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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

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

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The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

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 pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

What is Critical Thinking in Nursing? (With Examples, Importance, & How to Improve)

Successful nursing requires learning several skills used to communicate with patients, families, and healthcare teams. One of the most essential skills nurses must develop is the ability to demonstrate critical thinking. If you are a nurse, perhaps you have asked if there is a way to know how to improve critical thinking in nursing? As you read this article, you will learn what critical thinking in nursing is and why it is important. You will also find 18 simple tips to improve critical thinking in nursing and sample scenarios about how to apply critical thinking in your nursing career.

What is Critical Thinking in Nursing?

4 reasons why critical thinking is so important in nursing, 1. critical thinking skills will help you anticipate and understand changes in your patient’s condition., 2. with strong critical thinking skills, you can make decisions about patient care that is most favorable for the patient and intended outcomes., 3. strong critical thinking skills in nursing can contribute to innovative improvements and professional development., 4. critical thinking skills in nursing contribute to rational decision-making, which improves patient outcomes., what are the 8 important attributes of excellent critical thinking in nursing, 1. the ability to interpret information:, 2. independent thought:, 3. impartiality:, 4. intuition:, 5. problem solving:, 6. flexibility:, 7. perseverance:, 8. integrity:, examples of poor critical thinking vs excellent critical thinking in nursing, 1. scenario: patient/caregiver interactions, poor critical thinking:, excellent critical thinking:, 2. scenario: improving patient care quality, 3. scenario: interdisciplinary collaboration, 4. scenario: precepting nursing students and other nurses, how to improve critical thinking in nursing, 1. demonstrate open-mindedness., 2. practice self-awareness., 3. avoid judgment., 4. eliminate personal biases., 5. do not be afraid to ask questions., 6. find an experienced mentor., 7. join professional nursing organizations., 8. establish a routine of self-reflection., 9. utilize the chain of command., 10. determine the significance of data and decide if it is sufficient for decision-making., 11. volunteer for leadership positions or opportunities., 12. use previous facts and experiences to help develop stronger critical thinking skills in nursing., 13. establish priorities., 14. trust your knowledge and be confident in your abilities., 15. be curious about everything., 16. practice fair-mindedness., 17. learn the value of intellectual humility., 18. never stop learning., 4 consequences of poor critical thinking in nursing, 1. the most significant risk associated with poor critical thinking in nursing is inadequate patient care., 2. failure to recognize changes in patient status:, 3. lack of effective critical thinking in nursing can impact the cost of healthcare., 4. lack of critical thinking skills in nursing can cause a breakdown in communication within the interdisciplinary team., useful resources to improve critical thinking in nursing, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. will lack of critical thinking impact my nursing career, 2. usually, how long does it take for a nurse to improve their critical thinking skills, 3. do all types of nurses require excellent critical thinking skills, 4. how can i assess my critical thinking skills in nursing.

• Ask relevant questions • Justify opinions • Address and evaluate multiple points of view • Explain assumptions and reasons related to your choice of patient care options

5. Can I Be a Nurse If I Cannot Think Critically?

What is Critical Thinking in Nursing? (Explained W/ Examples)

Last updated on August 23rd, 2023

Critical thinking is a foundational skill applicable across various domains, including education, problem-solving, decision-making, and professional fields such as science, business, healthcare, and more.

It plays a crucial role in promoting logical and rational thinking, fostering informed decision-making, and enabling individuals to navigate complex and rapidly changing environments.

In this article, we will look at what is critical thinking in nursing practice, its importance, and how it enables nurses to excel in their roles while also positively impacting patient outcomes.

What is Critical Thinking?

Critical thinking is a cognitive process that involves analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

It’s a mental activity that goes beyond simple memorization or acceptance of information at face value.

Critical thinking involves careful, reflective, and logical thinking to understand complex problems, consider various perspectives, and arrive at well-reasoned conclusions or solutions.

Key aspects of critical thinking include:

• Analysis: Critical thinking begins with the thorough examination of information, ideas, or situations. It involves breaking down complex concepts into smaller parts to better understand their components and relationships.
• Evaluation: Critical thinkers assess the quality and reliability of information or arguments. They weigh evidence, identify strengths and weaknesses, and determine the credibility of sources.
• Synthesis: Critical thinking involves combining different pieces of information or ideas to create a new understanding or perspective. This involves connecting the dots between various sources and integrating them into a coherent whole.
• Inference: Critical thinkers draw logical and well-supported conclusions based on the information and evidence available. They use reasoning to make educated guesses about situations where complete information might be lacking.
• Problem-Solving: Critical thinking is essential in solving complex problems. It allows individuals to identify and define problems, generate potential solutions, evaluate the pros and cons of each solution, and choose the most appropriate course of action.
• Creativity: Critical thinking involves thinking outside the box and considering alternative viewpoints or approaches. It encourages the exploration of new ideas and solutions beyond conventional thinking.
• Reflection: Critical thinkers engage in self-assessment and reflection on their thought processes. They consider their own biases, assumptions, and potential errors in reasoning, aiming to improve their thinking skills over time.
• Open-Mindedness: Critical thinkers approach ideas and information with an open mind, willing to consider different viewpoints and perspectives even if they challenge their own beliefs.
• Effective Communication: Critical thinkers can articulate their thoughts and reasoning clearly and persuasively to others. They can express complex ideas in a coherent and understandable manner.
• Continuous Learning: Critical thinking encourages a commitment to ongoing learning and intellectual growth. It involves seeking out new knowledge, refining thinking skills, and staying receptive to new information.

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 patient care.

It’s an essential aspect of a nurse’s professional practice as it enables them to provide safe and effective care to patients.

Critical thinking involves a careful and deliberate thought process to gather and assess information, consider alternative solutions, and make informed decisions based on evidence and sound judgment.

This skill helps nurses to:

• Assess Information: Critical thinking allows nurses to thoroughly assess patient information, including medical history, symptoms, and test results. By analyzing this data, nurses can identify patterns, discrepancies, and potential issues that may require further investigation.
• Diagnose: Nurses use critical thinking to analyze patient data and collaboratively work with other healthcare professionals to formulate accurate nursing diagnoses. This is crucial for developing appropriate care plans that address the unique needs of each patient.
• Plan and Implement Care: Once a nursing diagnosis is established, critical thinking helps nurses develop effective care plans. They consider various interventions and treatment options, considering the patient’s preferences, medical history, and evidence-based practices.
• Evaluate Outcomes: After implementing interventions, critical thinking enables nurses to evaluate the outcomes of their actions. If the desired outcomes are not achieved, nurses can adapt their approach and make necessary changes to the care plan.
• Prioritize Care: In busy healthcare environments, nurses often face situations where they must prioritize patient care. Critical thinking helps them determine which patients require immediate attention and which interventions are most essential.
• Communicate Effectively: Critical thinking skills allow nurses to communicate clearly and confidently with patients, their families, and other members of the healthcare team. They can explain complex medical information and treatment plans in a way that is easily understood by all parties involved.
• Identify Problems: Nurses use critical thinking to identify potential complications or problems in a patient’s condition. This early recognition can lead to timely interventions and prevent further deterioration.
• Collaborate: Healthcare is a collaborative effort involving various professionals. Critical thinking enables nurses to actively participate in interdisciplinary discussions, share their insights, and contribute to holistic patient care.
• Ethical Decision-Making: Critical thinking helps nurses navigate ethical dilemmas that can arise in patient care. They can analyze different perspectives, consider ethical principles, and make morally sound decisions.
• Continual Learning: Critical thinking encourages nurses to seek out new knowledge, stay up-to-date with the latest research and medical advancements, and incorporate evidence-based practices into their care.

In summary, critical thinking is an integral skill for nurses, allowing them to provide high-quality, patient-centered care by analyzing information, making informed decisions, and adapting their approaches as needed.

It’s a dynamic process that enhances clinical reasoning , problem-solving, and overall patient outcomes.

What are the Levels of Critical Thinking in Nursing?

The development of critical thinking in nursing practice involves progressing through three levels: basic, complex, and commitment.

The Kataoka-Yahiro and Saylor model outlines this progression.

1. Basic Critical Thinking:

At this level, learners trust experts for solutions. Thinking is based on rules and principles. For instance, nursing students may strictly follow a procedure manual without personalization, as they lack experience. Answers are seen as right or wrong, and the opinions of experts are accepted.

2. Complex Critical Thinking:

Learners start to analyze choices independently and think creatively. They recognize conflicting solutions and weigh benefits and risks. Thinking becomes innovative, with a willingness to consider various approaches in complex situations.

3. Commitment:

At this level, individuals anticipate decision points without external help and take responsibility for their choices. They choose actions or beliefs based on available alternatives, considering consequences and accountability.

As nurses gain knowledge and experience, their critical thinking evolves from relying on experts to independent analysis and decision-making, ultimately leading to committed and accountable choices in patient care.

Why Critical Thinking is Important in Nursing?

Critical thinking is important in nursing for several crucial reasons:

Patient Safety:

Nursing decisions directly impact patient well-being. Critical thinking helps nurses identify potential risks, make informed choices, and prevent errors.

Clinical Judgment:

Nursing decisions often involve evaluating information from various sources, such as patient history, lab results, and medical literature.

Critical thinking assists nurses in critically appraising this information, distinguishing credible sources, and making rational judgments that align with evidence-based practices.

Enhances Decision-Making:

In nursing, critical thinking allows nurses to gather relevant patient information, assess it objectively, and weigh different options based on evidence and analysis.

This process empowers them to make informed decisions about patient care, treatment plans, and interventions, ultimately leading to better outcomes.

Promotes Problem-Solving:

Nurses encounter complex patient issues that require effective problem-solving.

Critical thinking equips them to break down problems into manageable parts, analyze root causes, and explore creative solutions that consider the unique needs of each patient.

Drives Creativity:

Nursing care is not always straightforward. Critical thinking encourages nurses to think creatively and explore innovative approaches to challenges, especially when standard protocols might not suffice for unique patient situations.

Fosters Effective Communication:

Communication is central to nursing. Critical thinking enables nurses to clearly express their thoughts, provide logical explanations for their decisions, and engage in meaningful dialogues with patients, families, and other healthcare professionals.

Aids Learning:

Nursing is a field of continuous learning. Critical thinking encourages nurses to engage in ongoing self-directed education, seeking out new knowledge, embracing new techniques, and staying current with the latest research and developments.

Improves Relationships:

Open-mindedness and empathy are essential in nursing relationships.

Critical thinking encourages nurses to consider diverse viewpoints, understand patients’ perspectives, and communicate compassionately, leading to stronger therapeutic relationships.

Empowers Independence:

Nursing often requires autonomous decision-making. Critical thinking empowers nurses to analyze situations independently, make judgments without undue influence, and take responsibility for their actions.

Facilitates Adaptability:

Healthcare environments are ever-changing. Critical thinking equips nurses with the ability to quickly assess new information, adjust care plans, and navigate unexpected situations while maintaining patient safety and well-being.

Strengthens Critical Analysis:

In the era of vast information, nurses must discern reliable data from misinformation.

Critical thinking helps them scrutinize sources, question assumptions, and make well-founded choices based on credible information.

How to Apply Critical Thinking in Nursing? (With Examples)

Here are some examples of how nurses can apply critical thinking.

Assess Patient Data:

Critical Thinking Action: Carefully review patient history, symptoms, and test results.

Example: A nurse notices a change in a diabetic patient’s blood sugar levels. Instead of just administering insulin, the nurse considers recent dietary changes, activity levels, and possible medication interactions before adjusting the treatment plan.

Diagnose Patient Needs:

Critical Thinking Action: Analyze patient data to identify potential nursing diagnoses.

Example: After reviewing a patient’s lab results, vital signs, and observations, a nurse identifies “ Risk for Impaired Skin Integrity ” due to the patient’s limited mobility.

Plan and Implement Care:

Critical Thinking Action: Develop a care plan based on patient needs and evidence-based practices.

Example: For a patient at risk of falls, the nurse plans interventions such as hourly rounding, non-slip footwear, and bed alarms to ensure patient safety.

Evaluate Interventions:

Critical Thinking Action: Assess the effectiveness of interventions and modify the care plan as needed.

Example: After administering pain medication, the nurse evaluates its impact on the patient’s comfort level and considers adjusting the dosage or trying an alternative pain management approach.

Prioritize Care:

Critical Thinking Action: Determine the order of interventions based on patient acuity and needs.

Example: In a busy emergency department, the nurse triages patients by considering the severity of their conditions, ensuring that critical cases receive immediate attention.

Collaborate with the Healthcare Team:

Critical Thinking Action: Participate in interdisciplinary discussions and share insights.

Example: During rounds, a nurse provides input on a patient’s response to treatment, which prompts the team to adjust the care plan for better outcomes.

Ethical Decision-Making:

Critical Thinking Action: Analyze ethical dilemmas and make morally sound choices.

Example: When a terminally ill patient expresses a desire to stop treatment, the nurse engages in ethical discussions, respecting the patient’s autonomy and ensuring proper end-of-life care.

Patient Education:

Critical Thinking Action: Tailor patient education to individual needs and comprehension levels.

Example: A nurse uses visual aids and simplified language to explain medication administration to a patient with limited literacy skills.

Adapt to Changes:

Critical Thinking Action: Quickly adjust care plans when patient conditions change.

Example: During post-operative recovery, a nurse notices signs of infection and promptly informs the healthcare team to initiate appropriate treatment adjustments.

Critical Analysis of Information:

Critical Thinking Action: Evaluate information sources for reliability and relevance.

Example: When presented with conflicting research studies, a nurse critically examines the methodologies and sample sizes to determine which study is more credible.

Making Sense of Critical Thinking Skills

What is the purpose of critical thinking in nursing.

The purpose of critical thinking in nursing is to enable nurses to effectively analyze, interpret, and evaluate patient information, make informed clinical judgments, develop appropriate care plans, prioritize interventions, and adapt their approaches as needed, thereby ensuring safe, evidence-based, and patient-centered care.

Why critical thinking is important in nursing?

Critical thinking is important in nursing because it promotes safe decision-making, accurate clinical judgment, problem-solving, evidence-based practice, holistic patient care, ethical reasoning, collaboration, and adapting to dynamic healthcare environments.

Critical thinking skill also enhances patient safety, improves outcomes, and supports nurses’ professional growth.

How is critical thinking used in the nursing process?

Critical thinking is integral to the nursing process as it guides nurses through the systematic approach of assessing, diagnosing, planning, implementing, and evaluating patient care. It involves:

• Assessment: Critical thinking enables nurses to gather and interpret patient data accurately, recognizing relevant patterns and cues.
• Diagnosis: Nurses use critical thinking to analyze patient data, identify nursing diagnoses, and differentiate actual issues from potential complications.
• Planning: Critical thinking helps nurses develop tailored care plans, selecting appropriate interventions based on patient needs and evidence.
• Implementation: Nurses make informed decisions during interventions, considering patient responses and adjusting plans as needed.
• Evaluation: Critical thinking supports the assessment of patient outcomes, determining the effectiveness of intervention, and adapting care accordingly.

Throughout the nursing process , critical thinking ensures comprehensive, patient-centered care and fosters continuous improvement in clinical judgment and decision-making.

What is an example of the critical thinking attitude of independent thinking in nursing practice?

An example of the critical thinking attitude of independent thinking in nursing practice could be:

A nurse is caring for a patient with a complex medical history who is experiencing a new set of symptoms. The nurse carefully reviews the patient’s history, recent test results, and medication list.

While discussing the case with the healthcare team, the nurse realizes that the current treatment plan might not be addressing all aspects of the patient’s condition.

Instead of simply following the established protocol, the nurse independently considers alternative approaches based on their assessment.

The nurse proposes a modification to the treatment plan, citing the rationale and evidence supporting the change.

This demonstrates independent thinking by critically evaluating the situation, challenging assumptions, and advocating for a more personalized and effective patient care approach.

How to use Costa’s level of questioning for critical thinking in nursing?

Costa’s levels of questioning can be applied in nursing to facilitate critical thinking and stimulate a deeper understanding of patient situations. The levels of questioning are as follows:

• 15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)
• Nursing Concept Map (FREE Template)
• Clinical Reasoning In Nursing (Explained W/ Example)
• 8 Stages Of The Clinical Reasoning Cycle
• How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples
• What is the “5 Whys” Technique?
• What Are Socratic Questions?

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.

Reading Recommendation

Potter, P.A., Perry, A.G., Stockert, P. and Hall, A. (2013) Fundamentals of Nursing

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Critical thinking in nursing clinical practice, education and research: From attitudes to virtue

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• 1 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, Consolidated Research Group Quantitative Psychology (2017-SGR-269), University of Barcelona, Barcelona, Spain.
• 2 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, Consolidated Research Group on Gender, Identity and Diversity (2017-SGR-1091), University of Barcelona, Barcelona, Spain.
• 3 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, University of Barcelona, Barcelona, Spain.
• 4 Multidisciplinary Nursing Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Hospital, Barcelona, Spain.
• PMID: 33029860
• DOI: 10.1111/nup.12332

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 profession. 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 of virtue consider how cultivating virtues are necessary to understand and justify the decisions and guide the actions. Based on selective analysis of the descriptive and empirical literature that addresses conceptual review of critical thinking, we conducted an analysis of this topic in the settings of clinical practice, training and research from the virtue ethical framework. Following JBI critical appraisal checklist for text and opinion papers, we argue the need for critical thinking as an essential element for true excellence in care and that it should be encouraged among professionals. The importance of developing critical thinking skills in education is well substantiated; however, greater efforts are required to implement educational strategies directed at developing critical thinking in students and professionals undergoing training, along with measures that demonstrate their success. Lastly, we show that critical thinking constitutes a fundamental component in the research process, and can improve research competencies in nursing. We conclude that future research and actions must go further in the search for new evidence and open new horizons, to ensure a positive effect on clinical practice, patient health, student education and the growth of nursing science.

Keywords: critical thinking; critical thinking attitudes; nurse education; nursing care; nursing research.

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Critical thinking skills for back to school

Davis, Charlotte BSN, RN, CCRN

Charlotte Davis is a CCU/CVICU Clinical Nurse at Heritage Medical Center in Shelbyville, Tenn., and a Clinical Nurse/Charge Nurse/CCRN Review Program Coordinator at Alvin C. York VA Medical Center in Murfreesboro, Tenn. She is also a Nursing made Incredibly Easy! Editorial Advisory Board Member.

The author has disclosed that she has no financial relationships related to this article.

Thinking about returning to school or have you recently returned? If so, then you need to hone your critical thinking skills. These are skills you use every day in your practice—the purposeful, disciplined, intellectual process of applying skillful reasoning as a guide to our thoughts, assessments, or interventions.

In nursing, critical thinking is a logical and multifaceted process that guides our clinical decision making. It's a systematic and logical approach that encourages us to question our current nursing interventions through logical reasoning and reflection. Critical thinking requires us to ask: “Is this the best way to perform this intervention? Or is this the most effective intervention for my patient or my work area?”

So how can you put these skills to work when going back to school? Let's take a closer look.

The crucial seven

There are seven critical thinking skills that all nurses utilize in their professional roles.

Our job roles call for us to analyze objective and subjective data. As clinical nurses, we utilize the critical thinking skill of objectively analyzing the efficacy of new evidence-based practice (EBP) interventions as we incorporate them into our daily practice.

When returning to school, use your analytical skills to compare each school's curriculum and costs to ensure they meet your professional goals.

• Applying standards

All members of the healthcare team should utilize their intellectual integrity and apply professional and organizational standards of care into their daily practice. As nurses, we apply professional standards to ensure that we remain proficient and competent in our job roles. Common places to search for professional standards are your state board of nursing, the American Nurses Association, or the American Nurses Credentialing Center. Professional standards are the basic guidelines and principles around which we base our interventions and care plans. They help us ensure clinically competent, skillful, and safe care.

Utilize your critical thinking skill of applying standards when evaluating undergraduate and graduate programs to ensure they're accredited by a widely accepted governing body such as the American Association of Colleges of Nursing.

• Discriminating data

We must discriminate data and decide if an intervention has been effective or if it's safe and appropriate for our patient population or clinical work area. We're inundated with extensive data from pharmaceutical companies, research trials, governing bodies, and scholarly journals. We must distinguish the potential risks and benefits associated with any procedure, intervention, or treatment that might resolve a system failure, improve a patient outcome, or improve the work environment. As clinical nurses, we routinely discriminate data to identify any potential risks associated with a new intervention before we implement it into our daily practice.

When returning to school, you'll discriminate data as you evaluate each nursing program's curriculum, costs, reputation, and retention rates to determine what's the best fit to help meet your long-term professional goals.

• Seeking information

Inquiry is an eagerness to know by seeking knowledge and understanding through observation, review, analysis, and thoughtful questioning to explore possibilities and effective alternatives. Inquisitiveness is a thirst for knowledge and understanding through observation and targeted questioning with a goal of identifying the possibility of more effective or efficient alternatives. You can foster your sense of inquiry by exploring new EBP guidelines and clinical research outcomes within your specialty area.

Nurses have always sought more efficient ways to provide safe patient care, resolve delays in care delivery, and improve clinical outcomes and work areas. Seeking information exposes us to innovative interventions, procedures, or practices that can enhance our professional nursing role. Begin your journey of attaining an advanced degree by first seeking information on what job role you'd like to have and determining the educational requirements that are needed. Nursing is a highly specialized field with limitless possibilities that range from positions such as certified registered nurse anesthetist to advanced practice nurse practitioner to executive leadership positions.

• Logical reasoning

Logical reasoning allows us to interpret conclusions that are supported by evidence. We can assess the efficacy of nursing interventions and delivery systems, along with identifying patterns and predicting likely outcomes. Systematic processing of information is a characteristic of logical reasoning to identify trends and outcomes associated with specific interventions, diagnoses, symptoms, or behaviors.

You can utilize your logical reasoning skills to resolve barriers that may impair your ability to return to school, such as childcare arrangements or applying for scholarships. If you struggle with successfully navigating or completing online in-services, you might utilize your logical reasoning skills to determine that your education action plan may be most effective if delivered in a classroom versus an online setting.

• Envisioning a plan

We must be forward thinkers and envision a plan for our patients, clinical work areas, professional projects, and careers to meet the expectations of tomorrow. Formulating a plan requires us to utilize the nursing process steps of assessment, diagnosis or problem identification, planning, implementation, and evaluation. This is a step-by-step process with a clear goal or objective.

When contemplating returning to school, envision a plan on how to realistically attain that goal. This plan should include how to maintain your work, family, and school obligations. After you begin to formulate your plan, you can resolve barriers to meeting your goal.

• Transforming knowledge

It's vital to the nursing profession that we transform our knowledge to meet the growing complexities of our patients' healthcare needs. There's an evolving need for nurses to utilize the knowledge we acquire and function as transformational leaders who create positive change and can translate the vision, goals, and purpose of our organization and profession to peers and staff on the unit and organizational level.

As our profession continues to grow in both clinical practice and national recognition, we must be open to exploring innovative, safe alternatives to all aspects of our nursing practice. When you seek additional education, you expand your current knowledge base and challenge your old thought processes. We must continue to utilize our newly acquired knowledge and insight to formulate creative solutions to improve our current practices and resolve barriers that impact the nursing profession and our healthcare team, facility, and patient population.

Let's get critical

As nurses, we utilize our critical thinking skills as we collect and analyze data while providing direct care to patients, as well as evaluate qualitative or quantitative research studies to decide if interventions may be applicable to our patient population. We can use the same skills to attain a professional goal, such as specialty certification or an advanced nursing degree (see Using your critical thinking skills to choose a program ).

Critical thinking inspires us to thoroughly evaluate all aspects of a problem and acquire an adequate knowledge base to help us see all of the possible solutions. Enhancing your critical thinking skills can help you develop a clear education action plan to achieve your professional goals. Let's get started!

cheat sheet

Seven critical thinking skills.

Using your critical thinking skills to choose a program

• Analyze —Gather information on the schools you're considering, such as their retention and graduation rates. Ask questions such as how long have their instructors been educating nurses, what's the curriculum, and what's the duration of classes.
• Apply standards —Is your targeted school accredited? Check with the school or accrediting body to determine the length of time for which the school is accredited. Common accrediting organizations include the Accreditation Commission for Education in Nursing, the Commission on Collegiate Nursing Education, the Council on Accreditation of Nurse Anesthesia Educational Programs, and the American College of Nurse-Midwives.
• Discriminate data —Multiple factors may need to be evaluated when contemplating returning for an undergraduate or graduate nursing degree, such as cost, convenience, and the quality of the curriculum.
• Seek information —Consider attending an onsite tour of the school you're considering. Preschedule an appointment with the admissions department, financial aid, program coordinator, or curriculum consultant for your perspective nursing program.
• Logical reasoning —Look at each program to see which one fits best with your lifestyle and learning needs. Although many nurses prefer to take online classes for convenience, live classes may better meet your learning style. Also, many organizations offer to pay for your tuition, but you must typically be committed to staying at the organization for a set number of years or you'll have to repay tuition and expenses.
• Envision a plan —You're in charge of your career success. You must envision a plan on how you can attain your degree and apply your energy to make that dream happen. It can be challenging to balance your home, work, and educational obligations to plan for a better, more rewarding career in the future. You can do this!
• Transform knowledge —By starting on your journey to attaining your targeted nursing degree, you'll evolve into a leader within your organization. As you progress though each class, you're one step closer to your dream job and changing the lives of many patients and peers along the way.

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Home / Nurse Practitioner / Critical Care Nurse Practitioner

Critical Care Nurse Practitioner

What is a Critical Care Nurse Practitioner (CCNP)?

Becoming a critical care nurse practitioner, step 1: ccnp education requirements and training, step 2: ccnp examination, licensure, and certification, step 3: finding a job and career outlook, critical care nurse practitioner salary & employment, helpful organizations, societies, and agencies.

Critical Care Nurse Practitioners, or CCNPs, are advanced practice registered nurses (APRNs) who specialize in treating critically ill patients. Like all nurse practitioners, they are trained to diagnose, treat, and manage medical conditions, but their specialization is focused on life-threatening illnesses. They work closely with physicians, nurses, and other healthcare team members to provide comprehensive care, including the administration of advanced therapies, monitoring of vital signs, and making critical decisions regarding patient treatment plans. Their role is essential in ensuring that patients receive timely and effective care during the most critical stages of their illness, making them an integral part of the healthcare team in settings like ICUs, trauma centers, and emergency departments.

Overview of CCNP Careers

The journey to becoming a Critical care nurse starts with your educational prospects. Here are the requirements you must meet before entering the field.

Once you’ve met the preliminary requirements, here’s what you can expect upon entering the field.

Why Are Critical Care Nurse Practitioners So Important?

Out of the pool of potential nurse practitioner specializations, there are few that present a more important role in the lives of their patients than a critical care nurse practitioner. The word “critical” is in the title for a reason. Critical care nurse practitioners are often the barrier between life and death. When a patient’s life is at stake, critical care nurse practitioners rely on their training of life-treatening conditions and work under immense pressure to save their lives.

If working in a face-paced and intense but highly rewarding medical setting sounds like the career path for you, you’ll need to invest at least six years towards your education and several more to fulfill your licensening, training, and certification requirements. Here is a collection of general timelines to expect throughout the process:

To become a critical care nurse practitioner, you’ll have to earn a Bachelor’s Degree in Nursing (BSN) followed by either a Master’s Degree in Nursing (MSN) or a Doctorate of Nursing Practice (DNP). Once you have a graduate degree in nursing, you’ll be eligible to get your license as a nurse practitioner and specialize in critical care.

See our compiled list of available ACNP programs available to you.

Educational Prerequisites

Before you begin your educational journey, it’s important to make sure that you meet the prerequisite requirements. Because you’ll need to graduate from a nursing graduate degree program, first you’ll need a BSN and RN licensure. To achieve these you’ll need the following:

• Minimum GPA : Usually 3.0 or higher.
• Prerequisite Courses : Completion of courses like statistics, anatomy, and physiology.
• Letters of Recommendation : From nursing supervisors or faculty.
• Clinical Nursing Experience : 1-2 years of experience, often in a relevant field.

If you already have an Associate’s Degree in Nursing (ADN), you may be eligible to enroll in an RN to BSN program . This bridge program allows you to get your BSN in as little as two years as opposed to four years without licensure. If you hold an ADN and are certain you’d like to join the nurse practitioner ranks, you can also consider an RN to MSN degree program to speed up the process of earning an advanced nursing degree.

Upon the completion of your graduate nursing degree, you will be eligible to get your nurse practitioner license and get certified in the critical care field. During your graduate program, you will likely be given the opportunity to specialize in the critical care field. During this time, you’ll be given field-specific training, which will come in handy when it comes time to pass a certification exam offered by recognized bodies like the American Nurses Credentialing Center (ANCC) or the American Association of Critical-Care Nurses (AACN) upon graduation. These exams assess the candidate's ability to manage complex, critically ill patients and their proficiency in performing advanced procedures.

CCNPs must also obtain licensure to practice in their respective states. This involves holding an active and unencumbered RN license and applying for state-specific Advanced Practice Registered Nurse (APRN) licensure, which may include meeting additional state requirements such as supervised clinical hours or a jurisprudence exam. Certification renewal typically requires ongoing continuing education and clinical practice hours, ensuring that CCNPs stay current with the latest advancements in critical care. This rigorous process ensures that CCNPs are well-equipped to provide high-quality, life-saving care in the most challenging healthcare environments.

Since Critical Care NP licensing, certification, and renewals can have slightly different requirements from state to state, it’s crucial to check with your state’s Board of Nursing for specific instructions on securing and maintaining your Critical Care Nurse Practitioner license.

Education, licensing, training, and certification make up the bulk of the journey to becoming a critical care nurse practitioner, but finding your first job as a CCNP is a journey. Fortunately, the job market is incredibly forgiving of nurse practitioners with limited field experience. CCNP positions are expected to grow at around 46% by 2032. For many future CCNPs, this will mean that there will be ample opportunity to find the perfect position in:

• Intensive Care Units (ICUs)
• Trauma Centers
• Emergency Departments (EDs)
• Cardiac Care Units (CCUs)
• Surgical Intensive Care Units (SICUs)

Working Conditions

The day-to-day work environment of a critical care nurse practitioner is not an easy one. In fact, it’s one of the most intense and stressful career paths you could choose in the medical field. CCNPs must navigate the challenges of providing compassionate care while maintaining the clinical detachment needed to make sound medical decisions. They are frequently involved in difficult conversations about prognosis, treatment options, and end-of-life care, which requires not only medical expertise but also strong communication skills and emotional resilience. Despite these challenges, many CCNPs find their work deeply rewarding, as they play a vital role in saving lives and improving patient outcomes, especially amongst chronically ill and underserved demographics.

Critical Care Nurse Practitioner Responsibilities & Duties

The role of a critical care nurse will vary depending on the location of employment. Still, it’s safe to assume that it will involve providing care and treatment to patients facing life-treatening conditions. Here are a few examples of typical duties that critical care nurse practitioners will fulfill:

• Performing Comprehensive Patient Assessments : Evaluate the physical and mental condition of critically ill patients, including interpreting diagnostic tests.
• Developing and Implementing Treatment Plans : Create individualized care plans based on patient needs, involving medication management, advanced therapies, and interventions.
• Performing Advanced Procedures : Carry out procedures such as intubation, central line insertion, chest tube placement, and managing mechanical ventilation.
• Monitoring Patient Progress : Continuously assess patient responses to treatment, adjusting care plans as needed.
• Collaborating with Healthcare Teams : Work closely with physicians, nurses, and other healthcare professionals to ensure comprehensive patient care.
• Educating Patients and Families : Provide guidance and support to patients and their families, explaining treatment options and expected outcomes.

Because they lead incredibly stressful careers (even compared to the medical field), critical care nurse practitioners have some of the highest NP salaries , some even matching some types of physicians. According to ZipRecruiter, the average annual wage for critical care nurse practitioners is $172,199 with a total range of $54,000 to $400,000; however, most salaries fall in the range of $90,000 to $190,000. If you’re looking to make the higher end of this spectrum, you may want to consider getting licensed in a state that has higher-paying salaries or those with a higher rate of employment. According to the Bureau of Labor Statistics , the highest-paying states for nurse practitioners are:

The states with the highest level of employment for nurse practitioners are:

• AACN: American Association of Critical-Care Nurses
• Society of Critical Care Medicine | SCCM
• Critical Care Societies Collaborative | SCCM

List of Other Nurse Practitioner & APRN Careers

• Open access
• Published: 27 September 2024

Relationship between hospital ethical climate, critical thinking disposition, and nursing task performance

• Seul-Ki Park   ORCID: orcid.org/0000-0003-0151-4161 1 &
• Yeo-Won Jeong   ORCID: orcid.org/0000-0003-3824-5209 2  

BMC Nursing volume  23 , Article number:  696 ( 2024 ) Cite this article

Metrics details

As ethical conflicts increase in the ever-changing healthcare field, nursing task performance, which is the overall ability of a nurse’s professional knowledge, attitude, and skills, is important for patient health and safety, the provision of quality nursing care, and the appropriate resolution of nursing ethical problems. This study aimed to evaluate the mediating effect of critical thinking disposition on the relationship between hospital ethical climate and nursing task performance.

A cross-sectional study was conducted. A total of a convenience sample of 200 clinical nurses from two Korean cities were recruited between November and December 2021. Direct questionnaires and online surveys were used to collect the data. The study variables were analyzed using descriptive statistics, correlations, and a model tested using the Hayes PROCESS macro (Model 4) mediation model.

The mean scores for hospital ethical climate, critical thinking disposition, and nursing task performance were 91.86 ± 11.29, 97.74 ± 10.70, and 138.58 ± 14.95, respectively. Hospital ethical climate and critical thinking disposition were positively correlated with nursing task performance. In the mediation test model, hospital ethical climate was found to be positively and significantly associated with nursing task performance (ß = 0.46, p  < .001) with the mediation of critical thinking disposition (ß = 0.70, p  < .001).

Conclusions

Hospital ethical climate and critical thinking disposition may be important determinants of task performance among clinical nurses. Hospital administrators should make efforts to create a more positive ethical climate in hospitals and conduct education and campaigns on a positive hospital ethical climate for hospital staff to improve nurses’ performance.

Peer Review reports

Introduction

Owing to changes in disease structure and the rapidly aging population, nurses face ethical issues and ethically difficult situations in their daily work. The frequent triggers of ethical dilemmas in nursing practice are conflicting interpersonal relationships (patient, co-workers, or physicians), lack of trust of the patient or family member, workload affecting quality of nursing, poor organization of working process, and conflicts related to the health service and management system [ 1 , 2 ]. Haahr et al. reported that balancing harm and care is one of the ethical dilemmas, that refers to nurses’ values practice conflict leading them to perform nursing actions that are against their personal and professional values [ 1 ]. Moreover, the complexity of ethical situations in healthcare environments and nursing is increasing, affecting not only nurses but also the quality of nursing [ 3 , 4 ]. The Korean nursing community has adopted the Nursing Code of Ethics [ 5 ], emphasizing the significance of ethical environments and nurses’ ethical behavior in the field of nursing [ 6 ]. Ethical behavior of organizational members occurs among individuals; however, an individual’s unethical behavior may be condoned or aided depending on the organization’s ethical environment [ 6 ]. Therefore, the ethical climate of an organization influences the behavior or practice of members in the work environment.

Hospital ethical climate and nursing task performance

Hospital ethical climate refers to nurses’ perceptions of how ethical issues are handled in their work setting [ 7 , 8 ]. Different researchers mention multiple constructs of hospital ethical climate [ 7 , 9 ]; among them, our study adopted Olson’s conceptualization of hospital ethical climate with five dimensions related to colleagues, patients, managers, hospital/organization, and physicians [ 7 ]. Many studies on hospital ethical climate have focused on its association with work-related factors, such as job satisfaction, moral distress, and turnover intentions [ 4 , 6 ]. In South Korea, the variables commonly found in jobs and organizations are job stress, supervisor trust, and organizational commitment rather than personal [ 6 ]. In particular, the hospital ethical climate reflects organizational practices and values in care issues and is an important factor that affects the professional performance and ethical practices of nurses in that organization [ 8 ]. However, most previous studies did not address nursing professional practices as a personal variable, such as nursing task performance, when investigating hospital ethical climate [ 4 , 6 , 10 , 11 , 12 ]. In addition, Noh and Lee suggested expanding the research to evaluate the relationship between hospital ethical climate and various variables such as nursing tasks and nursing outcomes [ 6 ].

Nursing task performance refers to the ability to perform tasks that require the nursing process and provide effective patient care [ 13 , 14 , 15 ]. Nursing task performance has a significant impact on the quality of nursing and nursing competency [ 15 , 16 ]. Nursing competency—an integrated or effective performance required for nurses’ roles in the work setting [ 17 , 18 ]—is positively affected by ethical climate [ 8 ]. Numminen et al.’s study of 318 newly graduated nurses showed that the hospital ethical climate is positively correlated with nurse competency [ 8 ]. However, some studies have reported that nurses with less than one year of work experience are susceptible to hospital ethical climates [ 8 , 19 ]. Thus, this study included nursing task performance as a variable in our exploration of hospital ethical climate with nurses who had been working for more than one year to compare our work with previous findings.

Hospital ethical climate, nursing task performance, and critical thinking disposition

Critical thinking disposition can be defined as a person’s consistent internal motivation to solve problems and make decisions by thinking critically [ 20 ], and a measure to a tendency towards critical thinking [ 20 , 21 ]. Critical thinking disposition is an attitude to actively engage in critical thinking in situations that require critical thinking [ 21 ]. Nurses with a higher critical thinking disposition solve clinical problems to search for the cause and make decisions with careful consideration based on clinical evidence [ 22 ]. In particular, in rapidly changing clinical settings, nurses experience ethical dilemmas in the relationships with patients, colleagues, and organization, which are key elements of the hospital ethical climate, and this has been shown to be a factor that causes difficulties in nursing task performance and inhibiting nurse’s professional decision-making [ 1 ]. In addition, owing to the emergence of new infectious diseases such as COVID-19, nurses face more complex and high-level ethical challenges including fear of infection, disappointing results of treatment, and high mortality rate [ 23 ], and they are required to think critically to make decisions appropriate for these ethical situation. In Yuxiu Jia et al.’s qualitative study, nurses were reported to develop nursing strategies rooted in critical thinking to cope with ethical challenges [ 23 ], influenced by the hospital ethical climate [ 1 , 8 ]. Furthermore, some studies reported that critical thinking disposition is significantly associated with nursing task performance [ 24 , 25 ]. Choi & Cho's study targeting 419 nurses in a general hospital, critical thinking disposition and problem-solving processes were found to be factors that significantly affect nursing task performance [ 24 ]. In rapidly changing clinical setting, the study reported that critical thinking disposition of nurses is the one of the most important ability in resolving various ethical issues or dilemmas that arise during the process of nursing to patients from diverse cultural, social, and religious backgrounds [ 24 ]. Based on existing findings, we theorized that hospital ethical climate and nursing task performance may be related in a pathway through critical thinking disposition among nurses with one year of experience in a clinical setting.

Despite the need to consider hospital ethical climate, in a scoping review on ethical climate in the nursing environments, South Korea has the least amount of research compared to other countries [ 4 ], and interest in nurses’ perception of the ethical climate has not sufficiently spread in South Korea [ 6 ]. Moreover, the higher the critical thinking disposition, the higher the nurses’ decision making [ 22 ]. Therefore, to provide quality care to patients through accurate judgment in clinical settings, a disposition toward critical thinking and nursing task performance is important for nurses. However, to the best of our knowledge, no previous studies have examined the relationship between these three variables. Thus, we addressed this gap in the literature by investigating the relationship between hospital ethical climate, critical thinking disposition, and nursing task performance.

Research design

We conducted a cross-sectional survey. This study aimed to investigate the association between hospital ethical climate, critical thinking disposition, and nursing task performance, and confirm the mediating effect of critical thinking disposition on these relationships (Fig.  1 ).

Study model

Settings and participants

Nurses working in cities in Ulsan, South Korea were recruited using convenience sampling. Based on prior studies, nurses with less than one year of work experience were susceptible to the hospital ethical climate [ 8 , 19 ]; therefore, in this study, the inclusion criteria for the participants were nurses with more than one year of experience working in a general hospital. For regression analysis, the sample size was calculated using G*Power 3.1.9.7. The minimum number of participants needed for a statistical power of 0.95, a significance level of 0.05, and 12 predictors based on an effect size of 0.15, was 184. Considering an expected dropout rate of 20%, 220 printed questionnaires with consent forms were distributed and returned. A total of 200 valid questionnaires were used in the final analysis, after excluding 20 questionnaires with missing data.

Instruments

Hospital ethical climate.

Hospital ethical climate was measured using the Korean version of the Hospital Ethical Climate Survey (HECS) for Nurses developed by Olson [ 7 ]. Hwang and Park translated and validated the scale [ 26 ]; it comprises 26 items across five components: relationship with peers (four items), relationship with patients (four items), relationship with managers (six items), relationship with physicians (six items), and relationship with hospital/organization (six items). The responses are assessed on a 5-point Likert scale (ranging from 1 = “almost never true” to 5 = “almost always true”). A higher score indicated a more positive the perception of the hospital ethical climate. Cronbach’s alpha was 0.91 in Olson’s study, 0.95 in Hwang and Park’s study, and 0.92 in this study.

Critical thinking disposition

The Critical Thinking Disposition Scale, developed by Yoon [ 21 ] and validated by Shin, Park, and Kim [ 27 ] was used to measure critical thinking disposition. The scale comprises 27 items and seven categories: intellectual eagerness/curiosity (five items), prudence (four items), self-confidence (four items), systematicity (three items), intellectual fairness (four items), healthy skepticism (four items), and objectivity (three items). Each item is rated on a 5-point Likert scale (1 = do not agree at all, 5 = absolutely agree), and a higher score with a total score ranging from 27 to 135. Higher total or item scores indicate a higher critical thinking disposition. Two negatively worded items were reverse scored. Cronbach’s alpha was 0.84 in Yoon’s study and.90 in this study.

Nursing task performance

The Nursing Task Performance Scale developed by Paik, Han, and Lee was used to measure task performance among clinical nurses [ 28 ]. The scale comprises 35 items in four categories: knowledge-related nursing task performance (eight items), attitude evaluation regarding passion on nursing task performance (13 items), skills for nursing task performance (seven items), and evaluation of nursing ethics levels (seven items). Each item is rated on a 5-point Likert scale (1 = not at all, 5 = always). The higher total and item scores indicating higher nursing task performance. Cronbach’s alpha was 0.97 in Pack, Han and Lee’s study, and 0.96 in this study.

The measured covariates included age, sex, marital status, religion, education level, total duration of clinical experience, department, recognition of the Korean code of ethics for nurses, and education on nursing ethics.

Survey data collection and procedure

Survey data were collected between November and December 2021. First, permission for the study was obtained from the chief nursing department of each hospital. Thereafter, one of the researchers contacted the nurses directly at each hospital and explained the study’s purpose, procedure, and questionnaire content. Moreover, nurses were informed that participation was voluntary and that they could withdraw at any time during the study without any negative consequences. The questionnaires were then distributed along with a consent form, and those who did not understand the items in the questionnaires could ask the researcher for help to fill them out. One of the researchers collected the completed questionnaires. In the case of another hospital, we provided the URL for the survey using Google Surveys owing to the risk of COVID-19. We uploaded the same questionnaires to a Google survey, and the first page of the survey contained the purpose, procedure, voluntary nature, and withdrawal from the study. In addition, at the bottom of the first page, a button (“I agree”) was created, and clicking it would denote that the participants has agreed to participate in the study. For those who did not understand the items in the questionnaire, the contact number and email were provided on the first page, and the researchers responded and explained the study whenever the participants requested.

Data analysis

Data were analyzed using SPSS (version 25.0; IBM Corp., Armonk, NY, USA) and the SPSS PROCESS macro v3.4. Skewness and kurtosis for each main variable (critical thinking disposition, hospital ethical climate, and nursing task performance) were checked to determine whether the data were normally distributed (skewness range of all main variables -0.121 to 0.347, kurtosis range of all main variables -0.357 to 0.330). The main variables and covariates were analyzed using descriptive statistics. Correlations between the study variables were analyzed using Pearson’s correlation coefficients. PROCESS macro for SPSS (Model 4) was used to evaluate the mediating effect of hospital ethical climate on the relationship between critical thinking disposition and nursing task performance [ 29 , 30 ]. A 95% bias-corrected confidence interval from 5,000 resamples was generated using the bias-corrected bootstrapping method. The bootstrapping size was 5,000. Significant indirect effects were identified as p < 0.05 when the confidence interval (CI) did not include zero [ 29 , 30 ]. For analysis of correlations and mediating effect, main study variables was used the item scores.

Ethical consideration

This study was approved by the Institutional Review Board of Dongguk University, to which the authors belong (DGU IRB 20210040). This study was conducted on human participants in accordance with the Declaration of Helsinki and its subsequent amendments. The purpose, procedures, and rules of the study were explained to all the participants. In addition, the voluntary nature and confidentiality of the study were highlighted, and participants’ personal information was not revealed. Informed consent was obtained from all the subjects.

General characteristics

Of the 200 participants, 92.0% (184) were female, and the mean age was 30.50 years (range 23–64). A total of 142 (71.0%) participants were unmarried and 27.5% (55) were religious. A total of 141 (70.5%) participants held a bachelor’s degree or higher. The mean total period of clinical experience was 7.38 years (range 1–32), about half of the participants had worked in a general ward (56%), and 163 participants responded that their positions were staff nurses. A total of 117 participants were aware of the Korean code of ethics for nurses (58.5%), and 69.5% of the participants responded that they had experience receiving nursing ethics education (Table  1 ).

Descriptive statistics and correlations between hospital ethical climate, critical thinking disposition, and nursing task performance

The total score of hospital ethical climate was 91.86 ± 11.29. The mean scores of hospital ethical climate and critical thinking disposition were 3.53 ± 0.43 and 3.62 ± 0.40, respectively (Table  2 ). The mean nursing task performance score was 3.96 ± 0.43. The higher mean score for hospital ethical climate was peer and manager, 3.92 ± 0.47 and 3.80 ± 0.53, respectively. Hospital ethical climate was positively correlated with critical thinking disposition (r = 0.37, p  < 0.001) and nursing task performance (r = 0.57, p  < 0.001). In addition, nursing task performance was positively correlated with critical thinking disposition (r = 0.64, p  < 0.001).

Mediating effect of critical thinking disposition on the relationship between hospital ethical climate and nursing task performance

As shown in Table  3 , the direct association between hospital ethical climate and nursing task performance was significant (ß = 0.34, p  < 0.001). In the mediation analysis, hospital ethical climate was positively associated with critical thinking disposition (ß = 0.30, p  < 0.001), and critical thinking disposition was positively associated with nursing task performance (ß = 0.54, p  < 0.001). The indirect pathway of hospital ethical climate on nursing task performance through critical thinking disposition was significant (index = 0.16; Boot SE = 0.04; Boot CI:0.09, 0.25). Figure  2 shows the indirect pathway for critical thinking disposition on the relationship between hospital ethical climate and nursing task performance.

The indirect pathway of hospital ethical climate on the relationship between critical thinking disposition and nursing task performance (*** p  < .001)

The findings of this study show that hospital ethical climate has a positive association with nursing task performance and that critical thinking disposition has a mediating effect on this relationship. This study makes an important contribution to the literature, given that it is the first to evaluate the association between hospital ethical climate, critical thinking disposition, and nursing task performance, and the mediating effect of critical thinking disposition on the relationship between hospital ethical climate and nursing task performance in nurses in Korea.

Participants in this study evaluated the hospital ethical climate positively and higher than neutral with a total sum of 91.86, which is in accordance with previous studies [ 8 , 19 , 31 ]. In addition, domains that were positively perceived in the hospital ethical climate were particularly related to peers and managers rather than patient, hospital/organization and physicians. The results of this study are consistent with earlier studies [ 24 ]. Nurse managers are commonly appointed from among the nursing staff in the hospital, and most have a long-term clinical background and a good understanding of the hospital’s ethical climate in the field [ 11 ]. This makes managers willing to listen and support staff nurses in decision-making when they face ethical dilemmas regarding a nursing situation. Through this process, staff nurses come to trust and respect their managers, which has a crucial impact on creating and maintaining positive perceptions of the hospital’s ethical climate. Moreover, their leadership and support to staff nurses are related to the hospital’s ethical climate and, consequently, how ethical issues are dealt with for the benefit of patients [ 8 ]. The previous study reported that access to knowledgeable peers for decision support on ethical issues is important resources for preventing and handling ethical conflicts [ 32 ]. In addition, it is reported that after particularly difficult events, when reflecting whit colleagues, action, feeling, and new perspectives on ethical conflicts are made visible, processed, and normalized [ 32 ]. Thus, the exchange of experience and judgements between peers contribute to self-confidence and the ability to act in ethical conflicts.

The relationship among hospital ethical climate, critical thinking disposition, and nursing task performance

In this study, nurses with a positive perception of their hospital’s ethical climate showed increased nursing task performance. Although it is difficult to compare our results with those in currently published literature, few studies have examined the relationship between hospital ethical climate and nursing task performance. Numminen et al. showed that newly graduate nurses who had a positive perception of hospital ethical climate had significantly higher nursing competency [ 8 ]. In addition, nurses with a more positive perception of the “patient” dimension of hospital ethical climate were less likely to have made medical errors [ 26 ]. Considering job satisfaction and turnover as factors affecting nursing competency, including nursing task performance, a previous study reported that hospital ethical climate was positively correlated with job satisfaction [ 10 ]. Other studies found that nurses with more negative perceptions of hospital ethical climate were highly inclined to leave the hospital or their previous position [ 19 , 33 ]. Moreover, a negative or poor ethical climate can contribute to burnout [ 12 ]. Job satisfaction, intent to leave, and burnout are associated with lower nursing task performance or nursing competency correlated with hospital ethical climate [ 8 , 34 , 35 ] and result in poor patient safety and quality of care [ 34 ]. Therefore, hospital administrators should pay attention to a more positive institutional ethical climate.

Critical thinking disposition was significantly positively associated with nursing task performance, and this is consistent with previous findings [ 24 , 25 ]. In a study by Mohamed et al., critical thinking disposition was significantly correlated with nursing performance in patients undergoing hemodialysis [ 25 ]. Moreover, in Park et al.’s study of 188 nurses with more than 13 months of clinical experience, critical thinking disposition was a major factor influencing nurses’ competency as measured using the nursing performance appraisal tool [ 36 ]. Dispositions are the tendency to do something, and critical thinking disposition is included in the concept of critical thinking [ 37 ]. In addition, critical thinking does not occur or may be substandard without critical thinking disposition [ 38 ]. In nursing, nurses with higher critical thinking or critical thinking dispositions, are able to perform their professional work efficiently and provide effective nursing care [ 24 , 36 , 39 ]. Thus, helping nurses increase their critical thinking disposition enables them to engage proactively in job performance.

Critical thinking disposition mediated the relationship between hospital ethical climate and nursing task performance. It was confirmed that a more positive perception of the hospital’s ethical climate was associated with increased critical thinking disposition, which subsequently increased nursing task performance. In addition, nurses who perceived the hospital’s ethical climate as more negative decreased nursing task performance with decreasing critical thinking disposition. This suggests that critical thinking disposition is an important factor in the hospital ethical climate and nursing task performance, which can be explained by several factors. Given that the hospital ethical climate sets standards for how problems should be addressed, focusing on interactions with colleagues and patients [ 7 ], when nurses perceive a more positive hospital ethical climate, their communication self-efficacy increases [ 40 ], and when communication competency increases, critical thinking disposition increases [ 41 ]. In other words, nurses perceived the hospital’s ethical climate positively and actively communicated with other professionals, including managers or physicians, about patient care, treatment, or further treatment plans, and an increase in critical thinking disposition in the process of exchanging opinions. The higher the critical thinking disposition, the higher the nurse’s critical decision-making [ 22 ] and the nursing task performance [ 36 , 39 ]. Therefore, in order to improve nurses’ task performance, the first step would be to improve the hospital ethical climate more positively. Organizations can improve their hospital ethical climate through ethics training, support, and information exchange within the nursing team [ 4 ]. Moreover, the code of ethics for nurses is to be built upon in combination with the laws, regulation and professional standards [ 42 ], and culture plays an important role in giving shape to nursing professional ethical values [ 43 ]. Therefore, to develop ethical training/education for nurses, there should be mandated and customized by the local law and culture. Together with this, critical thinking disposition is also an important factor to consider improving nurses’ task performance, and it is important to provide various training or education programs to improve critical thinking disposition. Hospital policymakers or administrators should identify the characteristics of the hospital ethical climate and create a positive hospital ethical climate, as well as increase nurses’ critical thinking disposition and improve task performance. It also enhances quality of care and patient safety.

Limitations

This study had some limitations. First, the findings have limited generalizability because the nurses were conveniently sampled. Second, this was a cross-sectional study, which limits the interpretation of causality. Hence, future research can be improved through longitudinal studies. Third, as some responses were made through an online self-report questionnaire, participants may have exaggerated or reduced their performance and perceptions according to their understanding. Additionally, we did not consider the number of hospitals or universities involved in nursing ethics education. This may have affected nurses’ perceptions of the hospital’s ethical climate. Future research should test this hypothesis, including the number and places of nursing ethics education. Finally, numerous factors influenced nursing task performance, and only hospital ethical climate and critical thinking dispositions were included in this study. Hospital ethical climate and critical thinking disposition could explain a limited portion of nursing task performance. Hence, further research is recommended to explore various factors affecting nursing task performance.

The results of this study indicated that nursing task performance was significantly influenced by hospital ethical climate, and the “hospital/organization and physicians” domain was lower than other domains in the hospital ethical climate. To improve a hospital’s ethical climate, small meetings or conferences should be held periodically to exchange opinions and experiences with physicians and nurses regarding patient care and ethical issues. Increasing the number of nursing staff may also be considered to address patients’ needs and health expectations. In addition, there are different action proposed related on other domains, e.g., the workshop, seminars, or periodic counseling to develop leadership competencies among nurse [ 44 ], in-service training which adjusted for the hospital/organization to enhance nurses’ perception of the ethical climate [ 31 ]. Moreover, sufficient publicity and related education should be provided so that nurses can be aware of the ethical ideology pursued by the organization and achieve ideological alignment [ 32 ]. Critical thinking disposition mediates the relationship between hospital ethical climate and nursing task performance. Therefore, to enhance nursing task performance, hospital administrators should provide training programs or education related to critical thinking while making efforts to create a positive ethical hospital climate.

Availability of data and materials

The datasets analyzed during the current study are not publicly available because of privacy or ethical restrictions but are available from the corresponding author upon reasonable request.

The authors declare no competing interests.

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This study is a reanalysis of the data from the first author’s master’s thesis.

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Conceptualization, P.S.K. and J.Y.W; methodology, P.S.K. and J.Y.W.; investigation, H.Y.R.; data curation, software, and formal analysis, J.Y.W.; writing – original draft preparation, P.S.K. and J.Y.W.; writing – review and editing, J.Y.W. All authors have read and agreed to the published version of the manuscript.

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Park, SK., Jeong, YW. Relationship between hospital ethical climate, critical thinking disposition, and nursing task performance. BMC Nurs 23 , 696 (2024). https://doi.org/10.1186/s12912-024-02366-1

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Factors associated with the critical thinking ability of professional nurses: A cross‐sectional study

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

Hsueh‐Erh Liu

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

Associated Data

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.

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,  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.

2. BACKGROUND

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.

3.1. Research design

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 ).

3.2. Setting and sampling

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. Data assessment

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.

3.3.2. Vietnamese version of the Nursing Critical Thinking in Clinical Practice Questionnaire ((N‐CT‐4 Practice (V‐v))

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.

3.4. Ethical considerations

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.

3.5. Data analysis

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 ).

4.1. Characteristics of the participants

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)

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).

4.2. Level of the critical thinking of the professional nurses

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.

4.3. Work‐related and personal‐related factors associated with critical thinking ability

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)

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)

5. DISCUSSION

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.

6. CONCLUSIONS

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.

CONFLICT OF INTEREST

The authors declare that they have no competing interests.

ACKNOWLEDGEMENTS

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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