstracting the common feature — 'fever', 'infection'), symbols and language; concept formation runs from the concrete to the abstract as the child grows, which is why a child of five understands 'a small prick' and not 'a minor procedure'.
Kinds of thinking: perceptual or concrete thinking tied to what is seen; conceptual or abstract thinking with ideas; reflective thinking that weighs evidence to reach a solution; creative thinking that produces something new (divergent, many answers) as against convergent thinking towards the one right answer; and autistic or fantasy thinking that follows wishes rather than reality — normal in daydreams, abnormal when it replaces reality in psychosis.
Reasoning is thinking to a conclusion: inductive from particular cases to a general rule (three patients on the ward vomited after the same dish, so the dish is suspect) and deductive from a general rule to the case (all patients on opioids are at risk of constipation; this patient is on morphine; therefore prevent constipation) — the nursing process is both, in order.
Problem solving has recognisable steps — define the problem, gather information, generate alternatives, choose and act, evaluate — and uses trial and error, insight, algorithms (a fixed procedure that always works, like the drug-calculation formula) and heuristics (rules of thumb that usually work, like 'the sickest-looking patient first', which fail when the quiet patient is the sickest).
Obstacles to good thinking: mental set (using the method that worked last time), functional fixedness (seeing a thing only in its usual use), emotional bias, fatigue, and the confirmation bias of noticing only what fits the first impression — the reason a hand-over that names a diagnosis can stop the next nurse thinking.
Thinking is assessed at the bedside through speech: its stream (pressure, retardation, blocking), form (loosening of associations, flight of ideas, circumstantiality, perseveration) and content (delusions, obsessions, preoccupations, suicidal ideas); a fixed false belief held against evidence and out of keeping with the person's culture is a delusion.
Creativity is fostered by a safe, questioning environment, time, varied experience and the tolerance of wrong answers, and it is what quality improvement on a ward depends on; brainstorming separates the generation of ideas from their judgement for that reason.

Intelligence — IQ, classification and intelligence tests

Intelligence is the general capacity to understand, reason, learn from experience, adapt to new situations and solve problems, measured by standardised tests as a quotient that compares a person's mental performance with that of others of the same age. The intelligence quotient, its classification and the tests that give it are examined in every nursing paper, and the nurse uses them in the assessment of the child who is slow at school and in the classification of intellectual disability that decides education and support.

Definitions to quote: Binet — the ability to judge well, reason well and comprehend well; Terman — the ability to think abstractly; Wechsler — the aggregate capacity to act purposefully, think rationally and deal effectively with the environment; Spearman's two-factor theory (a general factor g and specific factors s) and Thurstone's primary mental abilities, with Gardner's multiple intelligences and Goleman's emotional intelligence as the modern additions.
Alfred Binet and Simon built the first intelligence scale in Paris in 1905 to find children needing special schooling and introduced mental age; William Stern proposed the quotient, and Terman's Stanford-Binet revision (1916) made it IQ = mental age divided by chronological age, multiplied by 100 — a ten-year-old who scores like a twelve-year-old has an IQ of 120.
Modern tests use the deviation IQ — a score placed on a normal curve with a mean of 100 and a standard deviation of 15 — so that about two-thirds of people fall between 85 and 115 and about 2 per cent below 70; the ratio formula is still asked, the deviation IQ is what the tests report.
Classification: above 130 very superior, 120 to 129 superior, 110 to 119 high average, 90 to 109 average, 80 to 89 low average, 70 to 79 borderline; intellectual disability begins below 70 with deficits in adaptive functioning before 18 years — mild 50 to 69 (educable), moderate 35 to 49 (trainable), severe 20 to 34, profound below 20 — and the level, not the number alone, decides schooling and care.
Tests by kind: individual (Stanford-Binet; the Wechsler scales — WAIS for adults, WISC for children, with verbal and performance parts) and group tests; verbal and non-verbal or performance tests (Raven's Progressive Matrices, Bhatia's battery, Seguin form board, Alexander's pass-along, Koh's blocks) for those who cannot read or whose language differs; and culture-fair tests that try to remove the advantage of schooling.
A good test is standardised on a defined population, reliable (gives the same result on repetition) and valid (measures intelligence and not schooling or mood); testing a sick, anxious, sedated or unschooled patient gives a false low, and a single test never labels a child.
Heredity and environment both act: identical twins reared apart still resemble each other, but nutrition, iodine, iron, stimulation, schooling and freedom from lead and infection change the score by many points — which is why nutrition programmes and early childhood education are intelligence interventions.

Personality — theories, traits and assessment

Personality is the characteristic and relatively stable pattern of thinking, feeling and behaving that distinguishes one person from another and persists across situations and time — from the Latin persona, the mask an actor wore. Its theories (psychoanalytic, trait, type, humanistic, social learning), its development and its assessment by interview, questionnaire and projective test are asked in the psychology paper, and the nurse uses them to understand why one patient fights the diagnosis and another gives up.

Freud's psychoanalytic theory divides the mind into the conscious, preconscious and unconscious, and the personality into the id (pleasure principle, present from birth), the ego (reality principle, the executive) and the superego (the conscience and ego-ideal, formed by about five years); development passes through the oral, anal, phallic (the Oedipus complex), latency and genital psychosexual stages, and fixation at a stage shapes the adult.
Type theories sort people into a few kinds: Hippocrates' four humours (sanguine, choleric, melancholic, phlegmatic), Kretschmer's body types (pyknic, athletic, asthenic), Sheldon's somatotypes (endomorph, mesomorph, ectomorph), Jung's introvert and extrovert, and Friedman and Rosenman's Type A (hurried, competitive, hostile — the coronary-prone personality) and Type B.
Trait theories describe personality by dimensions rather than boxes: Allport's cardinal, central and secondary traits; Cattell's sixteen personality factors; Eysenck's extraversion-introversion, neuroticism-stability and psychoticism; and the modern Big Five — openness, conscientiousness, extraversion, agreeableness and neuroticism (OCEAN).
Humanistic theories — Maslow's self-actualisation and Rogers' self-concept, with unconditional positive regard as the condition of growth — and Bandura's social learning theory, in which personality is learnt by observation, reinforcement and self-efficacy, are the theories behind patient-centred care and health-behaviour change.
Determinants: heredity (temperament, body build), the family and early experience (the first five years, attachment, parenting style), school, peers, culture and later life events; personality is stable but not fixed — brain injury, chronic illness, alcohol and dementia change it, and a change in personality is a symptom to report.
Assessment methods: the interview and observation; self-report inventories — the Minnesota Multiphasic Personality Inventory (MMPI), the Eysenck Personality Questionnaire, Cattell's 16PF; rating scales; and projective tests that present an ambiguous stimulus and read the unconscious in the response — the Rorschach inkblots, the Thematic Apperception Test (TAT, pictures to tell a story about), sentence completion, word association and the draw-a-person test.
In nursing the personality decides the reaction to illness — the dependent patient who regresses, the controlling patient who refuses, the anxious patient who over-reports — and the plan is fitted to it: information and choice for the controller, reassurance and structure for the anxious, gradual responsibility for the dependent.

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