2. When was the patient’s last bowel movement?
3. Who is the patient’s emergency contact person?
4. Describe the patient’s current level of pain.
5. What information is in the patient’s medical record?
Critical thinking in nursing is the foundation that underpins safe, effective, and patient-centered care.
Critical thinking skills empower nurses to navigate the complexities of their profession while consistently providing high-quality care to diverse patient populations.
Potter, P.A., Perry, A.G., Stockert, P. and Hall, A. (2013) Fundamentals of Nursing
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Critical thinking is an integral part of nursing, especially in terms of professionalization and independent clinical decision-making. It is necessary to think critically to provide adequate, creative, and effective nursing care when making the right decisions for practices and care in the clinical setting and solving various ethical issues encountered. Nurses should develop their critical thinking skills so that they can analyze the problems of the current century, keep up with new developments and changes, cope with nursing problems they encounter, identify more complex patient care needs, provide more systematic care, give the most appropriate patient care in line with the education they have received, and make clinical decisions. The present chapter briefly examines critical thinking, how it relates to nursing, and which skills nurses need to develop as critical thinkers.
Critical thinking in nursing.
This painting shows a nurse and how she is thinking critically. On the right side are the stages of critical thinking and on the left side, there are challenges that a nurse might face. The entire background is also painted in several colors to represent a kind of intellectual puzzle. It is made using colored pencils and markers.
(Adapted with permission from the Association of Science and Art (ASA), Universal Scientific Education and Research Network (USERN); Painting by Mahshad Naserpour).
Unless the individuals of a nation thinkers, the masses can be drawn in any direction. Mustafa Kemal Atatürk
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Şefika Dilek Güven
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Güven, Ş.D. (2023). Critical Thinking in Nursing. In: Rezaei, N. (eds) Brain, Decision Making and Mental Health. Integrated Science, vol 12. Springer, Cham. https://doi.org/10.1007/978-3-031-15959-6_10
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Working in health care requires quick thinking and confident decision-making to care for patients. While nurses use a broad range of technical skills to provide quality care, an essential skill that’s easy to overlook is critical thinking. Nursing professionals should explore the benefits of critical thinking skills in nursing, how to apply them, and the ways that advanced education can sharpen their ability to make precise decisions.
Critical thinking is the process of evaluating facts, interpreting information, and analyzing situations to make informed decisions in various situations. Finding the correct answer to a complex problem isn’t easy. When situations don’t have clear answers and many factors to consider, critical thinking can help individuals move forward and make decisions.
Critical thinking competencies can be applied to a wide range of workplaces and personal situations. In nursing, critical thinking skills can help deliver effective care, handle a patient crisis, and assess the efficacy of treatment plans.
The fast-paced nursing environment requires prompt, data-driven decisions. Nurses use critical thinking daily, reviewing information and making decisions to promote quality care for patients. The following benefits of critical thinking highlight the importance of this skill in nursing careers:
Improves decision-making speed. A critical thinking mindset can help nurses make timely, effective decisions in difficult situations. A systematic method to evaluate decisions and move forward is a powerful tool for nurses.
Refines communication. Improving professional communication allows for factual, efficient, and empathetic conversations with patients and other health care professionals.
Promotes open-mindedness. It’s easy to overlook certain opinions or viewpoints in a high-pressure situation. Thankfully, critical thinking promotes open-mindedness in exploring solutions.
Combats bias. A critical look at different behaviors, contexts, and viewpoints can be helpful for identifying and addressing bias. Nurses must actively seek out ways to confront and remove bias in the workplace.
There are many ways to apply critical thinking skills to nursing situations. The nursing process is a five-step process to assist nurses in applying critical thinking skills to their daily duties. Experienced nurses and professionals considering a career change to nursing should review the steps as part of their critical thinking process.
Assessing a patient means far more than taking their vital signs. It also includes collecting sociocultural and psychological data. Lifestyle factors and experiences can affect the treatment process and approach, so skilled nurses review these areas before moving toward the next step, diagnosis.
For example, if a patient reports dizziness or shortness of breath, a nurse should not only check the patient’s temperature, blood pressure, and heart rate but also ask about their family history and recent events.
During the second step, a nurse’s assessment and critical thinking skills produce a clinical judgment. Nurses need to carefully consider all the factors included in the first step. When necessary, consult with other health care professionals before reaching a diagnosis or communicating that diagnosis with the patient.
Discussing a patient’s assessment with other health care professionals requires critical thinking, as the information provided about vital signs, recent events, and family history are key components of this step.
A nurse may be responsible for setting goals and planning a treatment plan for patients. The third step can include setting measurable, achievable goals. Nurses also coordinate care with other health care professionals.
Goals can be simple or complex, depending on the assessment and diagnosis. For example, one patient’s goals may include eating three meals a day, while another’s may include having multiple medications, specialist visits, and physical therapy activities as part of their treatment plan.
Critical thinking is needed to implement the nursing process, finding ways to carry out the plan with empathy. It’s also important for nurses to document care throughout the fourth step of the process.
For example, nurses should review patient history and consider symptoms before administering medication. Nursing professionals should also think critically about which patients to see first and how to prioritize patients who may need critical attention.
Nurses need to continue to evaluate and review the patient’s condition using critical thinking. Evaluation allows nursing professionals to review patient conditions, recommend care plan modification, and consider overall patient status.
For example, identifying whether patients may be ready for a care plan modification or another change in care requires critical thinking and a clear, focused evaluation of multiple patient factors.
Critical thinking is integral to success in the health care field. Thankfully, many ways are available for nurses to improve their critical thinking skills. Below are training, mentoring, and education options for fostering critical thinking.
Because critical thinking is so critical to the daily duties of nurses, experience in the field can improve their ability to evaluate situations and make data-driven decisions. Working firsthand with patients and alongside skilled professionals is a powerful way to see and apply critical thinking in real-world scenarios.
Nurses should seek mentorship opportunities for personalized, side-by-side instruction and inspiration from fellow professionals. Mentorships can be either formal or informal opportunities to learn from skilled nurses and health care professionals to promote critical thinking.
Many continuing education opportunities are available for nurses. Professionals looking to improve their critical thinking skills should consider enrolling in a course that promotes reflection, evaluation, and analytical thinking.
Expand your critical thinking skills in nursing by enrolling in a program to earn a degree in the field. The University of Tulsa offers an accelerated online RN to Bachelor of Science in Nursing (RN to BSN) program for students to earn their BSN in as little as 12 months. Take 30 credits of online courses to expand your medical knowledge, general education, and critical thinking abilities. Review the features of this online opportunity to see if it’s the right decision for your career.
Recommended Readings:
The Benefits of Nurse Mentoring
Hospice Nurse: Job Description and Salary
Work-From-Home Safety Checklist: Securing Your Virtual Workspace
American Nurses Association, The Nursing Process
American Nurses Association, What Are the Qualities of a Good Nurse?
Forbes , “The Power of Critical Thinking: Enhancing Decision-Making and Problem-Solving”
Indeed, “Critical Thinking in Nursing (Definition and Vital Tips)”
Indeed, “Critical Thinking Skills in Nursing: Definition and Improvement Tips”
Indeed, “15 Essential Nursing Skills to Include on Your Resume”
StatPearls, “Nursing Process”
University of Tulsa
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Sep 17, 2024
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Learning objectives.
By the end of this section, you will be able to:
Thinking is something we usually do subconsciously, because we are not usually “thinking about thinking.” However, with the ever-increasing autonomy being afforded to nurses, there is also an increased need for nurses to be able to critically think effectively and intentionally. Being able to critically think helps nurses’ problem solve, generate solutions, and make sound clinical judgments that affect the lives of their patients. Keep reading to learn more about how nurses use critical thinking in practice and how you can develop your own critical thinking skills.
Nurses make decisions while providing patient care by using critical thinking and clinical reasoning. In nursing, critical thinking is a broad term that includes reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” On the other hand, clinical reasoning is defined as a complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions. Each of these types of thinking is described in more detail in the following sections.
The term cognitive thinking refers to the mental processes and abilities a nurse uses to interpret, analyze, and evaluate information in their practice. Basically, it encompasses how nurses think about the practice decisions they are making. Cognitive thinking and critical thinking go hand in hand because nurses must be able to use their knowledge and mental processes to devise solutions and actions when caring for patients. Using critical thinking means that nurses take extra steps to maintain patient safety and do not just follow orders. It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research. Critical thinkers possess certain attitudes that foster rational thinking:
Cognitive thinking is significant to nursing because it provides a foundation on which nurses can make rapid and accurate decisions in clinical practice. Nurses must be able to think quickly and make informed decisions to promote optimal patient outcomes.
To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process. Effective thinking in nursing involves the integration of clinical knowledge and critical thinking to make the best decisions for patients. For example, if a nurse was caring for a patient who presents with hypertension and new-onset left-sided weakness, it is important that the nurse be able to quickly consider potential causes for the weakness and implement immediate stroke protocols. Without the ability to critically think, the nurse may overlook the weakness as being unrelated to the hypertension and not consider the possibility of stroke, leading to a poor patient outcome. Thus, it is imperative that nurses develop effective thinking skills.
The term inductive reasoning involves noticing cues, making generalizations, and creating hypotheses. Cues are data that fall outside of expected findings and give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A generalization is a judgment formed on the basis of a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes clearer. On the basis of generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. Remember, a hypothesis is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored. No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to act quickly, especially in emergency situations. They can see how certain objects or events form a pattern (or a generalization) that indicates a common problem.
Consider this example: A nurse assesses a patient who has undergone surgery and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.
Another type of critical thinking is deductive reasoning ; it is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.
Think about this example: On the basis of research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking, because the intervention is applied to all patients regardless of whether they have difficulty sleeping or not.
Rationalizing the purpose of thinking is probably not something you do often, but it is the foundational first step in critical thinking. To effectively use critical thinking in practice, the nurse must first identify the purpose of thinking. For example, the nurse is caring for a patient who presents with fever, tachycardia, and shortness of breath. The patient also has an open, infected wound on the left foot that is not healing. The nurse must recognize that the patient is exhibiting signs and symptoms that may be indicative of an underlying problem. At this point, the nurse must be able to identify that the purpose of thinking with regard to the patient is to consider what might be happening with the patient and formulate a plan of care. This begins the process of critical thinking, which involves several steps: thinking ahead, thinking in action, and reflection on thinking.
Thinking ahead in nursing involves considering what may be going on with the patient to anticipate potential outcomes and complications that may arise. Remember competent nurses are proactive versus reactive. Reactive nursing is letting situations arise and then responding to the change, but proactive nursing is recognizing cues behaviors and patterns that are leading up to a complicated event. Additionally, the nurse will formulate goals of care and must try to anticipate specific needs the patient will have. Considering the patient discussed in the preceding paragraph, the nurse should begin the process of thinking ahead about potential outcomes and complications. The nurse may hypothesize that the patient is starting to develop sepsis from the open wound on the foot so severe sepsis and/or septic shock could be a complication to begin preparing for. The nurse thinks ahead about goals of care for the patient and determines that wound care to prevent infection spread and sepsis is the priority goal at this time.
Thinking in action encompasses the thought processes occurring while the nurse is performing interventions. So, if the nurse in our example begins performing wound care, they are thinking about the best dressing to use, how to clean the wound, and if antibiotics should be considered. All of these thoughts are likely occurring as the nurse is providing the care; thus, they are examples of how the nurse is using thinking in action.
After performing interventions or making decisions, the nurse should reflect on the thinking that occurred. The nurse will use this thinking process to determine if the decision was reactive or responsive. Reactive decision-making involves responding to situations after they have occurred, often in a hurried or unplanned manner. These decisions tend to be impulsive and are driven by immediate needs or crises. Responsive decisions, on the other hand, involve careful deliberation about how to address a situation based on careful consideration of information. In our example, the nurse’s decision appears to have been responsive. The patient was exhibiting some altered vital signs, but nothing indicated that the situation had become emergent yet. The nurse was able to think carefully about the patient’s situation and determine that wound care was the highest priority and begin to implement care in a calm, deliberate manner. In an ideal world, all nursing decisions would be responsive, but in a lot of cases, they must be reactive because of situation severity and medical emergencies.
During the outset of the critical thinking process, nurses must judge whether their knowledge is accurate, complete, factual, timely, and relevant. This can be done by applying knowledge to nursing practice in a multitude of ways, including drawing from past education and experience in nursing and using professional resources and standards. Each of these is discussed in more detail in the following sections.
Becoming a nurse requires years of schooling, which contributes to the development of a robust knowledge base. Nurses receive formal education and training that provides them foundational knowledge in anatomy, physiology, pharmacology, and patient care techniques, among many others. Additionally, nurses are required to complete continuing education courses specific to their chosen practice setting, further developing their knowledge base. When applying knowledge in practice, nurses can draw from their knowledge base and make informed decisions about patient care.
Nursing is considered a practice. Nursing practice means we learn from our mistakes and our past experiences and apply this knowledge to our next patient or to the next population we serve. As nurses gain more experience, they can use what they have learned in practice and apply it to new patient situations. Each new encounter with a patient presents unique challenge and learning opportunities that contribute to the development of clinical expertise. Reflecting on these experiences allows nurses to recognize patterns, anticipate patient outcomes, and refine their decision-making processes. Whether they are identifying effective nursing interventions for common conditions, adapting care plans to individual patient needs, or navigating complex situations with compassion, nurses draw upon their accumulated knowledge base from clinical experience to provide high-quality, patient-centered care. Through reflection and continuous learning from past experiences, nurses enhance their clinical skills, ultimately improving patient outcomes.
In addition to foundational knowledge bases and experience, nurses can also use professional resources and standards to gain and apply knowledge in practice. Nurses can refer to clinical practice guidelines that have been established by professional organizations and healthcare institutions to help provide a framework for implementing nursing interventions based on the best evidence. By following the guidelines, nurses are ensuring that their care aligns with established standards and promotes optimal patient outcomes. Additionally, nurses should remain up to date about new and emerging research in their practice area, which can be obtained by reading professional journals and publications and attending conferences, workshops, and other trainings. Nurses can use the information learned from these resources to influence practice and ensure the highest standards of care are being performed in their practice setting. By staying informed about the latest developments in nursing and health care, nurses enhance their knowledge base and can adapt their practice to incorporate new evidence and innovations. Along with professional development and staying current with professional practices, nursing students should actively seek and join professional organizations such as critical care nursing or oncology nursing societies because this will lead the student to become expert in that subject and stay relevant with current evidence and practice guidelines.
Qsen competency: evidence-based practice.
Definition: Providing quality patient care based on up-to-date, theory-derived research and knowledge, rather than personal beliefs, advice, or traditional methods.
Knowledge: The nurse will describe how the strength and relevance of available evidence influences the choice of intervention in provision of patient-centered care.
Skill: The nurse will:
Attitude: The nurse will appreciate the importance of regularly reading relevant professional journals.
After determining the best course of action based on the application of knowledge, the nurse can critique the decisions that were made. Specifically, the nurse will use self-reflection to review their actions and thoughts that led them to the decision. The nurse will consider the outcomes of their chosen interventions, reflect on the effectiveness of their approach, and identify areas of improvement. Additionally, the nurse may seek feedback from colleagues to obtain different perspectives about decisions made. Soliciting input from others helps the nurse gain insight and learn from their peers to further inform their future practice. Reflection questions that the nurse may ask themselves to critique their decision include the following:
Certain behaviors that demonstrate the knowledge, skills, and attitudes that promote critical thinking are called critical thinking indicators (CTIs) . Critical thinking indicators are tangible actions that are performed to assess and improve your thinking skills.
There are many models and frameworks within nursing and other disciplines that attempt to explain the process of critical thinking. One of the most popular is Alfaro-LeFevre’s 4-Circle CT Model (Alfaro-LeFevre, 2016). This model breaks critical thinking into four components: personal characteristics, intellectual and cognitive abilities, interpersonal abilities and self-management, and technical skills. These four components overlap, forming interconnections in critical thinking.
Learn more here about the 4-Circle CT Model and see an illustration of it.
Personal CTIs are behaviors that are indicative of critical thinkers. Some of these behaviors that are most relevant to nursing include:
Personal knowledge and intellectual skills encompass the knowledge gained from nursing school and clinical experiences. Examples of each of these kinds of skills are listed in Table 28.3 .
Personal Knowledge | Intellectual Skills |
---|---|
Interpersonal and self-management skills encompass the knowledge and skills needed for effective collaboration. These include:
Technical skills in nursing refer to the practical abilities and competencies that nurses use in the delivery of patient care. These skills are typically learned through education, training, and hands-on experience. Some common technical skills in nursing include:
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Johanson, Linda EdD, MS, RN
Linda S. Johanson is an associate professor of nursing at Appalachian State University in Boone, N.C.
The author has disclosed no financial relationships related to this article.
After a brief interaction with a nursing student, this nurse educator saw the wisdom of using critical thinking when teaching critical thinking.
IN NURSING SCHOOL, I learned about two types of thinking: There is the regular kind, and then there is critical thinking. Although it sounds like it means thinking about important things, critical thinking really means using reflective, systematic thought processes while weighing alternatives and finding a creative solution. For example, if a patient requests something for pain, the nurse will assess the pain, consider options for resolution, and individualize the intervention. This will often lead to a creative solution. When I became a nursing instructor, encouraging critical thinking at any plausible juncture for my students became one of my priorities.
Critical thinking comes easily to some students, but it can be a challenge for others. This is where a student I'll call Tiffany comes in. Her story, from one of my first years as a senior-level clinical instructor in the ICU, taught me an important lesson about educating aspiring nurses on critical thinking skills.
It was a Friday, my only office day for the week. The phone rang, and the coordinator for the first-level students was in a panic. Their instructor had called in sick, and a group of brand-new nursing students was assembled on the gerontology unit awaiting direction. My office was in a building adjacent to the hospital, and I was asked to run over there, quickly give assignments, and get the students started. I was unfamiliar with this level of student, but the coordinator assured me that I could handle it. The students would just be changing bed linens and providing bed baths.
I grabbed my lab coat and headed over to the unit. I quickly took inventory of the patient census and assigned each student to a patient. They set off with their arms full of linens and ambition.
Feeling satisfied that I had intervened effectively, I stationed myself at the central desk where I could be found if anyone needed me. About 15 minutes later, Tiffany hurried toward the nursing station with a panicked look on her face.
“I need help with my patient,” she said. “It's an emergency!” I quickly walked her back toward her assigned patient's room. As we walked, I encouraged her to explain the emergency. Thoughts of a cardiac arrest, patient fall, seizure, or violent behavior emerged from my critical care mindset. However, Tiffany relayed none of those potential emergencies in her explanation. Instead she informed me, “My patient said he needs to use the urinal!”
I stopped and looked at her incredulously. “That is the emergency?”
When her eyes began to fill with tears, compassion overwhelmed me. Of course that would be an emergency to this brand-new student. She had been told to give a bath and make the bed. Something outside of that assignment had come up.
I told her that she could let the patient use the urinal if he needed it before his bath. Confident that she could now conduct the new task on her assignment list, I gave her a word of encouragement and went back to the nursing station. All was quiet for about 10 minutes until Tiffany returned in another state of panic. Her patient was now too weak to hold on to the urinal. This time, I was a bit calmer in response.
After explaining to the student what it meant to be a critical thinker and the value and characteristics thereof, I asked her to try to reason out an answer to her problem. She suggested she could hold the urinal for him.
“Yes! Outstanding!” I exclaimed. “That is how you use critical thinking!” After encouraging her to just be professional about it and act confidently, off she went to apply her new solution.
This experience helped me to see the need to use critical thinking when teaching critical thinking. After all, one of the hallmark characteristics of critical thinking is to avoid making assumptions. As an instructor, I now develop assignments that require students to be creative, encourage problem-solving skills with individualized case studies and simulations, and challenge students with Socratic questioning and open-ended examinations instead of using a strict multiple-choice format. By taking this approach, instructors can begin to build those critical thinking skills that are so essential to professional practice.
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Every nursing shift brings new patients, challenges, and choices. In a fast-paced environment where there’s no room for mistakes, nurses must be able to think critically and make the right decisions before moving on from one situation to another. “Critical thinking” is often touted as one of the most important skills a nurse can possess, but what exactly is critical thinking? Why is critical thinking important in nursing? Moreover, is it an innate skill, or can it be learned?
Critical thinking is the process of “actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action.” It’s based on accuracy, sound evidence, fairness, and other universally accepted intellectual values. Put simply, it’s the ability to be objective. Rather than allow emotions or opinions to guide their beliefs and actions, critical thinkers are driven by facts.
According to Edward M. Glaser , critical thinking contains three components:
As a nurse, your overall goal is to improve patient outcomes. Critical thinking is important in nursing because if all healthcare providers can think critically and utilize evidence-based decision-making, there’s a better chance of improving patient outcomes. In fact, the Bureau of Labor Statistics (BLS) lists critical thinking as one of the most important qualities a nurse can have, alongside qualities like communication and organizational skills and emotional stability.
The fight-or-flight response is a physiological reaction that occurs when there is a perceived threat to survival. When our brain registers this threat, our bodies are flooded with stress hormones, such as adrenaline and norepinephrine. Heart rates increase, pupils dilate, and muscles tense up. The fight-or-flight response may have helped our distant ancestors take down mammoths, but it’s far less helpful when rushing to make an important decision regarding a patient’s care plan. Worse still is when a patient is in a life-or-death situation and their survival depends on poise under pressure.
If your goal is to work in a hospital, especially in an intensive care unit (ICU), you must be able to think critically in all manner of situations. By cultivating your critical thinking skills, you can respond appropriately even when your heart is pounding and your thoughts are racing.
In order to think critically, it’s not enough to be able to recite medical information verbatim. Critical thinkers are always logical and unbiased in their assessments, challenging the accuracy of information and beliefs when they have cause to doubt them. Although some are naturally inquisitive, all nurses can develop their innate curiosity, medical knowledge, and ability to think on their feet.
Looking at the three components of critical thinking, your first step in developing your skill set is to develop a wise, problem-solving attitude. Nurses are no longer the untrained caregivers of the past. Today, nurses play a vital role in patient-centered care, often assisting doctors by contributing to care plans, analyzing diagnostic tests, administering medicine, and monitoring vital signs. As the duties of a nurse continue to evolve and expand, nurses can excel by remaining open-minded and becoming lifelong learners.
The second component of critical thinking is the knowledge of methods of logical investigation. Essentially, your goal is to develop a repository of medical knowledge to draw upon when making decisions. Medical knowledge can be obtained from years of experience, guidance from colleagues, and academic programs like those offered by The University of Texas Permian Basin. As a registered nurse (RN), it’s likely that your academic and working experiences already shape your decision-making. If that’s the case, you’re already employing one of the tenets of critical thinking.
The ability to not only understand medical knowledge but effectively apply it to your decision-making may be the most difficult component of critical thinking to adopt. Fortunately, you’re not alone. In addition to staying up-to-date on best practices, you can draw upon the experience of doctors, educators, and fellow nurses. No one knows more about critical thinking than the professionals who’ve spent years in your role. Over time, you’
ll be able to calmly and effectively apply your skills to help patients regardless of the medical, cultural, or linguistic challenges facing you.
Critical thinking is absolutely a skill set that can be developed with the help of an online RN to BSN program . At UT Permian Basin, we can empower you with the critical thinking skills needed to excel in your current position and the leadership skills needed to advance your career.
With the exception of leadership clinical experiences, our program is asynchronous and 100% online, and there’s no travel required. Remain in your current nursing role while continuing your education on your own time and at your own pace. In as little as eight months, you can complete our online RN to BSN program. During those eight months, you’ll gain first-rate instruction accredited by the Commission on Collegiate Nursing Education (CCNE).
UT Permian Basin’s online RN to BSN program offers the education and experiences needed to prosper in a leadership role. The critical thinking, management, and transcultural nursing skills taught in our virtual classrooms will prove indispensable in your nursing career. By enrolling in our online RN to BSN program, you’ll not only be more capable of stepping into a leadership role but also better able to assist the patients under your care.
Learn more about UT Permian Basin’s online RN to BSN program .
https://www.researchgate.net/publication/336058016_Critical_Thinking_Skills
https://science.howstuffworks.com/life/inside-the-mind/emotions/fear2.htm
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What is critical thinking in nursing? It’s the ability to observe, process, and analyze information to draw an evidence-supported conclusion. Critical thinking in nursing involves observation, critical analysis, inference, communication, problem-solving, decision-making, and prioritization. This process enables nurses to support favorable patient outcomes.
Like many professions, nursing is often challenging and fast-paced, demanding a blend of hard and soft skills. Not only must nurses assess patients and perform clinical skills like placing nasogastric tubes, but they also need soft skills such as communication, bedside manners, and teamwork. Critical thinking in nursing is another essential soft skill.
Critical thinking skills in nursing refer to a nurse’s ability to question, analyze, interpret, and apply various pieces of information based on facts and evidence rather than subjective information or emotions. Critical thinking leads to decisions that are both objective and impartial. This aspect of clinical practice allows nurses to assess the patient holistically and offer creative solutions.
Critical thinking is not to be confused with clinical reasoning or judgment. Clinical reasoning is the process required to reach the final conclusion, called a clinical judgment. It requires an accumulation of information and experience to weigh different types of knowledge, evidence, and past diagnoses to contribute to your clinical judgment. As such, reflection is a critical component of clinical judgments because it helps nurses understand how an outcome was achieved and how to ensure a positive outcome for similar cases in the future.
To make a further distinction, critical thinking is the cognitive process and clinical reasoning or judgment is the application, backed up with prior knowledge and experience. One is objective while the other is inherently social.
Each piece plays a part in the puzzle, but nurses can only see the whole picture when they are used together.
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Every patient you’ll encounter as a registered nurse (RN) will differ slightly. Some patients may be excellent about communicating their symptoms and other issues clearly, while others will be more reticent. Some patients have a higher pain tolerance than others. Some may present with co-morbidities that can make patient assessments, diagnoses, and treatments more challenging.
As a nurse, it’s your job to determine exactly what’s going on with each patient and how best to support that patient’s progress toward a favorable outcome. Why is critical thinking important in nursing? Critical thinking skills allow you to evaluate each situation to understand it more thoroughly. This, in turn, will enable you to develop evidence-based clinical judgments that are appropriate for the patient’s unique situation.
Now that you know the general answer to the question, “What is critical thinking in nursing?” you may wonder what critical thinking looks like in action. Nurses rely on their critical thinking skills throughout their shifts, so there are many examples of critical thinking in nursing.
A few examples of how critical thinking assists with nursing decision-making include:
Critical thinking is often considered just one skill, yet it comprises various discrete skills. To exercise critical thinking skills in nursing, you must master each discrete skill, including those below.
Develop your personal philosophy of nursing with these tips.
Observation skills are the foundation of critical thinking in any industry and profession, especially nursing. Nurses need to be observant to identify problems quickly. In some cases, observation skills allow nurses to predict if and when a situation will occur.
Observation is also crucial for nurses because not all patients openly discuss their symptoms. For instance, a patient might assume that pain in the leg could never be related to cardiovascular trouble, so they might not mention it. It’s the nurse’s responsibility to observe whether a patient seems to be experiencing pain, such as if they repeatedly rub their leg.
If observation skills allow nurses to collect and process information, critical analysis enables nurses to use the information to draw evidence-supported conclusions. Nurses employ critical analysis to evaluate the situation. Part of this involves identifying which bits of information are important and relevant and then assessing that information objectively.
Critical thinking skills in nursing include making an inference (an educated guess). After collecting, processing, and analyzing information, nurses can develop inferences based on available information. It is important to recognize when something is an inference versus a conclusion. The latter can be developed when nurses have the information to form an evidence-supported conclusion.
Nurses rely on communication skills to obtain more information to form a conclusion. They may need to question the patient more closely about an issue, confer with their colleagues, or double-check the patient’s records. In some cases, diagnostic testing may be warranted. These methods allow nurses to develop a firm conclusion and identify possible solutions.
Problem-solving is part of critical thinking. In any given patient care scenario, several possible clinical responses may exist. The nurse’s job is to identify which response is the most clinically appropriate based on the patient’s unique situation (not only their symptoms but also their co-morbidities, medications, and so on).
Decision-making is the culmination of critical thinking in nursing, and this is the point where clinical judgment comes into play. Once a nurse has all the available information, thoroughly analyzes the data, confers with colleagues as needed, and identifies clinical responses, they must decide which action to take. At this point, nurses must factor in ethical, diagnostic, and therapeutic dimensions and research-based knowledge afforded to them through experience.
Sometimes, the decision is temporary, pending physician-authorized treatment plan changes. For instance, if a nurse is supposed to administer a medication to a patient but notices their kidney values are not looking robust enough, the nurse may hold off administering the medication if one of the possible side effects is renal failure. The nurse may instead wait for the physician to determine if a change in medication is necessary.
Prioritization is another component of critical thinking in nursing, and it is the result of processing information and drawing a conclusion. For instance, after analyzing available data, a nurse should be able to prioritize which patients to tend to first based on how urgent their clinical situations are.
The Joint Commission states implicit biases are “attitudes or stereotypes that affect our understanding, actions and decisions in an unconscious manner.” These biases can negatively impact patient care, so it’s essential to recognize that everyone has them. These implicit biases may concern age, gender, race, sexual orientation, gender identity, religion, weight, drug usage, homelessness, and other personal characteristics.
Implicit biases can manifest in language or actions that make patients feel uncomfortable and may discourage them from seeking the care they need. In some cases, implicit biases can also affect a patient’s treatment plan, potentially leading to life-threatening consequences.
For instance, let’s say a 25-year-old patient, Jane, is taken to the ER with shortness of breath, profuse sweating, and low blood pressure. Because Jane is young and female, the nurse may assume a heart attack isn’t the cause and that her symptoms are instead indicative of a drug overdose. Instead of ordering an EKG, the nurse orders a drug test without even considering the possibility of cardiovascular trouble. This implicit bias in action could prove disastrous for Jane.
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Nursing students develop critical thinking skills in nursing school, particularly during simulation labs and clinical rotations. However, these skills aren’t learned overnight. Refinement can take years of experience on the job.
You can nurture your critical thinking skills with the following steps:
A solid academic foundation is essential for developing critical thinking skills in nursing. If you’re eager to begin a career in nursing and you have a prior non-nursing college education, you may be eligible to apply to the Accelerated Bachelor of Science in Nursing (ABSN) program at Xavier University in Ohio.
Our ABSN program offers three locations, three start dates each year, and the opportunity to graduate with your BSN in as few as 16 months (after completing prerequisite courses, if necessary). Develop the required academic foundation and polish your critical thinking skills while you work through our comprehensive curriculum .
Begin a meaningful career in nursing that offers versatility and advancement possibilities, along with the chance to help others. Contact our admission counselors today to learn more about our accelerated nursing program.
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9 Critical Thinking, Clinical Judgment, and the Nursing Process Brenda Morris, EdD, RN, CNE OBJECTIVES At the completion of this chapter, the reader will be able to: • Define critical thinking. • Describe the components and characteristics of critical thinking. • Understand the relationship of critical thinking to clinical judgment and the nursing process. • Describe the steps of the nursing process and the relationships among those steps. • Discuss nursing activities associated with each step of the nursing process. • Evaluate the utility of the nursing process as a systematic framework for the delivery of nursing care. • Apply critical thinking in nursing practice situations. The author acknowledges the important foundational work for this chapter developed by Dr. C. Fay Raines in the previous edition of this book. PROFILE IN PRACTICE Elizabeth R. Lenz PhD, RN, FAAN Dean and Professor, College of Nursing, The Ohio State University, Columbus, Ohio Critical thinking: it’s recognizable when someone does it well and certainly evident when it is not happening. During the past 20 years we have talked increasingly about critical thinking in nursing, but that wasn’t always the case. In the early 1960s, when I was entering the profession, serious efforts to change the “handmaiden” image of nursing were only just beginning. Clearly, if one’s role is defined as handmaiden, rather than as colleague or independent decision maker, critical thinking is not deemed particularly important or even desirable. Rather, blind, noncritical obedience is the order of the day. Fortunately, as nursing has become more truly professional and nurses have functioned with increasing autonomy in increasingly complex situations, critical thinking has become a most important and valued competency. What elements converge to produce a good critical thinker? It seems to me that there are several requisites, not the least of which is intelligence. However, even though intelligence is a necessary condition, critical thinking is not guaranteed to occur without training and a nourishing environment as well. We assume that critical thinking is something that can be learned; hence we address it at all levels of nursing curricula. Based on my experience, I believe that two essential types of learning provide the basis for critical thinking. The first is substantive. It is impossible to think truly critically about something you do not understand or about which you possess only partial information. Mastery of the theory and research findings that relate to the problem or issue to be addressed is critical, but this is not something that nurses always take time to achieve. Unfortunately, we have been less successful than other professions (namely, medicine) in socializing our practitioners to value learning as a career-long pursuit; yet pursuit of the most state-of-the-science information is an essential ingredient of critical thinking. The second type of learning involves the process of critical thinking itself. The skills of raising questions, using logic, and comprehensively considering alternative perspectives, explanations, and courses of action can often best be learned experientially within a structure that encourages and, in fact, mandates that kind of thoughtful consideration. The model that comes to mind is the daily medical rounds in which physicians-in-training are challenged to present cases and to lay out their diagnostic reasoning clearly for others to critique. Equally valid as an environment for cultivating critical thinking is that found in many of the social sciences and humanities, where freewheeling debate and open challenge of ideas are encouraged. At first frightened by that kind of candor during my doctoral studies in sociology, I later came to value greatly the critical input of my peers. More of that kind of willingness to challenge one another’s assumptions and ideas within an atmosphere of mutual respect would benefit our profession. For me, the groundwork for critical thinking was laid early in my education. Fortunately, the faculty responsible for the BSN program I attended were forward-thinking and highly committed to the emerging definition of nursing as a true profession, with the requisite obligation to base action on scientific knowledge and clear and logical thinking. Without labeling the goal as such, we were consistently encouraged, groomed, and enabled to be critical thinkers. We were continually challenged by being asked to provide rationales for our decisions, to make explicit all of the alternative approaches and explanations we had considered and rejected, and to explain why. Not inconsequentially, the school was in a small liberal arts institution, where we were exposed on a daily basis to a wide range of points of view and disciplinary perspectives and assumptions. If anything, the nursing students were the “oddballs” whose pragmatism and goal-directedness seemed strange to the arts, sciences, and music majors. I wrestled more than once with how in the world assignments such as dissecting the symbolism in Moby Dick might be relevant to my career in nursing, but I now appreciate the mind-expanding contribution that such activities made to my ability to think critically. The base hopefully having been laid during one’s professional education, critical thinking depends not only on training but also on an environment or context that enables, encourages, and rewards it. Regretfully, today’s employment picture in nursing is typically one with precious little time for contemplation. Downsizing, high proportions of nonprofessional personnel, high levels of acuity, and high productivity requirements may discourage critical thinking. That means every effort must be made to counter the tendency to let critical thinking slide and, instead, to encourage, nurture, and reward it, even if that means bucking the tide and incurring some additional short-term costs. The “community of scholars” type of environment to which top educational institutions aspire should, by definition, be conducive to critical thinking. Nevertheless, even in those settings, time and energy to engage in deliberation, to exchange ideas, and to critique those ideas openly are scarce, and the kind of culture that encourages such scholarly dialogue is relatively rare. When it is in place, it is wonderful. One of my most exciting opportunities to engage in intense and prolonged critical thinking occurred when a group of four colleagues and I were “freed up” from many of our routine responsibilities to plan a doctoral program “from scratch.” In weekly full-day sessions we argued, debated, challenged, cajoled, compromised, and created. We drew on what we knew substantively about nursing, science, philosophy, and the disciplines of our respective doctoral degrees (none of which were in nursing). It was hard work, but invigorating. The ground rules were that no idea was to be belittled or rejected out of hand; all perspectives were heard and considered. We were given time to think with minimal interruption and maximal flexibility; accordingly, the end product was excellent and the process truly energizing. Such time away from the routine is rarely available in today’s environment, but the model is certainly not without merit. Essential are a culture and leadership that permit and encourage critique without recrimination. In clinical settings, time to engage in deliberative critical thinking is even more difficult to attain. Rather, critical thinking seems to be expected to occur routinely without much cultivation. Benner’s model of progression from novice to expert suggests that excellent clinical experience fosters critical thinking that eventually becomes almost automatic and intuitive. However, I assert that the level of critical thinking displayed by clinical experts needs to be developed deliberately and strategically. The clinical environment in which I have seen critical thinking encouraged most effectively was one in which the expectations were explicit, critical thinking was measured routinely in the practice context, relevant learning and growth opportunities were provided, and critical thinking was taken into account in performance evaluation. In other words, the nursing leadership in that academic medical center truly valued critical thinking and was willing to assign it priority. Nursing has reached the point in its evolution in which a consistent and continuous pattern of critical thinking by its practitioners is a mandate—a sine qua non . The assurance that critical thinking will be truly woven into the fabric of our profession will depend on our ability to recruit and retain intelligent, interested, and committed nurses; to provide challenging educational opportunities that develop the requisite competencies; and to provide and sustain the kinds of environments in which critical thinking is valued and demanded. Introduction The ability to process information from multiple sources and make decisions is a fundamental ability of professional nursing practice. Dramatic changes in the health care system and the practice of nursing have occurred during the past decade as a result of an aging population, cost containment efforts, technological advances, increased complexity of clients’ health care needs, decreased average hospital length of stay, and a shift from acute care to community-based care. All of these changes have emphasized the need for professional nurses to think critically in order to provide safe and effective client care to diverse populations. To function effectively in complex, rapidly changing health care environments, nurses must use higher-order thinking skills and apply content knowledge to clinical practice. The critical thinking process provides nurses with the ability to use purposeful thinking and reflective reasoning to examine ideas, assumptions, principles, conclusions, beliefs, and actions in the context of professional nursing practice ( Brunt, 2005 ). Professional nurses must think critically to process complex data from multiple sources and make intelligent decisions in planning, managing, delivering, and evaluating the health care of their clients. Nurses also use their critical thinking skills to reduce health care errors and improve client safety ( Fero, Witsberger, Wesmiller, Zullo, & Hoffman, 2008 ). To become a critical thinker, a nurse must understand the concept of critical thinking; possess or acquire the essential knowledge, skills, and attributes required to think critically; and deliberately apply critical thinking principles in making clinical judgments. This chapter covers both classical and current sources to examine critical thinking, clinical judgment, and the nursing process. Defining Critical Thinking Critical thinking, as a concept, has been examined and presented from a variety of perspectives. An early definition, proposed by Watson and Glaser (1964) , described critical thinking as the combination of abilities needed to define a problem, recognize stated and unstated assumptions, formulate and select hypotheses, draw conclusions, and judge the validity of inferences. A less prescriptive definition was offered by Ennis (1989) , who characterized critical thinking as “reasonable reflective thinking focused on deciding what to believe or do” (p. 4). Paul (1992) stated that critical thinking is a process of disciplined, self-directed rational thinking that “certifies what we know and makes clear wherein we are ignorant” (p. 47). Alfaro-LeFevre (2006) presented critical thinking for nursing as informed, purposeful, and outcome-focused thinking that requires the ability to identify problems, issues, and risks and make judgments based on evidence. Bandman and Bandman (1995) describe critical thinking for nursing as “the rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs, and actions” (p. 7) and include the following functions: • Discriminating among use and misuse of language • Analyzing the meaning of terms • Formulating nursing problems • Analyzing arguments and issues into premises and conclusions • Examining nursing assumptions • Reporting data and clues accurately • Making and checking inferences based on data • Formulating and clarifying beliefs • Verifying, corroborating, and justifying claims, beliefs, conclusions, decisions, and actions • Giving relevant reasons for beliefs and conclusions • Formulating and clarifying value judgments • Seeking reasons, criteria, and principles that justify value judgments • Evaluating the soundness of conclusions Conclusions are drawn as a result of this reasoning process. In nursing practice, the desired outcome of this reasoning is effective action. Conflicting viewpoints exist regarding whether critical thinking is subject specific or generalizable ( U.S. Department of Education, 1995 ). Most authors agree that the critical thinking processes are not discipline specific but, rather, are generalizable ( Ennis, 1987 ; Facione, 1990 ; Paul, 1992 ; Watson & Glaser, 1964 ). The same critical thinking skills of interpretation, analysis, inference, and evaluation are applied in different subjects. However, the difference lies in how the critical thinking processes are applied to specific disciplines. For example, professional nurses apply critical thinking skills to client care situations in order to make sound clinical judgments, whereas engineers apply critical thinking skills to business or industrial situations in order to make sound decisions. Meyers (1991) and McPeck (1990) believe that mastery of basic terms, concepts, and methodologies must occur before critical thinking skills can be developed. Ennis (1987) agrees that some familiarity with subject matter is necessary for the development of critical thinking; however, some principles of critical thinking bridge many disciplines and can transfer to new situations. An attempt to define critical thinking by consensus was begun in the late 1980s, and the results became known as the Delphi Report. The Delphi research project used an expert panel of theoreticians representing several disciplines from the United States and Canada to develop a conceptualization of critical thinking from a broad perspective ( Facione, 1990 ). The resulting work described critical thinking in terms of cognitive skills and affective dispositions. The outcome was a definition of critical thinking as the process of purposeful, self-regulatory judgments: an interactive, reflective reasoning process ( Facione & Facione, 1996 ). A critical thinker gives reasoned consideration to evidence, context, theories, methods, and criteria to form a purposeful judgment. At the same time, the critical thinker monitors, corrects, and improves the judgment. The Delphi project produced the following consensus definition from its panel of experts: We understand critical thinking (CT) to be purposeful, self-regulatory, judgment which results in interpretation, analysis, evaluation, and inference, as well as explanation of evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment is based. … CT is essential as a tool of inquiry. As such, CT is a liberating force in education and a powerful resource in one’s personal and civic life. ( American Philosophical Association, 1990 ) The Delphi participants identified core critical thinking skills as interpretation, analysis, inference, evaluation, and explanation. These critical thinking cognitive skills and subskills are listed in Box 9-1 . BOX 9-1 Critical Thinking Cognitive Skills and Subskills Interpretation Inference Categorization Querying evidence Decoding sentences Conjecturing alternatives Clarifying meaning Drawing conclusions Analysis Explanation Examining ideas Stating results Identifying arguments Justifying procedures Analyzing arguments Presenting arguments Evaluation Self-regulation Assessing claims Self-examination Assessing arguments Self-correction Critical Thinking in Nursing Scheffer and Rubenfeld (2000) replicated the Delphi study with a panel of 55 nurse educators to obtain a consensus definition of critical thinking for nursing. That study resulted in the identification of 17 dimensions of critical thinking and agreement on the definition of critical thinking for nursing as: … an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge. (p. 7) Although many areas overlap with the American Philosophical Association’s (1990) Delphi Report definition of critical thinking, some important differences also exist. According to Allen, Rubenfeld, and Scheffer (2004) , the dimensions of creativity, intuition, and transforming knowledge that are so crucial to effective clinical practice were not included in the Delphi Report definition. These dimensions emerged in the consensus definition of critical thinking for nursing. SUMMARY OF DEFINITIONS OF CRITICAL THINKING Although a universally accepted definition of critical thinking has not emerged, agreement exists that it is a complex process. The variety of definitions helps provide insight into the myriad dimensions of critical thinking. Commonalities in definitions include an emphasis on knowledge, cognitive skills, beliefs, actions, problem identification, and consideration of alternative views and possibilities ( Daly, 1998 ). The definitions presented earlier are summarized for comparison in Table 9-1 , and characteristics of critical thinking are listed in Box 9-2 . BOX 9-2 Characteristics of Critical Thinking Involves conceptualization Is rational and reasonable Is reflective Is partially attitudinal Is autonomous Includes creativity Is fair Focuses on what to believe and do From Wilkinson, J. M. (2001). Nursing process: A critical thinking approach (2nd ed.). Upper Saddle River, NJ: Prentice-Hall. TABLE 9-1 Definitions of Critical Thinking Author(s) Definition Watson and Glaser (1964) Combination of abilities needed to define problems, recognize assumptions, formulate and select hypotheses, draw conclusions, and judge validity of inferences Ennis (1989) Reasonable reflective thinking focused on deciding what to believe or do Paul (1992) Process of self-disciplined, self-directed, rational thinking that verifies what we know and clarifies what we do not know The Delphi Report ( American Philosophical Association, 1990 ); Facione, Facione, and Sanchez (1994) Purposeful, self-regulatory judgments resulting in interpretation, analysis, inference, evaluation, and explanation Bandman and Bandman (1995) Rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs, and actions Alfaro-LeFevre (2006) Informed, purposeful, and outcome-focused thinking that uses evidence to make clinical judgments The activities involved in the process of critical thinking include appraisal, problem solving, creativity, and decision making. The interrelationships among these concepts are illustrated in Figure 9-1 . These activities are embedded in the critical thinking process in both nursing education and nursing practice. FIGURE 9-1 Critical thinking model. (Modified from Strader, M. K., & Decker, P. J. [1995]. Role transition to patient care management. Upper Saddle River, NJ: Prentice-Hall.) CRITICAL THINKING AND THE NURSING PROCESS In nursing, critical thinking has often been portrayed as a rational, linear process that is synonymous with clinical judgment, problem solving, and the nursing process ( Ford & Profetto-McGrath, 1994 ; Huckabay, 2009 ; Jones & Brown, 1993 ; Kintgen-Andrews, 1991 ; Wilkinson, 1996 ). However, some critics believe that the problem-solving emphasis of the nursing process constrains critical thinking because it does not incorporate the creativity and open-mindedness components of critical thinking ( Conger & Mezza, 1996 ; Duchscher, 1999 ; Jones & Brown, 1993 ; Miller & Malcolm, 1990 ). Although critical thinking skills are important components of the nursing process and problem solving, these are not synonymous terms. The nursing process serves as a tool for applying critical thinking to nursing practice. The nurse uses critical thinking throughout the nursing process, by sorting and categorizing data; identifying patterns in the data; drawing inferences; developing hypotheses that are stated in the form of outcomes; testing these hypotheses as care is delivered; and making criterion-based judgments of effectiveness. Therefore critical thinking can distinguish between fact and fiction, providing a rational basis for clinical judgments and the delivery of nursing care. Although an argument can be made that the nursing process constrains critical thinking because of its structured format, general agreement exists that critical thinking skills and subskills are evident throughout the nursing process ( Alfaro-LeFevre, 2006 ). Although the components of the nursing process are described as separate and distinct steps, they become an integrated way of thinking as nurses gain more clinical experience. An overview of critical thinking throughout the nursing process is presented in Table 9-2 . A thorough understanding of the nursing process reveals that critical thinking is indeed an integral part of its most effective use. TABLE 9-2 Overview of Critical Thinking Throughout the Nursing Process Nursing Process Critical Thinking Assessment Observing Distinguishing relevant from irrelevant data Distinguishing important from unimportant data Validating data Organizing data Categorizing data Analysis/diagnosis Finding patterns and relationships Making inferences Stating the problem Suspending judgment Planning Generalizing Transferring knowledge from one situation to another Developing evaluative criteria Hypothesizing Implementation Applying knowledge Testing hypotheses Evaluation Deciding whether hypotheses are correct Making criterion-based evaluations and judgments Modified from Wilkinson, J. M. (2001). Nursing process: A critical thinking approach (2nd ed.). Upper Saddle River, NJ: Prentice-Hall. The Nursing Process The nursing process is a systematic, problem-solving approach used extensively in the United States and Canada for the delivery of nursing care. The nursing process was first described in the literature in 1955 by Lydia Hall. Her approach was built around three interrelated spheres of nursing activity: care, core, and cure. The focus in the care sphere is the body, including assessment and evaluation of the client’s ability to perform basic functions and activities of daily living. The focal point in the core sphere was on the therapeutic use of self in providing nursing care, whereas nursing activities related to the cure sphere centered on the administration of treatments and therapies, as well as supporting the patient and family during the treatment process. Subsequently, many others have described a “nursing process,” but the model that has withstood the test of time is that developed by Yura and Walsh (1988) . They proposed a four-step nursing process model that consisted of assessing, planning, implementing, and evaluating. The current model closely resembles the Yura and Walsh model, but with the addition of a diagnostic component. The five-step nursing process consists of the following elements: • Assessment —gathering and validating client health data, strengths, risks, and concerns • Analysis/diagnosis —processing client data and identifying appropriate nursing diagnoses • Planning —designing strategies to solve identified problems and build on client strengths • Implementation —delivering and documenting the planned care • Evaluation —determining the effectiveness of the care delivered The American Nurses Association (ANA), in its publication Nursing: Scope and Standards of Practice (2004), parallels the steps of the nursing process and supports its use. Outcome identification, which follows the nursing diagnosis phase and precedes the planning phase, is identified as a separate step in the ANA model. The nursing process is sometimes depicted as a systematic, linear model proceeding from assessment through diagnosis, planning, implementation, and evaluation. It is more appropriately conceptualized as a continuous and interactive model ( Figure 9-2 ), thereby providing a flexible and dynamic approach to client care. This model can accommodate changes in the client’s health status or failure to achieve expected outcomes through a feedback mechanism. The interactive nature of the model with its feedback mechanism permits the nurse to reenter the nursing process at the appropriate stage to collect additional data, restructure nursing diagnoses, design a new plan, or change implementation strategies. This model is consistent with the concept of critical thinking as a continuous reflective process. Further examination of the elements of the nursing process reveals the multiple activities embedded in each step. FIGURE 9-2 The interactive nursing process model. (Modified from Christensen, P. J., & Kenney J. W. [1995]. Nursing process: Application of conceptual models [4th ed.], St. Louis: Mosby.) ASSESSMENT In the assessment phase, the nurse deliberately and systematically collects data to determine the client’s health, functional status, strengths, and risk factors ( Carpenito, 2008 ). Data collection centers on the use of multiple sources and types of data, a variety of data collection techniques, and the use of reliable and valid measurement instruments. All these elements are critical to building a comprehensive database. Sources of Data The primary source of data is the client, whether the client is defined as the individual, the family, or the community. Secondary sources of data include written records, other health care providers, and significant others (e.g., family members, friends). To strengthen the overall assessment and validate client data, it is important to use primary and secondary data sources. Data Collection Techniques Assessment techniques include measurement, observation, and interview. Measurement is used to determine the dimensions of a given indicator (e.g., blood pressure) or to ascertain characteristics such as quantity, size, or frequency. Measurement may require the use of specialized equipment (e.g., stethoscope, thermometer) or specialized assessment tools (e.g., pain scale, depression scale) to assess functional, behavioral, social, or cognitive domains. Data collection by observation requires the use of the senses, including visual observation and tactile (palpation) and auditory techniques (auscultation). Observation provides a variety and depth of data that may be difficult to obtain by other methods. A structured or unstructured interview may be used to obtain information such as a health history and demographic data. A structured interview is commonly used in emergency situations when the nurse needs to gather specific information. An unstructured interview is commonly used in situations in which the nurse wishes to elicit information from the client’s perspective or gain insight to the client’s understanding of a problem. The unstructured interview allows the nurse to use active listening skills while building rapport with the client through the use of an open-ended interview format. These communication techniques are discussed in chapter 8 Types of Data To complete a comprehensive assessment, objective and subjective data are obtained. Objective data are factual data, usually obtained through observation or measurement. An example of objective data occurs when the nurse uses an otoscope to assess the client’s tympanic membrane and observes that it is reddened and inflamed. Subjective data are based on the client’s perception of the health problem. An example of subjective data occurs when the client states that he is having pain in his right ear. It is important to collect both objective and subjective data to complete a comprehensive assessment. Care should be taken to record data factually and to avoid personal or biased interpretations. Data Collection Instruments The use of selected data collection measures and instruments can assist the nurse in compiling a comprehensive database and organizing data into meaningful patterns. Assessment usually begins by taking a nursing history and conducting a physical examination. Many clinical areas have developed nursing history and physical forms specific to the type of agency and the clients served. Regardless of the format, the nursing database should include the following categories of information ( Edelman & Mandle, 1994 ): • Demographic data • Current and past medical problems • Family medical history • Surgical and (if appropriate) obstetrical history • Childhood illnesses • Allergies • Current medications • Psychological status • Social history • Environmental background • Physical assessment
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Critical thinking skills are essential to function in today's complex health care environment and to ensure continuing competence for the future. This article provides a review of various definitions and research studies related to critical thinking. Educators and researchers need to clearly define critical thinking, because there has been wide variation in definitions and descriptions of critical thinking. Research studies have shown inconsistent findings, and many have used a one-group pretest-posttest design over a single course or during the length of a nursing program. Studies have not shown an association between critical thinking and competence; rigorous research studies are needed to understand the process of critical thinking.
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How many times did you hear the phrase “critical thinking” in your training to become a nurse? I must have heard it a thousand times, and I still don’t think I ever had a clear definition of it in my mind. What exactly is critical thinking? In this course, we will answer those questions and provide insight into how you can teach critical thinking in nursing. Also included are some self-guided exercises to practice critical thinking skills. After all this, you will be ranting about the vital importance of critical thinking too.
Ask yourself...
Critical thinking is a term that is difficult to define because it is, by nature, somewhat subjective. The National Council for Excellence in Critical Thinking defines it as “the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action” (4). That’s a long definition. Essentially, critical thinking is a way of thinking that allows a person to recognize important information and process it to solve problems. Let us break this down further into the key characteristics of critical thinkers.
How are “text-book smart” and “street smart” different from each other?
There are some key characteristics of critical thinkers that appear consistently throughout the literature. The first of these attributes is information gathering (1). Critical thinkers are adept at gathering information from situations. They pay attention to details and pick up on the information that others may miss. Critical thinkers try to uncover the particulars to ensure they are well informed in their thinking and decision-making. Critical thinking is not a passive acceptance of information but rather an active collection of data. In terms of nursing, the critical thinker will place a lot of importance on their assessment. Rather than focusing simply on the tasks that need to be completed, critical thinking in nursing means staying in tune with assessment findings and changes. For example, if a patient has labs drawn, the critically thinking nurse will watch for the results of these labs to have the most up-to-date information and be alert to any changes.
How do you incorporate “information gathering” into your routine?
Another important attribute of critical thinkers is their habit of investigating (1). They do not accept information at face value. They have a tendency to question information, especially that which contradicts other data. When critical thinkers see the information that doesn’t seem right or raises questions, they investigate it. This way of thinking goes together with seeking out information.
With critical thinking in nursing, a nurse may ask themselves, “What else do I need to know? What comes next?” Rather than simply reporting one change to the physician, they think “what could this change represent? What other information would support this idea?” Continuing our example of following labs, if the nurse notices that the white blood cell count has increased, they will investigate to see why that might be. They would likely assess the patient for signs of infection, such as fever or chills.
If you get the feeling that “something isn’t right,” what do you do next?
Critical thinkers also can evaluate the information they have gathered to create new ideas or hypotheses (1). This is the cognitive “connecting the dots” that allows critical thinkers to synthesize pieces of data into a complete picture of what is happening.
Critical thinking in nursing doesn’t mean just collecting and reporting information; they process it and form ideas of their own. They ask questions like “how do these pieces of information fit together? Does this fit with any knowledge I already have?” Going back to our example, let’s say after the nurse notices the white blood cell count and assesses the patient, they find the patient has a fever and cloudy urine. Evaluation of this information would lead the nurse to think the patient has a urinary tract infection (UTI).
Think of a time you diagnosed a patient’s problem. How did you come to this conclusion?
An important aspect of critical thinking is problem solving. After gathering and evaluating information, the critical thinker tries to solve any problems that surface (1). This is a key point that separates critical thinking from merely being perceptive. Recognizing important information and problems is vital but being able to then think through and solve the problem is what makes critical thinking stand out. Looking at our example again, once the nurse has recognized symptoms consistent with a UTI they will begin formulating ideas on how to treat the problem. The first action would likely be notifying the provider of all the information gathered, the nurse’s hypothesis and a recommendation to solve the problem. You may recognize this format as being similar to Situation-Background-Assessment-Recommendation (SBAR). SBAR is a tool that is used to help guide critical thinking in nursing (1).
Now that we understand what exactly critical thinking means, let’s ask: why is it so important? You may have already formulated some ideas about how critical thinking in nursing can be helpful in practice. Critical thinking is a pattern of recognizing and reacting to the most important pieces of information. This is crucial in nursing, where we are presented with a plethora of information and expected to use the most important pieces to save lives and make people healthy. Now, let us get more specific on what areas would benefit from critical thinking in nursing.
First, and maybe most important, is that critical thinking improves patient outcomes (3).
Studies have shown that critical thinking skills in nurses are linked to lower hospital costs to patients, as well as to the facility thanks to lower in-hospital complications (3). Critical thinking by nurses also decreases the length of hospital stay (4). It has also been shown to improve outcomes and lower complications in surgical patients when the operating room nurses had a higher level of critical thinking (3). Despite these positive results and every nursing instructor ranting on the importance of critical thinking, there is a lack of research into the connection between critical thinking in nursing and patient outcomes. This is primarily because of the difficulty of assessing critical thinking skills specific to nurses and linking these skills to a measurable outcome without confounding factors (3).
You will be pleasantly surprised to learn that critical thinking in nursing leads to higher staff satisfaction! Research has found a strong correlation between critical thinking ability and perceived autonomy and job satisfaction in nurses (5). It is believed that critical thinking fosters autonomy or at least increases the sense of autonomy, which generally leads to higher job satisfaction. Critical thinking has been shown to improve confidence as well, and feeling confident in your work generally improves satisfaction as well (5). Interestingly, there has also been research that shows that critical thinking is linked to higher satisfaction with life decisions and less adverse life events (6). The idea here is that critically thinking through a decision before making it leads to less regret. So, this course will make you happier with work and help you make better life choices – you’re welcome.
Another important benefit of critical thinking is that it improves efficiency. Studies found that nurses with higher critical thinking skills work more efficiently (1). If you are thinking critically you are better able to prioritize and plan to avoid wasting time and energy. As we all know, nursing can be very demanding, and efficiency is important for tending to all our patients’ needs. Also, if the nurse manager of a unit has higher critical thinking skills, they implement changes that improve overall efficiency and morale (7). This highlights that critical thinking is important to all nursing forms and how one person practicing critical thinking can impact others.
A large reason why critical thinking has become so important is the ever-increasing complexity of healthcare. As we develop new treatments, we are always being asked to learn new processes and how to monitor patients receiving these treatments. Also, as the healthcare system improves treatments, the average patient is becoming older and has more co-morbidities (4). This adds to the complexity of each patient. Critical thinking is a great skill that aids in learning new tasks and comprehending more complicated patients. Nurses arguably have the most complex set of tasks, as we are often asked to perform some of the duties of other healthcare professions. Being adaptable to whatever changes come and taking on new responsibilities is a great benefit of critical thinking.
When have you been asked to make a change to your practice? How did you adapt to this change?
Now that we understand what critical thinking is and why it’s important let us discuss how critical thinking is taught. Critical thinking in nursing has become an integral part of many programs. Many healthcare institutions are looking for ways to incorporate critical thinking into their training process as well (1). Critical thinking is, however, an abstract concept and truly is a whole new way of thinking. So, how do we teach someone how to think? There are several factors that should be considered when trying to teach or learn critical thinking.
First, educators have an important influence on the instruction of critical thinking skills. Educators that are effective at teaching critical thinking skills are open-minded, flexible, and supportive of their students (1). Showing flexibility and not firmly holding to one set way of doing things allows the students to adopt their own version of critical thinking. Role-modeling, guiding, and being knowledgeable about critical thinking also leads to a more effective educator (1). The educator should guide learners through their understanding of critical thinking while role-modeling critical thinking behaviors.
The learning environment also plays an important role in a nurse’s ability to learn critical thinking skills. The environment should be inclusive, non-judgmental, and allow for open discussion (1). This applies to both nursing schools and nurses being trained into a new unit. Feeling accepted on a unit allows for better learning and has a positive impact on critical thinking skills (1). It is important for nurses looking for a new work unit to find one with a welcoming, safe environment to aid in learning. On the other side, we should always strive as nurses to be inclusive and facilitate this type of environment as it benefits everyone. I was always told that “nurses eat their young,” and this attitude does not foster learning or growth.
The education system also impacts the teaching of critical thinking. Education systems, for one, largely shape the learning environment and educators. The education system should strive to create the type of learning environment where critical thinking skills can grow. Too much emphasis on classroom lectures and power dynamics between teachers and students hinders the development of critical thinking skills (1). Teaching critical thinking as its own subject also helps students learn the skill (1).
Lastly, there are some individual factors that affect a person’s ability to cultivate critical thinking skills. Chief among these are a lack of confidence and fear of questioning an instructor (1). You can see how all these concepts seem to be centered on the fact that learners perform best when they are comfortable and have the freedom to discuss ideas. This is the central concept that should be understood and practiced by both mentor and mentee, as well as the education system as a whole. So, as we move into the next section teaching critical thinking skills, put yourself in a comfortable place – physically and mentally. Be sure to keep thinking of questions and follow your own ideas.
Now that we have an understanding of the right mindset to have when learning critical thinking, let us actually discover how to teach and learn it. Some common strategies that appear to be effective are targeted questioning, case studies and simulation (1). These are all approaches that require more than one person, so they are best practiced as part of training. If you have a colleague or mentor, you may try some of these strategies with them as well.
First, we have targeted questioning, which is a tactic of asking questions in order to promote further thinking (8). This often involves asking questions of increasing difficulty to encourage the learner to think deeper about what the facts represent. It is the educator’s equivalent of a toddler asking “why?” over and over. The purpose is not to be annoying but to discover how deep down the rabbit hole the learner will go. Socratic questioning is another common type of targeted questioning designed to encourage learners to think further on the subject matter. This is commonly used in continuing education (check the italicized text), and helps to promote further thinking on facts rather than just accepting them at face value.
The next exercise that helps teach critical thinking is case studies. Case studies help promote critical thinking by allowing learners to think through a real-life scenario without the stressors of experiencing the scenario (1).
It is important for learners to acknowledge how they might feel in that scenario so that they can be better prepared for the pragmatic aspects and the personal aspects of dealing with the presented problem (4). Case studies typically move chronologically through a scenario and often guide learners through the critical thinking behaviors of information gathering, investigating, evaluating and problem-solving. This helps build the mental framework of moving step-wise through a problem in order to find the best solution.
Finally, simulation has proven to be useful in fostering critical thinking. Simulation, similar to case studies, promotes thinking through a scenario in a low-risk, low-stress environment with the added benefit of going through the physical motions involved (8). This allows the learner to physically experience the situation as well as think through the problems. This can help familiarize someone with the actual physical interventions involved so they are more comfortable when practiced in real scenarios. This is often used in life support training so that learners understand how to actually connect the defibrillator and which button to press, so there is less fumbling in the high-stress scenario where these motions are used (8).
We have examined ways to teach critical thinking skills to others, but what about developing critical thinking within ourselves? Luckily, there are a couple of exercises that can be practiced individually to foster critical thinking skills. This is helpful to those of us who are finished with our training and looking to better ourselves. Start with a desire to improve, as none of us are perfect. These exercises are best practiced by focusing on a specific scenario, particularly if there is a scenario that you didn’t fully grasp or that felt overwhelming.
The first exercise is concept mapping. Concept mapping is the practice of visually representing ideas on paper and showing connections between these ideas (2). They are often presented in either a hierarchical or web pattern with the key ideas at the top or center of the diagram, respectively.
This helps a learner visualize their thinking process and further think about what connected and how. For example, let's think of our scenario earlier with the suspected UTI. We might see a change in vital signs as a central idea which connects us to signs of infection and then to interventions. This can help us see the progression of ideas, how they are connected, and possible other explanations.
Our final means of learning critical thinking in nursing is reflective writing. Reflective writing or journaling helps to identify thought patterns and promote critical thinking skills (1). Again, this is most useful for examining a specific situation. Breaking down a complex situation when you have more time to analyze it will help you learn more from that challenge.
It may seem silly to write a journal but reflecting and processing your ideas is an important practice for growth. The act of formulating your thoughts into written words helps to make more sense of the ideas and feelings you have. You don’t have to keep a daily journal, but if you have a challenging shift it may help to reflect on it and write down your ideas. It is important to treat this exercise as a learning opportunity, and to not ruminate on failures or beat yourself up for not being perfect.
In summary, critical thinking in nursing is essential. It impacts our efficiency, the well-being of our patients, and our own happiness. Critical thinking is a broad way of thinking that involves gathering information, investigating, and evaluating the information in order to solve a problem. Critical thinking is best learned and practiced with an open mind. We can foster critical thinking in each other through case studies, simulations and targeted questioning. We can improve our critical thinking in nursing skills ourselves by practicing reflective writing and concept mapping. If you are a nurse educator or preceptor, I hope you have found something you can use to shape future nurses. If you are a nurse looking to better understand critical thinking, I hope you have learned something you can take to your nursing practice.
Use of Course Content. The courses provided by NCC are based on industry knowledge and input from professional nurses, experts, practitioners, and other individuals and institutions. The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NCC. The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare. The information provided in this course is general in nature and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Knowledge, procedures or insight gained from the Student in the course of taking classes provided by NCC may be used at the Student’s discretion during their course of work or otherwise in a professional capacity. The Student understands and agrees that NCC shall not be held liable for any acts, errors, advice or omissions provided by the Student based on knowledge or advice acquired by NCC. The Student is solely responsible for his/her own actions, even if information and/or education was acquired from a NCC course pertaining to that action or actions. By clicking “complete” you are agreeing to these terms of use.
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By Hannah Meinke on 07/05/2021
The nursing profession tends to attract those who have natural nurturing abilities, a desire to help others, and a knack for science or anatomy. But there is another important skill that successful nurses share, and it's often overlooked: the ability to think critically.
Identifying a problem, determining the best solution and choosing the most effective method to solve the program are all parts of the critical thinking process. After executing the plan, critical thinkers reflect on the situation to figure out if it was effective and if it could have been done better. As you can see, critical thinking is a transferable skill that can be leveraged in several facets of your life.
But why is it so important for nurses to use? We spoke with several experts to learn why critical thinking skills in nursing are so crucial to the field, the patients and the success of a nurse. Keep reading to learn why and to see how you can improve this skill.
You learn all sorts of practical skills in nursing school, like flawlessly dressing a wound, taking vitals like a pro or starting an IV without flinching. But without the ability to think clearly and make rational decisions, those skills alone won’t get you very far—you need to think critically as well.
“Nurses are faced with decision-making situations in patient care, and each decision they make impacts patient outcomes. Nursing critical thinking skills drive the decision-making process and impact the quality of care provided,” says Georgia Vest, DNP, RN and senior dean of nursing at the Rasmussen University School of Nursing.
For example, nurses often have to make triage decisions in the emergency room. With an overflow of patients and limited staff, they must evaluate which patients should be treated first. While they rely on their training to measure vital signs and level of consciousness, they must use critical thinking to analyze the consequences of delaying treatment in each case.
No matter which department they work in, nurses use critical thinking in their everyday routines. When you’re faced with decisions that could ultimately mean life or death, the ability to analyze a situation and come to a solution separates the good nurses from the great ones.
Nursing school offers a multitude of material to master and upholds high expectations for your performance. But in order to learn in a way that will actually equip you to become an excellent nurse, you have to go beyond just memorizing terms. You need to apply an analytical mindset to understanding course material.
One way for students to begin implementing critical thinking is by applying the nursing process to their line of thought, according to Vest. The process includes five steps: assessment, diagnosis, outcomes/planning, implementation and evaluation.
“One of the fundamental principles for developing critical thinking is the nursing process,” Vest says. “It needs to be a lived experience in the learning environment.”
Nursing students often find that there are multiple correct solutions to a problem. The key to nursing is to select the “the most correct” solution—one that will be the most efficient and best fit for that particular situation. Using the nursing process, students can narrow down their options to select the best one.
When answering questions in class or on exams, challenge yourself to go beyond simply selecting an answer. Start to think about why that answer is correct and what the possible consequences might be. Simply memorizing the material won’t translate well into a real-life nursing setting.
As you know, learning doesn’t stop with graduation from nursing school. Good nurses continue to soak up knowledge and continually improve throughout their careers. Likewise, they can continue to build their critical thinking skills in the workplace with each shift.
“To improve your critical thinking, pick the brains of the experienced nurses around you to help you get the mindset,” suggests Eileen Sollars, RN ADN, AAS. Understanding how a seasoned nurse came to a conclusion will provide you with insights you may not have considered and help you develop your own approach.
The chain of command can also help nurses develop critical thinking skills in the workplace.
“Another aid in the development of critical thinking I cannot stress enough is the utilization of the chain of command,” Vest says. “In the chain of command, the nurse always reports up to the nurse manager and down to the patient care aide. Peers and fellow healthcare professionals are not in the chain of command. Clear understanding and proper utilization of the chain of command is essential in the workplace.”
“Nurses use critical thinking in every single shift,” Sollars says. “Critical thinking in nursing is a paramount skill necessary in the care of your patients. Nowadays there is more emphasis on machines and technical aspects of nursing, but critical thinking plays an important role. You need it to understand and anticipate changes in your patient's condition.”
As a nurse, you will inevitably encounter a situation in which there are multiple solutions or treatments, and you'll be tasked with determining the solution that will provide the best possible outcome for your patient. You must be able to quickly and confidently assess situations and make the best care decision in each unique scenario. It is in situations like these that your critical thinking skills will direct your decision-making.
While critical thinking skills are essential at every level of nursing, leadership and management positions require a new level of this ability.
When it comes to managing other nurses, working with hospital administration, and dealing with budgets, schedules or policies, critical thinking can make the difference between a smooth-running or struggling department. At the leadership level, nurses need to see the big picture and understand how each part works together.
A nurse manager , for example, might have to deal with being short-staffed. This could require coaching nurses on how to prioritize their workload, organize their tasks and rely on strategies to keep from burning out. A lead nurse with strong critical thinking skills knows how to fully understand the problem and all its implications.
Their solutions will take into account all their resources and possible roadblocks.
They’ll weigh the pros and cons of each solution and choose those with the greatest potential.
Finally, they will look back on the issue and evaluate what worked and what didn’t. With critical thinking skills like this, a lead nurse can affect their entire staff, patient population and department for the better.
You’re now well aware of the importance of critical thinking skills in nursing. Even if you already use critical thinking skills every day, you can still work toward strengthening that skill. The more you practice it, the better you will become and the more naturally it will come to you.
If you’re interested in critical thinking because you’d like to move up in your current nursing job, consider how a Bachelor of Science in Nursing (BSN) could help you develop the necessary leadership skills.
EDITOR’S NOTE: This article was originally published in July 2012. It has since been updated to include information relevant to 2021.
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By Brook Jillings, Contributor
Critical thinking in nursing is a learned skill that increases the quality of care given to patients and improves outcomes. It helps nurses fulfill their duties of advocating for patient safety, and helps everyone on the medical team function at their best. Find out why critical thinking is important and learn five ways to improve with examples of critical thinking in nursing.
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To be an effective nurse, it's important to step back and see the bigger picture. Critical thinking in nursing helps you analyze your patient's condition and current treatments to predict outcomes and identify potential issues. Hahnah Williams, Esq., RN, says, "Nurses who think critically do a better job of communicating across disciplines to ensure that all providers are aware of the patient's status, needs, and responses to treatment."
Being a strong critical thinker can greatly impact the experiences of your patients and enhance patient safety. Williams gives an example of this: "A critically thinking nurse will hold a patient's blood pressure medicines and contact the physician when he or she notes that the patient's blood pressure is below an acceptable level."
In contrast, a lack of critical thinking skills could put a patient in this situation in jeopardy by allowing the blood pressure to continue falling.
Nurses who are critical thinkers can best advocate for their patients: analyzing and evaluating facts in order to make a sound, evidence-based judgment. They should then speak up when necessary, and not just blindly follow orders."Nurses are often at the front line of patient care and serve as quarterbacks for patients with multi-disciplinary needs," Williams states.
Human beings tend to allow personal bias to affect their decisions, and critical thinking in nursing could be compromised. "Take a look at how you think," says Barb Lundy, author of Connections Count: Mastering the Human Side of Business . "Do hidden values or beliefs drive your behavior?" Some examples she gives of this include the belief that communicating with elderly patients is more difficult, or that parents will make unreasonable demands for their children's care.
Making assumptions can also be an issue. "Medical treatment relies on educated assumptions," Lundy explains. "Assumptions that send problem-solving off in the wrong direction come from not asking enough questions." She offers the following tips to keep nurses on the right path:
It's important to make sure any actions you take are evidence-based and not influenced by your personal feelings, or, as Lundy says, "Know where fact ends and opinion begins."
Take time to read nursing journals and peer-reviewed research, and engage in meaningful dialogue with your colleagues. Critical thinking in nursing requires familiarity with a range of medical conditions and procedures. Continually brushing up on your knowledge will help you identify connections in your patients' care and know how to address any issues.
Dr. Joyce Mikal-Flynn, a nurse practitioner and professor at the Sacramento State University School of Nursing, says, "On a regular basis, I spend time with associates reviewing diagnoses and treatment and making certain I am utilizing the most discerning evidence and up-to-date treatments."
Mikal-Flynn claims these efforts strengthen the team and "directly adds to and enhances critical thinking abilities." Spending time communicating with your peers can give you different perspectives while strengthening the relationship between you and the attending physicians. Keeping up with the latest medical findings and nursing care models will also keep your knowledge current and your skills ahead of the curve.
At the end of each nursing shift, take some time to reflect on the day's events. There will always be situations you could have approached differently or better solutions to the problems you faced, so it's important to go through those things to see where you can improve. Mikal-Flynn recommends you take time to review "your clinical day, what went well, what would you change, what do you need to improve your professional behavior and become more sophisticated in your thinking process."
Going over your decisions and interactions lets you analyze them in a low-pressure setting with a critical eye. Finding things you could have done differently helps you make better decisions in the future when faced with similar scenarios. Lundy also suggests, "Have an evaluation tool that helps you assess your critical thinking growth and development."
Critical thinking in nursing is a skill that can be learned and improved, so make sure you're enhancing your skills daily using the tools available to you. "Utilizing clinical debriefing is essential," says Mikal-Flynn. "It is a time to pull apart clinical decisions and add, subtract and enhance content."
You can also practice your critical thinking skills outside of the workplace. The Foundation for Critical Thinking offers nine suggestions to develop your critical thinking strategy that include daily, weekly and monthly goals for personal growth, along with tools and tips to create better self-awareness.
Finally, a good critical thinker will maintain flexibility. Critical thinking in nursing requires the ability to adapt to changing situations and share information. "Plan ahead knowing your plans will need adjustment as things change," suggests Lundy. "Listen to alternative ideas and approaches and offer your innovative ideas for problem-solving."
Nursing is a fast-paced profession that requires a unique approach to each patient. With so many variables that affect each case, you have to be willing to consider different perspectives to serve your patients well.
Critical thinking in nursing is a valuable skill that can greatly improve the care you provide to your patients. If you take the time to follow these five tips to improve your critical thinking skills, your reward will be better outcomes for your patients and more confidence in your abilities as a nurse.
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What are nursing smart goals? Setting realistic nursing SMART goals is the best way to lay the foundation for your success. Find out how to set smart goals for nursing as well as examples of nursing smart goals to get you started.
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Tuan van nguyen.
1 Faculty of Nursing and Medical Technology, Can Tho University of Medicine and Pharmacy, Can Tho Vietnam
2 School of Nursing, College of Medicine, Chang Gung University, Taoyuan Taiwan
3 Department of Rheumatology, Chang Gung Memorial Hospital, Linkou Taiwan
4 Department of Nursing, College of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
The data that support the findings of this study are available from the corresponding author upon reasonable request.
To measure the level of critical thinking among Vietnamese professional nurses and to identify the related factors.
A cross‐sectional design was used.
The total sample included 420 professional nurses. Data were collected from July to September 2019 in three public hospitals located in Southwestern Vietnam. The level of critical thinking was measured using the Vietnamese version of the Nursing Critical Thinking in Clinical Practice Questionnaire. The data were analysed using the independent Student's t tests, ANOVA, Pearson's correlation and regression analysis.
Most of the participants had a low (48.3%) or moderate (45.5%) level of critical thinking. Age, gender, ethnicity, education level, health condition, duration of working as a nurse, duration of working in the current hospital, having heard the term “critical thinking” and work position had an impact on the critical thinking ability. Work position and gender explained 11% of the total variance in critical thinking ability.
Critical thinking is defined as the cognitive process of reasoning that involves trying to minimize errors and to maximize positive outcomes while attempting to make a decision during patient care (Zuriguel‐Pérez et al., 2015 ). The importance of critical thinking in nursing practice has been identified in the literature (Chang et al., 2011 ; Ludin, 2018 ; Mahmoud & Mohamed, 2017 ; Yurdanur, 2016 ; Zuriguel‐Pérez et al., 2015 ). The current nursing environment has become more complex and demanding, especially regarding the acuity and safety of patients and the rapid turnover rate of hospitalization. If professional nurses want to provide high‐quality care, critical thinking is required (Berkow et al., 2011 ; Brunt, 2005 ; Fero et al., 2009 ; Zuriguel‐Pérez et al., 2015 ). Nurses are often the first‐line professionals to observe and provide direct care for patients. Therefore, critical thinking is a necessary skill for them to be able to analyse clinical situations in order to make fast and correct decisions (Lee et al., 2017 ). More importantly, critical thinking can also improve patient outcomes by preventing habitual thinking that may lead to incorrect medication or procedures (Fesler‐Birch, 2005 ). The critical thinking ability of nurses can have an impact on the patient's safety, and it is a priority in educational programs for healthcare providers (Berkow et al., 2011 ; Buerhaus et al., 2006 ). We can identify those with poor critical thinking and provide in‐service education. Although critical thinking has been shown that is influenced by the experience and knowledge acquired during clinical practice (Zuriguel‐Pérez et al., 2015 ), other personal information needs to be considered to clarifying. Therefore, it is essential to measure the levels of critical thinking and to identify the work‐related and personal‐related factors that influence the critical thinking of nurses.
The literature has identified that there is a relationship between leadership and positive patient outcomes, such as fewer medication errors and nosocomial infections, lower patient mortality and higher patient satisfaction (Van Dyk et al., 2016 ; Wong, 2015 ). Alongside leadership, critical thinking is an important factor that supports the management. They can apply critical thinking skills in decision‐making and problem‐solving, and they can develop strategies that help staff nurses to improve their critical thinking ability (Van Dyk et al., 2016 ; Wong, 2015 ; Zuriguel‐Pérez et al., 2018 ). Thus, the ability to think critically is necessary for nurses because it will help them to effectively make decisions and to solve problems in practice.
Although the importance of critical thinking in nursing practice has been identified, a limited number of studies have been conducted in this population. Particularly, few hospitals have evaluated the critical thinking skills of nurses before employment or during the clinical competency evaluation (Lang et al., 2013 ). By reviewing 90 articles to assess the current state of the scientific knowledge regarding critical thinking in nursing, Zuriguel‐Pérez et al., ( 2015 ) found that only 16 studies used working nurses as participants. Furthermore, Zuriguel‐Pérez et al., ( 2018 ) reported that few studies have explored the critical thinking ability of nurse managers (NMs). Moreover, several studies have identified that working nurses have a low (Lang et al., 2013 ; Yurdanur, 2016 ) or moderate level of critical thinking (Chang et al., 2011 ; Lang et al., 2013 ; Zuriguel‐Pérez et al., 2018 ). To the researchers’ knowledge, no studies have investigated this issue in Vietnam.
In order to improve the quality and safety of patient care, various types of professional nurses have been established, such as Registered Nurses (RNs), NMs and administrative assistants (AAs). RNs provide direct care to the patients, NMs are responsible for forwarding management and delivering expert clinical care for patients, and AAs are an integral part of maintaining the quality of patient care. The AAs perform administrative tasks (e.g. filing, taking meeting minutes and distributing them and undertaking regular reports) that help NMs to spend more time assisting staff nurses and taking care of patients (Locke et al., 2011 ). Therefore, RNs, NMs and AAs need to cooperate to help patients to regain their health.
In Vietnam, professional nurses work in three different positions, which are NMs, general nurses (GNs) and AAs (Ministry of Health, 1997 ). Specifically, NMs are recognized as head nurses in Western countries, and their responsibilities are in charge of organizing and implementing comprehensive patient care and conduct a variety of administrative work (e.g. planning and assigning work to nurses, planning the acquisition of tools and consumables, checking care sheets, recording daily labour). GNs are similar to RNs in Western countries, and they provide direct and comprehensive care to patients. AAs perform administrative tasks (e.g. keeping records about the hospitalized and discharged patients, preserving medical records, managing daily medications). They also participate in patients care if necessary (Ministry of Health, 1997 , 2011 ). Although the roles of these three types of professional nurses are different, their final goal is the same to provide holistic care for patients. With the cooperation and effort of these three types of professional nurses, patients can recover. Therefore, more surveys are needed that examine these participants’ level of critical thinking and the associated work‐related factors.
Previous studies have also found that several personal‐related factors are associated with the nurses' critical thinking ability, which are age, gender, ethnicity, education qualification, working experience and shift work (Chang et al., 2011 ; Feng et al., 2010 ; Howenstein et al., 1996 ; Lang et al., 2013 ; Ludin, 2018 ; Mahmoud & Mohamed, 2017 ; Ryan & Tatum, 2012 ; Wangensteen et al., 2010 ; Yildirim et al., 2012 ; Yurdanur, 2016 ; Zuriguel‐Pérez et al., 2018 ). However, the relationships between the critical thinking ability and these variables are inconsistent. For example, age and critical thinking have been found to be positively correlated (Chang et al., 2011 ; Ludin, 2018 ; Zuriguel‐Pérez et al., 2018 ), negatively correlated (Howenstein et al., 1996 ) and not related (Lang et al., 2013 ; Mahmoud & Mohamed, 2017 ; Yurdanur, 2016 ). Gender and critical thinking have been reported with a statistically significant relationship (Liu et al., 2019 ; Ludin, 2018 ) and no relationship (Mahmoud & Mohamed, 2017 ; Wangensteen et al., 2010 ). Level of education and critical thinking have been found in a positive association (Chang et al., 2011 ; Ludin, 2018 ) and not association (Lang et al., 2013 ; Mahmoud & Mohamed, 2017 ). Year of experiences and critical thinking have been shown to be positively correlated (Chang et al., 2011 ; Ludin, 2018 ), negatively correlated (Howenstein et al., 1996 ) and not related (Lang et al., 2013 ; Mahmoud & Mohamed, 2017 ). Those inconsistent findings indicated the relationships between the personal‐characteristics and the critical thinking ability of professional nurses need further exploration. Therefore, this study aimed to examine the level of critical thinking of professional nurses and to explore the work‐related and personal‐related factors. This is the first study to investigate this issue in Vietnam. The results of the current study will make a significant contribution to the literature because it will provide thorough descriptions of the critical thinking of professional nurses and its associated factors. Furthermore, the findings may be used as a baseline for nurse managers and nurse educators to propose further strategies to improve this ability in professional nurses.
A cross‐sectional design was used. The Strengthening the Reporting of Observational Studies in Epidemiology guidelines were applied in this report (Von Elm et al., 2014 ).
Data collection was carried out from July to September 2019 in three representative and major public hospitals located in the Southwestern region of Vietnam. These hospitals have the same organizational structure, role of treating, operation of professional nursing and provide similar quality of health care to people around that area. The total numbers of professional in these three hospitals nurses were around 1,200. Besides, our study has two steps. The first step was to translate the English version of the Nursing Critical Thinking in Clinical Practice Questionnaire (N‐CT‐4 Practice) into the Vietnamese version. In that step, we used data as a pilot study to estimate the sample size in the second step, which was reported here. Sample size calculation was done by the formula: n = 1.96 2 × p × (1‐p)/0.05 2 , where p = .46 came from the poor level of critical thinking among nurses in the first step and 0.05 indicated the acceptable margin of error (5.0%); 382 participants were required by this formula. An additional 10% of participants were done to adjust for potential failures such as withdrawals or missing data (Suresh & Chandrashekara, 2012 ). Therefore, in total, 420 participants were required for this study. Convenience sampling was conducted to recruit the sample. The inclusion criteria were the nurses' employed full‐time employment in the study hospitals. Participants who participated in step 1 or being absent during the data collection such as sick leave or delivering a baby were excluded. Participants were grouped in each hospital and received an envelope with all questionnaires. Then, researchers explained the research's purpose, benefits and risks to the potential participants and the procedure for ensuring confidentiality, and the voluntary nature of the participation. The informed consent form was signed immediately after they agreed to participate in this study. Then, the participants were required to complete the questionnaires in 20 to 30 min and to return them to the data collector.
3.3.1. sample characteristics.
This instrument collected data about the personal information and occupational variables. The personal information included age, gender, marital status, ethnicity, religion, education level and self‐rated health conditions. The occupational variables were the duration of working as a nurse, the duration of working in the current hospital, the duration of working in the specific position, having heard the term “critical thinking” or not, previous exposure to critical thinking training or education or not, and type of work position.
The N‐CT‐4 Practice (V‐v) was used to measure the critical thinking ability of the professional nurses. The original instrument (N‐CT‐4 Practice) was established and classified based on the four dimensions of the 4‐circle critical thinking model of Alfaro‐LeFevre (Zuriguel‐Pérez et al., 2017 ). These four dimensions were personal; intellectual and cognitive; interpersonal and self‐management; and technical dimensions. The personal dimension has 39 items to assess the individual pattern of intellectual behaviours; the intellectual and cognitive dimension has 44 items to assesses the knowledge of activity comprehension connected to the nursing process and decision‐making. For the interpersonal and self‐management dimension, it has 20 items to analyse interpersonal abilities that allow for therapeutic communication with patients and health teams and to gain information that is associated with the patient in the clinical environment. The final one, the technical dimension, has 6 items to is concerned with knowledge and expertise in the procedures that are part of the discipline of nursing. This scale has 109 items that are rated using a four‐point Likert response format (1 = never or almost never, 2 = occasionally, 3 = often, and 4 = always or almost always), for example: “I recognize my own emotions.” (item 1); “I have the scientific knowledge required to carry out my professional practice.” (item 40); “I adapt information to the needs and capacities of the patient.” (item 84); “I possess skills in the use of information and communication technologies needed to produce optimal professional results.” (item 105). The total score is obtained from the sum of the 109 items. The scores range from 109–436, and they are categorized into a low level (score <329), moderate level (score between 329–395) and high level (score >395). The overall Cronbach's alpha was 0.96, and the intraclass correlation coefficient (ICC) was 0.77 (Zuriguel‐Pérez et al., 2017).
The N‐CT‐4 Practice (V‐v) was translated, and its psychometric properties were tested with 545 Vietnamese nurses. The results showed that the N‐CT‐4 Practice (V‐v) has acceptable reliability (Cronbach's alpha) and validity (content and construct validity). Particularly, the overall Cronbach's alpha was 0.98, with that of the four dimensions ranging from 0.86–0.97. The ICC was 0.81 over two weeks. The item content validity index was 1.0. Moreover, the goodness‐of‐fit indexes in a confirmatory factor analysis showed acceptable values, which were χ 2 / df = 2.87, root mean square error of approximation (RMSEA) = 0.059, standardized root mean square residual (SRMR) = 0.063, comparative fit index (CFI) = 0.73 and Tucker Lewis index (TLI) = 0.72 (T. V. Nguyen & Liu, 2021 ). Therefore, the N‐CT‐4 Practice (V‐v) can be used to measure the critical thinking ability of Vietnamese professional nurses.
This study conformed with the ethical principles of the Declaration of Helsinki (Helsinki Declaration, 2013 ), and it was granted research ethics committee approval by the ethical review board of the first author's institution.
The data were analysed using SPSS for Windows version 23.0 (IBM Corp.), and both descriptive and inferential statistics were calculated. The level of significance for all analyses was set at < 0.05. First, descriptive statistics were employed to summarize the collected data. The continuous variables were described using the mean and standard deviation ( SD ), and the frequency and percentage (%) were used for the categorical variables. Next, independent Student's t tests, analysis of variance (with Scheffe's post hoc comparison) and Pearson's correlation analysis were conducted to explore the association between the critical thinking ability and the personal and occupational factors. Then, a multiple regression analysis using the stepwise method was performed to identify the predictors of critical thinking ability (Pallant, 2010 ).
A total of 420 participants completed the questionnaires; the characteristics of overall participants and subjects in each group are listed in Table 1 . Three groups of subjects were included, which were NMs (24.8%), GNs (49.8%) and AAs (25.4%), respectively. Regarding the personal variables, almost all participants were Vietnamese (96.7%), no religion (73.1%) and had good health condition (60%). Meanwhile, the comparison among each group showed that age ( F = 9.89, p < .001), gender (χ 2 = 6.48, p < .05), marital status (χ 2 = 6.77, p < .05) and education level (χ 2 = 147.38, p < .001) had reached the statistical significance. Further analysis showed that the age of NMs was significantly older than subjects in both the GN and AA group, AA group had a higher ratio of that in the GN group, and the AA group had a higher ratio of married one than the GN group. For educational levels, subjects in the NM group had a higher ratio of bachelor and master degree, whereas the other two groups had a high ratio of diploma and associate degree.
Characteristics of the participants ( n = 420)
Variables | Totals | Comparisons among work position | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
NM ( = 104) | GN ( = 209) | AA ( = 107) | χ | (1) NM | (2) GN | (3) AA | ‐test | Scheffe's post hoc | |||
(%) | Mean ± | (%) | Mean ± | ||||||||
Personal variables | |||||||||||
Age (years) | 32.54 ± 7.32 | 35.22 ± 7.08 | 31.46 ± 7.0 | 32.05 ± 7.56 | 9.89 | (1) > (2), (3) | |||||
Gender | |||||||||||
Male | 105 (25) | 28 (26.9) | 60 (28.7) | 17 (15.9) | 6.48 | ||||||
Female | 315 (75) | 76 (73.1) | 149 (71.3) | 90 (84.1) | |||||||
Marital status | |||||||||||
Single/divorced/widowed | 169 (40.2) | 34 (32.7) | 97 (46.4) | 38 (35.5) | 6.77 | ||||||
Married | 251 (59.8) | 70 (67.3) | 112 (53.6) | 69 (64.5) | |||||||
Ethnicity | |||||||||||
Vietnamese | 406 (96.7) | 101 (97.1) | 205 (98.1) | 100 (93.5) | 4.79 | ||||||
Other | 14 (3.3) | 3 (2.9) | 4 (1.9) | 7 (6.5) | |||||||
Religion | |||||||||||
No | 307 (73.1) | 82 (78.8) | 149 (71.3) | 76 (71) | 2.33 | ||||||
Yes | 113 (26.9) | 22 (21.2) | 60 (28.7) | 31 (29) | |||||||
Education level | |||||||||||
Diploma | 126 (30.0) | 3 (2.9) | 90 (43.1) | 33 (30.8) | 147.38 | ||||||
Associate | 123 (29.3) | 8 (7.7) | 64 (30.6) | 51 (47.7) | |||||||
Bachelor's/graduate | 171 (40.7) | 93 (89.4) | 55 (26.3) | 23 (21.5) | |||||||
Self‐rated health condition | |||||||||||
Very good | 51 (12.1) | 9 (8.7) | 27 (12.9) | 15 (14) | 6.63 | ||||||
Good | 252 (60.0) | 71 (68.3) | 126 (60.3) | 55 (51.4) | |||||||
Fair/bad/very bad | 117 (27.9) | 24 (23.1) | 56 (26.8) | 37 (34.6) | |||||||
Work‐related factors | |||||||||||
Duration of working as a nurse (years) | 9.30 ± 7.05 | 12.30 ± 7.12 | 8.08 ± 6.42 | 8.75 ± 7.20 | 13.08 | (1) > (2), (3) | |||||
Duration of working in the current hospital (years) | 8.81 ± 6.85 | 11.66 ± 7.02 | 7.66 ± 6.33 | 8.29 ± 6.93 | 12.98 | (1) > (2), (3) | |||||
Duration of working in the specific position (years) | 6.10 ± 5.46 | 5.06 ± 4.94 | 7.41 ± 6.21 | 4.05 ± 3.27 | 14.79 | (2) > (1) > (3) | |||||
Heard the term "CT" | |||||||||||
No | 280 (66.7) | 56 (53.8) | 151 (72.2) | 73 (68.2) | 10.74 | ||||||
Yes | 140 (33.7) | 48 (46.2) | 58 (27.8) | 34 (31.8) | |||||||
Previous exposure to CT training/education | |||||||||||
No | 420 (100) | 104 (100) | 209 (100) | 107 (100) |
Abbreviations: AA, Administrator assistant; CT , Critical thinking; GN, General nurse; NM, Nurses manager ; SD , standard deviation.
Chi‐square and one‐way ANOVA test; significant at * p < .05; ** p < .01; *** p < .001.
Regarding work‐related factors, the characters of all participants and subjects in each group are also listed in Table 1 . The comparison of professional experience, such as duration of working as a nurse, duration of working in the current hospital, duration of working in this specific position and heard the terminology of "critical thinking" showed a significant statistical difference among the three groups ( p < .001). They showed that NMs had a longer duration of working as a nurse (mean = 12.30, SD = 7.12) and duration of working in the current hospital (mean = 11.6, SD = 7.02) than the other two groups; GNs had the longest duration of working in the specific position (mean = 7.41, SD = 6.21). More subjects in the NM group heard the terminology of "critical thinking" than subjects in the other two groups. However, none of the subjects had been exposed to critical thinking training or education. Furthermore, there was a positive correlation among age, the duration of working as a nurse, the duration of working in the current hospital and duration of working in a specific position ( r = .78–.975, p < .01).
The mean of the total scores of the N‐CT‐4 Practice (V‐v) for all participants was 333.86 ± 40.22 (with the average score/item = 3.06 ± 0.37), the median score was 331 (interquartile range [IQR] = 311–359), and it ranged from 204–436, which indicates that they generally had a moderate level of critical thinking. Meanwhile, most of the participants reported a low (48.3%) or moderate (45.5%) level of critical thinking. Only 6.2% of the participants had a high level of critical thinking. Regarding the four dimensions of the N‐CT‐4 Practice (V‐v), the average sum score was 119.52 ± 14.19 (with the average score/item = 3.06 ± 0.36) in the personal dimension, 136.38 ± 17.62 (with the average score/item = 3.10 ± 0.40) in the intellectual and cognitive dimension, 68.71 ± 12.65 (with the average score/item = 3.44 ± 0.63) in the interpersonal and self‐management dimension and 18.09 ± 3.01 (with the average score/item = 3.01 ± 0.50) in the technical dimension.
There were statistically significant associations between the critical thinking ability and some work‐related factors, such as work position ( F = 23.30, p < .001), duration of working as a nurse ( r = 0.15, p < .01), duration of working in the current hospital ( r = 0.13, p < .05) and having heard the term "critical thinking" ( t = −2.48, p < .05; Table 2 ). The findings indicated that NMs had higher scores than GNs and AAs. Moreover, nurses who had worked for a longer duration as a nurse or worked longer in the current hospital had a higher critical thinking ability. Meanwhile, those who had not heard the term "critical thinking" had lower scores than participants who had heard this term.
Association between the participants’ characteristics and the critical thinking ability ( n = 420)
Variables | Mean ± | a/b/ ‐value | ‐value | Scheffe's comparison |
---|---|---|---|---|
Personal factors | ||||
Age | 0.12 | . | ||
Gender | ||||
Male | 341.70 ± 37.29 | 2.32 | . | |
Female | 331.24 ± 40.88 | |||
Marital status | ||||
Single/divorced/widowed | 331.24 ± 40.49 | −1.09 | .275 | |
Married | 335.62 ± 40.03 | |||
Ethnicity | ||||
Vietnamese | 334.57 ± 39.57 | 1.97 | . | |
Other | 313.07 ± 53.73 | |||
Religion | ||||
No | 334.63 ± 39.39 | 0.65 | .516 | |
Yes | 331.75 ± 42.51 | |||
Education level | ||||
(1) Diploma | 327.84 ± 38.20 | 7.45 | . | 3 > 1, 2 |
(2) Associate | 327.50 ± 39.25 | |||
(3) Bachelor's/graduate | 342.86 ± 40.80 | |||
Self‐rated health condition | ||||
(1) Very good | 343.94 ± 37.25 | 3.41 | . | 1 > 3 |
(2) Good | 334.97 ± 39.47 | |||
(3) Fair/bad/very bad | 327.06 ± 42.19 | |||
Occupational factors | ||||
Duration of working as a nurse | 0.15 | . | ||
Duration of working in the current hospital | 0.13 | . | ||
Duration of working in the specific position | 0.07 | .184 | ||
Heard the term “critical thinking” | ||||
No | 330.44 ± 39.68 | −2.48 | . | |
Yes | 340.69 ± 40.56 | |||
Work position | ||||
(1) Nurse manager | 355.49 ± 38.53 | 23.30 | 1 > 2, 3 | |
(2) General nurse | 329.11 ± 32.79 | |||
(3) Administrative assistant | 322.11 ± 46.89 |
The bolded values indicate the level of statistical significance (with p < .05; p < .01; or p < .001) between the independent and dependent variables.
Abbreviations: SD , standard deviation.
There were statistically significant associations between the critical thinking ability and some personal‐related factors, such as age ( r = 0.12, p < .05), gender ( t = 2.32, p < .05), ethnicity ( t = 1.97, p < .05), education level ( F = 7.45, p < .01) and health condition ( F = 3.14, p < .05; Table 2 ). The findings indicated that the older nurses reported a higher critical thinking ability, and male nurses had a higher score than female ones. Vietnamese participants had higher scores than participants with other ethnicities. Participants with a bachelor's/graduate degree level of education had higher scores than participants with a diploma and associate degree level of education. Those with very good health had a higher score than participants who rated their health as fair/bad/very bad.
All of the statistically significant variables identified in the univariate analysis were selected as independent variables to determine the predictors of critical thinking ability. For the regression analysis, the categorical variables were first coded as dummy variables. The factors of having never heard of “critical thinking,” being an NM being male, being Vietnamese, having a diploma degree and being in very good health were selected as the standard factors. The results of the stepwise multiple regression method showed that there were only two predictors, namely the variables of work position and gender. Working as an AA or GN or being female can predict the critical thinking ability, and they accounted for 11% of the total variance ( F = 17.12, p < .001). This indicates that the AAs and GNs had a lower level of critical thinking than the NMs. Besides, when compared with male nurses, the female nurses exhibited a lower level of critical thinking (Table 3 ).
Predictors of the critical thinking ability ( n = 420)
Model | Beta | ‐value | square | ‐value | ‐value | |
---|---|---|---|---|---|---|
Constant | 362.11 | 0.11 | 17.12 | |||
Administrative assistant | −32.38 | −0.351 | ||||
General nurse | −26.55 | −0.330 | ||||
Female | −9.05 | −0.098 | . |
This study showed that the critical thinking ability of most professional nurses was at a low or moderate level. This finding is consistent with previous studies (Chang et al., 2011 ; Lang et al., 2013 ; Zuriguel‐Pérez et al., 2018 ). Using the same tool, Zuriguel‐Pérez et al. ( 2018 ) found that the median score of the N‐CT‐4 Practice was 363 (IQR = 340–386) for clinical nurses in Spain. Our study found a slightly lower median score (331; IQR = 311–359) but it was still in a moderate level (range of score: 329–395). Although critical thinking is a relatively new issue in Vietnamese professional nurses, it is not a brand new concept. Certain elements have been included in the nursing curriculum and clinical practice (e.g. the nursing process, problem‐based learning, evidence‐based practice). Therefore, up to 66.7% of participants had never heard the term "critical thinking," but 45.5% still reported a moderate level when measured using the N‐CT‐4 Practice (V‐v).
In Vietnam, clinical professional nurses are categorized into NMs, GNs and AAs with different job descriptions. Critical thinking ability has been identified as an important component for the high quality of care around the world, except in Vietnam. In order to identify this ability, we collected data from 3 hospitals in one region and grouped these data for analysis. Based on the comparison among NMs, GNs and AAs, it was found that NMs had a higher level of critical thinking than GNs and AAs. This can be explained by the fact that NMs have a higher age, work experience and high educational qualification than the other two groups. This result partially supports the finding that NMs report a slightly higher level of critical thinking than RNs (Zuriguel‐Pérez et al., 2018 ). Critical thinking is a necessary skill for effective and efficient management. Evidently, at present, NMs with a high level of critical thinking create positive practice environments that can help the staff nurses to deliver high quality and safe patient care (Zori et al., 2010 ). Therefore, all healthcare personnel needs to learn and apply critical thinking in order to conduct their work effectively and efficiently.
For clinical nurses, continuous in‐service education is very important to update their knowledge and skill of care. Literature found various factors associated with curriculum design and learning of critical thinking ability. Therefore, grouping subjects in the present study together in order to identify the related factors could help the development of further in‐service education of critical thinking ability effectively and efficiently. In this study, a statistically significant positive correlation was found between the critical thinking ability and age, the duration of working as a nurse and the duration of working in the current hospital. These findings are consistent with previous studies. For example, older nurses have a higher level of critical thinking than younger ones (Chang et al., 2011 ; Chen et al., 2019 ; Feng et al., 2010 ; Ludin, 2018 ; Wangensteen et al., 2010 ; Yurdanur, 2016 ; Zuriguel‐Pérez et al., 2018 ), and nurses with more experience report a better critical thinking ability than those with less experience (Chang et al., 2011 ; Chen et al., 2019 ; Feng et al., 2010 ; Ludin, 2018 ). Older and experienced nurses are more mature in their way of thinking (Chen et al., 2019 ; Ludin, 2018 ). Because there were statistically significant positive correlations among age, the duration of working as a nurse and the duration of working in the current hospital. This indicates that older nurses have a longer duration of working as a nurse or working in the current hospital so they have better critical thinking. However, the correlation between these factors and critical thinking in the current study is small; further explorations are suggested.
This study showed that there is a significant association between critical thinking ability and gender and ethnicity, which is also supported by the literature. Ludin ( 2018 ) found that female nurses reported a lower critical thinking ability than male nurses. Traditionally, females have generally had fewer opportunities to receive education and more difficulty asserting their rights during decision‐making than males in Vietnam (L. T. Nguyen et al., 2017 ). Even today, the phenomenon of gender inequality still exists in certain areas in Vietnam. This traditional burden and the limited opportunities to practice in a clinical care setting might lower the levels of the female participants’ critical thinking. Ethnicity has a similar impact, as found in the present study. For example, it has been reported that Caucasian and Hispanic/Latino participants have a significantly higher critical thinking ability than African American participants (Lang et al., 2013 ) and that Malaysian and Indian participants report different levels of critical thinking; nevertheless, only 0.9% of the participants were Indian (Ludin, 2018 ). However, in the present study, as almost all of the participants were Vietnamese (96.7%), the skewed distribution of the ethnicity might limit the generalizability of the results. In future studies, an equal distribution of ethnicity is strongly recommended.
This study also confirmed that those who had a bachelor's/graduate degree had a higher level of critical thinking than those who had a diploma or associate degree, even though the former had never heard the term "critical thinking." A vast amount of studies has found that education has a positive impact on the level of critical thinking (Chang et al., 2011 ; Gloudemans et al., 2013 ; Ludin, 2018 ; Yildirim et al., 2012 ; Zuriguel‐Pérez et al., 2018 ). Meanwhile, this study found that participants who had heard the term "critical thinking" displayed a higher level of critical thinking than those who had not heard this term. Education might be the major reason for this variation. In the present study, only 40.7% of participants had a bachelor's/graduate degree. In order to promote their levels of critical thinking, it is necessary to arrange for them, to encourage them, to attend advanced education or to provide further content in the in‐service education.
In this study, participants with very good health had a higher level of critical thinking than participants who self‐rated their health as fair/bad/very bad. Health status does have an impact on work productivity, job performance, quality of care and extra learning (Letvak et al., 2011 ). Thus, poor health limits their learning and critical thinking ability. This ability is an important predictor of real‐life outcomes (e.g. interpersonal, work, financial, health and education) (Butler et al., 2017 ). Therefore, the causal effects between health and critical thinking ability need further exploration.
In the current study, only the female gender and the type of work position as an AA or GN were identified as predictors, and they explained only 11% of the total variance of critical thinking ability in the regression model. The uneven distribution of gender and work position might be the reason for the low variance. Even though the male was significantly less than the female, NM was fewer than GN and AA. More factors need to be included in further studies.
The limitations of this study include that it used a convenience sample from only three public hospitals located in the Southwestern part of Vietnam. This sample does not represent all professional nurses in Vietnam. The N‐CT‐4 Practice is the instrument with good psychometric properties specific for clinical practice and translated into English (Zuriguel‐Pérez et al., 2017), Persian (FallahNezhad & Ziaeirad, 2018 ) and Turkish (Urhan & Seren, 2019 ). Different points of the Likert response format were selected by tools to measure critical thinking ability. For example, the N‐CT‐4 Practice selected a four‐point Likert response and it was rated in frequency, such as 1 = never or almost never and 4 = always or almost always. However, a seven‐point Likert scale for the Critical Thinking Disposition Assessment (CTDA) was selected and rated in levels of agreement, such as 1 for very strongly disagree and 7 for very strongly agree (Cui et al., 2021 ). Which response format can be more reprinting the characters of critical thinking ability? Further investigation is strongly suggested. Besides, the N‐CT‐4 Practice (V‐v) questionnaire has too many items that may lead to the boredom of the participants to answer and thus affect the accuracy of the results. Moreover, the collapsing of three distinctly separate groups of nurses into one group for most of the analyses lead to not showing differences in critical thinking and influencing factors among the three groups. These factors all limit the generalization of the present results. Based on these limitations, it is suggested that the use of nationwide systematic sampling and an international comparison are strongly suggested in further studies. Regarding the critical thinking questionnaire, it would be better to use the revised versions with fewer questions. Therefore, developmental and psychometric properties are suggested to shorten this questionnaire.
The results demonstrate that most of the professional nurses had a low or moderate critical thinking ability. Certain personal and occupational variables were significantly associated with the level of critical thinking. Being male or working as an NM were statistically significant predictors of critical thinking ability, and they explained only 11% of the total variance.
The findings of this study indicate that it is necessary to develop strategies to improve the critical thinking ability of professional nurses. The critical thinking ability has been confirmed to be an essential factor for high‐quality health care that focuses on the quality of patient care and patient safety. Besides, providing more opportunities to pursue advanced degrees or enhancing the provision of in‐service education in hospitals that involves classroom teaching or web‐based learning is strongly recommended for this specific group of nurses. Consequently, the quality of patient care could be improved.
The authors declare that they have no competing interests.
The authors would like to thank the expert panel, translators, research assistants, the hospitals and all of the clinical nurses who participated in this study. We are indebted to the study participants and would like to dedicate the research findings to improving the critical thinking ability of Vietnamese professional nurses in the future. No specific grant was received from funding agencies in the public, commercial, or not‐for‐profit sectors.
Van Nguyen T, Liu H‐E. Factors associated with the critical thinking ability of professional nurses: A cross‐sectional study . Nurs Open . 2021; 8 :1970–1980. 10.1002/nop2.875 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
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Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills. Images sourced from Getty Images. Critical thinking in nursing is essential to providing high-quality patient care.
Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood ...
Critical thinking is applied by nurses in the process of solving problems of patients and decision-making process with creativity to enhance the effect. It is an essential process for a safe, efficient and skillful nursing intervention. Critical thinking according to Scriven and Paul is the mental active process and subtle perception, analysis ...
The following are examples of attributes of excellent critical thinking skills in nursing. 1. The ability to interpret information: In nursing, the interpretation of patient data is an essential part of critical thinking. Nurses must determine the significance of vital signs, lab values, and data associated with physical assessment.
Definition of Critical Thinking. Critical thinking is an intellectual process of analyzing, evaluating, and synthesizing information to make reasoned and informed decisions. What is Critical Thinking in Nursing? Critical thinking in nursing is a vital cognitive skill that involves analyzing, evaluating, and making reasoned decisions about ...
Critical thinking in nursing refers to the analytical process that nurses use to solve clinical problems and make decisions regarding patient care. It involves gathering information, questioning, analyzing, and applying theory to ensure high-quality care delivery. AI generated definition based on: Nurse Education in Practice, 2022
Critical thinking in nursing involves the ability to question assumptions, analyze data, and evaluate outcomes. It's a disciplined process that includes observation, experience, reflection, reasoning, and communication. For nurses, critical thinking means being able to make sound clinical judgments that can significantly affect patient outcomes.
Critical thinking is an integral part of nursing, especially in terms of professionalization and independent clinical decision-making. It is necessary to think critically to provide adequate, creative, and effective nursing care when making the right decisions for practices and care in the clinical setting and solving various ethical issues encountered.
Critical Thinking. Nursing education has emphasized critical thinking as an essential nursing skill for more than 50 years. 1 The definitions of critical thinking have evolved over the years. There are several key definitions for critical thinking to consider. ... resulting in the following definition: Critical thinking in nursing is an ...
The following benefits of critical thinking highlight the importance of this skill in nursing careers: Improves decision-making speed. A critical thinking mindset can help nurses make timely, effective decisions in difficult situations. A systematic method to evaluate decisions and move forward is a powerful tool for nurses. Refines communication.
In nursing, critical thinking is a broad term that includes reasoning about clinical issues such as teamwork, ... Definition: Providing quality patient care based on up-to-date, theory-derived research and knowledge, rather than personal beliefs, advice, or traditional methods.
In Brief. After a brief interaction with a nursing student, this nurse educator saw the wisdom of using critical thinking when teaching critical thinking. IN NURSING SCHOOL, I learned about two types of thinking: There is the regular kind, and then there is critical thinking. Although it sounds like it means thinking about important things ...
Critical thinking is a complex, dynamic process formed by attitudes and strategic skills, with the aim of achieving a specific goal or objective. The attitudes, including the critical thinking attitudes, constitute an important part of the idea of good care, of the good professional. It could be said that they become a virtue of the nursing ...
Critical thinking is the process of "actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action.". It's based on accuracy, sound evidence, fairness, and other ...
Critical thinking skills in nursing refer to a nurse's ability to question, analyze, interpret, and apply various pieces of information based on facts and evidence rather than subjective information or emotions. Critical thinking leads to decisions that are both objective and impartial. This aspect of clinical practice allows nurses to assess ...
Abstract Critical thinking is a complex, dynamic process formed by attitudes and strategic skills, with the aim of achieving a specific goal or objective. ... In this context, the ethics of virtue is a theoretical framework that becomes essential for analyse the critical thinking concept in nursing care and nursing science. Because the ethics ...
Defining Critical Thinking. Critical thinking, as a concept, has been examined and presented from a variety of perspectives. An early definition, proposed by Watson and Glaser (1964), described critical thinking as the combination of abilities needed to define a problem, recognize stated and unstated assumptions, formulate and select hypotheses, draw conclusions, and judge the validity of ...
Abstract. Critical thinking skills are essential to function in today's complex health care environment and to ensure continuing competence for the future. This article provides a review of various definitions and research studies related to critical thinking. Educators and researchers need to clearly define critical thinking, because there has ...
Critical thinking is the process of gathering information, fully assessing it and then developing an opinion in response. Nurses use critical thinking to make informed decisions about a patient's medical care such as choosing which tests to run and communicating their opinions to doctors. Nurses often are the first to examine a patient in a ...
What is Critical Thinking? Critical thinking is a term that is difficult to define because it is, by nature, somewhat subjective. The National Council for Excellence in Critical Thinking defines it as "the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation ...
The process includes five steps: assessment, diagnosis, outcomes/planning, implementation and evaluation. "One of the fundamental principles for developing critical thinking is the nursing process," Vest says. "It needs to be a lived experience in the learning environment.". Nursing students often find that there are multiple correct ...
5. Maintain flexibility. Finally, a good critical thinker will maintain flexibility. Critical thinking in nursing requires the ability to adapt to changing situations and share information. "Plan ahead knowing your plans will need adjustment as things change," suggests Lundy. "Listen to alternative ideas and approaches and offer your innovative ...
1. INTRODUCTION. Critical thinking is defined as the cognitive process of reasoning that involves trying to minimize errors and to maximize positive outcomes while attempting to make a decision during patient care (Zuriguel‐Pérez et al., 2015).The importance of critical thinking in nursing practice has been identified in the literature (Chang et al., 2011; Ludin, 2018; Mahmoud & Mohamed ...