critical thinking in emergency nursing

• Educational advances in emergency medicine
• Open access
• Published: 16 April 2020

How to think like an emergency care provider: a conceptual mental model for decision making in emergency care

• Nasser Hammad Al-Azri 1  

International Journal of Emergency Medicine volume  13 , Article number:  17 ( 2020 ) Cite this article

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General medicine commonly adopts a strategy based on the analytic approach utilizing the hypothetico-deductive method. Medical emergency care and education have been following similarly the same approach. However, the unique milieu and task complexity in emergency care settings pose a challenge to the analytic approach, particularly when confronted with a critically ill patient who requires immediate action. Despite having discussions in the literature addressing the unique characteristics of medical emergency care settings, there has been hardly any alternative structured mental model proposed to overcome those challenges.

This paper attempts to address a conceptual mental model for emergency care that combines both analytic as well as non-analytic methods in decision making.

The proposed model is organized in an alphabetical mnemonic, A–H. The proposed model includes eight steps for approaching emergency cases, viz., awareness, basic supportive measures, control of potential threats, diagnostics, emergency care, follow-up, groups of particular interest, and highlights. These steps might be utilized to organize and prioritize the management of emergency patients.

Metacognition is very important to develop practicable mental models in practice. The proposed model is flexible and takes into consideration the dynamicity of emergency cases. It also combines both analytic and non-analytic skills in medical education and practice.

Combining various clinical reasoning provides better opportunity, particularly for trainees and novices, to develop their experience and learn new skills. This mental model could be also of help for seasoned practitioners in their teaching, audits, and review of emergency cases.

“It is one thing to practice medicine in an emergency department; it is quite another to practice emergency medicine. The effective practice of emergency medicine requires an approach, a way of thinking that differs from other medical specialties” [ 1 ]. Yet, common teaching trains future emergency practitioners to “practice medicine in an emergency department.”

Emergency care is a complex activity. Emergency practitioners are like circus performers who have to “spin stacks of plates, one on top of another, of all different shapes and weights” [ 2 ]. This can be further complicated by simultaneous demands from various and multiple stakeholders such as administrators, patients, and colleagues. Add to that the time-bound interventions and parallel tasks required and it can be thought of no less than being chaotic.

There is a tendency to distinguish emergency care from other medical practices as being more action-driven than thought-oriented [ 3 ]. This probably stems from the presumption that emergency medicine follows the same strategy as other medical disciplines so it is judged within the same parameters. Another explanation for this is that emergency practitioners are seen to act immediately on their patients when other medical specialties might take longer time preparing for this action. However, the chaotic environment is different and it requires complex decision-making skills and strategies. Unlike general medical settings, in EM, often a history is unobtainable, and a physical examination and medical investigations are not readily available in a critically ill patient. Despite this, emergency medicine is still being taught using the conceptual model of general medicine that follows an information-gathering approach seeking optimal decision-making. In medical decision-making, the commonly adopted hypothetico-deductive method involving history taking, physical examination, and investigations corresponds to the general approach of medicine.

Importance of rethinking existing medical emergency care mental model

Education in medical emergency care adopts a strategy similar to that of general medicine despite the fact that it is not optimal in emergency departments. Emergency care providers cannot anticipate what condition their patients will be in and they cannot follow the steps of detailed history taking, complete physical examination, ordering required investigations, and, using the results, plan the management of their patient. Classical clinical decision theory may not fit dynamic environments like emergency care. Patients in the emergency department are usually critical, time is limited, and information is scarce or even absent, and decisions are still urgently required.

Croskerry (2002) has noted: “In few other workplace settings, and in no other area of medicine, is decision density as high” [ 4 ] as in emergency medicine. In an area where an information gap can be found in one third of emergency department visits, and more so in critical cases [ 5 ], an information-seeking strategy is unlikely to succeed. Moreover, diagnostic closure is usually the short-term target in the hypothetico-deductive method while this is less of a concern in emergency care. Instead, the short-term priorities in emergency care include assessment of acuity and life-saving [ 6 ]. Figure 1 presents a comparison of the conventional general medicine decision-making approach and how emergency care setting differs relatively with regard to those basic characteristics.

Comparing conventional decision-making in general medicine vs. emergency care setting

Hence, a different mental model with a distinctive approach for emergency care is required. Mental models are important to describe, explain, and predict situations [ 7 ]. This is the roadmap through the wilderness of emergency care rather than a guide on driving techniques. Experts are differentiated from novices in several aspects: sorting and categorizing problems, using different reasoning processes, developing mental models, and organizing content knowledge better [ 8 ]. In addition, experienced physicians form more rapid, higher quality working hypotheses and plans of management than novices do. Novices are especially challenged in this area, since teaching general problem solving was replaced with problem-based learning, as the emphasis shifted toward “helping students acquire a functional organization of content with clinically usable schemas” [ 9 ]. The proposed model is intended to better organize the knowledge and approach required in emergency care, which may eventually help improve the practice, particularly of novices.

Clinical decision-making in emergency care requires a unique approach that is sensitive to the distinctive milieu where emergency care takes place [ 10 ]. Xiao et al. (1996) have identified four components of task complexity in emergency medical care [ 11 ]. These include multiple and concurrent tasks, uncertainty, changing plans of management, and compressed work procedures with high workload. Such complex components require an approach that accommodates such factors and balances the various needs in a timely and priority-based, situationally adaptable methodology.

A different model for emergency care

This article addresses a general mental approach involving eight steps arranged with an initialism mnemonic, A–H. Figure 2 presents an infographic of the lifecycle of this A–H decision-making process. These steps represent the lifecycle of decision-making in emergency practice and form the core of the proposed conceptual model. Every emergency care encounter starts with the first step of situational awareness (A) where the provider starts to build up a workable mental template of the case presentation. This process is ongoing throughout the encounter to reflect the dynamic nature of emergency cases. The second to fourth steps (B–D) involve a triaging process in order to prioritize the most appropriate management at that point in time, through a series of risk-stratification stages. Then, additional emergency management (E) follows based on the flow of the case from earlier steps. Following emergency management, a planning step regarding further care (F) for the patient is required. The following step concerns emergency patients who may represent special high risk groups (G) with special precautions and particular diagnostic and management approaches to be considered. This step is, in fact, a mandate throughout the process but included here as a reminder. The final step is a reflection of the entire process that highlights (H) the learning aspects from the case management. Throughout the process, the first and last steps are ongoing as they reflect the dynamicity of the situation.

Situational decision-making model lifecycle

A: (awareness, situational)

It is likely that the first thought of an emergency care provider, when confronted with an acutely ill patient, is the issue of time: “how much time do I have to act and how much time do I have to think?” [ 12 ]. The mental brainstorming that takes place in a matter of seconds is a very valuable and indispensable part of every single emergency encounter. Providers’ prior beliefs, expectations, emotions, knowledge, skills, and experience all contribute to the initial approach adopted. Individuals vary in the importance they attach to different factors [ 13 ], and this variation is reflected in the decisions they make. The importance of this mental process is, unfortunately, not reflected in either general medicine or emergency medicine education and research. Traditionally, “medical education has focused on the content rather than the process of clinical decision making” [ 6 ].

The notion of “situational awareness” (SA) is a useful concept to borrow from aviation sciences. Situational awareness has been defined as the individual’s “perception of the elements of the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future” [ 14 ]. As noted from the definition, SA tries to amalgamate the experiences and background of the practitioner with the current situation in order to enable a more educated prediction of what will happen next. Although the concept originated outside of the medical field, it has already been utilized in several medical disciplines including surgery, anesthesiology, as well as quality care, and patient safety [ 15 , 16 , 17 ]. Moreover, SA has been discussed in several emergency care mandates and it is recommended for inclusion in the non-technical skills training of teams in acute medicine [ 15 ].

This emphasizes that an attentiveness to the dynamic nature of priorities in emergency management is as important as knowledge and skills. As such, SA provides a mental model that encourages emergency care practitioners to stay alert for changes in the surrounding environment and relate those changes to case management. The importance of this step in the model is that it prods us to go beyond our immediate perceptions and gut feelings and develop an overall view of the situation [ 18 ]. Practically, decision-making in emergency care has historically depended more on rapid situational assessment rather than optimal decision-making strategies as in the hypothetico-deductive method [ 19 ]. SA is probably one of the most neglected, yet distinguishing, skills in emergency medicine education.

B: (basic life, organ, and limb supportive measures)

The second step in emergency decision-making involves a clinical triaging process. The purpose of this triage is to prioritize time-bound interventions or treatment for the patient. Immediate risks to life, organs, or limbs take priority in case management. This precedes any analytical thinking provided by detailed history taking, physical examination, or investigations, even though a focused approach might be necessary. This step maintains the dynamicity of the process of decision-making and allows the practitioner a holistic view of available and appropriate options rather than ordinary linear thinking. It also provides flexibility of movement between treatment options in response to dynamic changes in the condition.

Life-threatening conditions always take precedence in emergency management. The next priority is to manage immediate risks to body organs or limbs; this is the essence of medical emergency management. Therefore, the aim of this step on basic supportive action (B) is to save the vitals of the patient. This is where advanced cardiac and trauma life support algorithms and emergency management protocols are important.

A useful approach at this step is pattern recognition. In real practice, when confronted with a critically ill or crashing patient, the emergency care provider usually abandons the time-consuming hypothetico-deductive method; pattern recognition offers a rapid assessment and clinical plan that permits immediate life-, organ-, or limb-saving measures to take place [ 20 ]. Pattern recognition, known also as non-analytic reasoning, is a central feature of the expert medical practitioner’s ability to rapidly diagnose and respond appropriately, compared to novices who struggle with linear thinking skills [ 21 , 22 , 23 ]. This approach could be further augmented by the availability of algorithms and protocols that allow immediacy of perception and initiation of management [ 4 ], as well as by including it in clinical teaching and education.

C: (control potential life, organ, and limb threats)

While emergency care providers must prioritize immediate threats to life, organs, and limbs, they must also anticipate and recognize imminent threats to the same and control them (C). This is one of the biggest challenges in emergency care compared to other medical settings; oftentimes, the grey cases are the hidden tigers. In fact, seasoned emergency care providers know that even the most unremarkable patients may have a catastrophic outcome within moments [ 24 ]. Emergency care providers usually adopt mental templates for the top diagnoses that they need to exclude for every particular presentation. This is a step of “ruling out” worst diagnoses before proceeding. Croskerry (2002) asserts that this “rule out the worst case” strategy is almost pathognomonic of decision-making in the emergency department [ 4 ]. Many emergency presentations (e.g., poisoning, head injury, and chest pain) are true time bombs that any emergency care provider should be alert to.

This step presents an intermediate stage between the previous step (B) where pattern recognition and non-analytic reasoning dominates decision-making, and the next step (D) where the hypothetico-deductive approach with its analytic reasoning starts to play a major role in decision-making. As such, this step utilizes a mixture of the analytic and non-analytic reasoning to aid emergency care practitioners the “rule out the worst case” scenario in their patients. Examples of presentation-wise “worst case” scenarios are illustrated in Table 1 .

Once a potential threat is discovered, the practitioner will be situationally more aware and this will help to initiate measures that could prevent further deterioration of the condition. Again, this step is another that is practiced commonly by expert practitioners but is presented informally or insufficiently in emergency medicine training or education. Emergency care practitioners should focus more on this step due to its centrality in emergency care practice as well as its importance for ensuring safety of patients.

D: (diagnostics)

Once immediate and/ or imminent threats have either been excluded or managed, the emergency care provider may move on to the next step of formulating a workable clinical diagnosis (D) through the commonly adopted hypothetico-deductive medical model via a focused history taking, physical examination, and investigations. This is basically what all medical students are trained for in their undergraduate and postgraduate medical education. This step involves the utilization of existing tools for optimal decision-making within the available resources in the emergency department. Nevertheless, a final diagnosis may not be reachable in the emergency department setting.

E: (emergency management)

This is the step that naturally follows the diagnostic step (D). After collecting appropriate information regarding patient presentation through a focused history, examination and investigations, the emergency care provider may start emergency management and treatment as indicated. This does not contradict utilizing appropriate interventions in earlier steps (B, C) that aim to save life, organs, or limbs.

F: (further care)

While decisions about intervention(s) in emergency care are very difficult, often decisions about the further management of the patient are just as difficult [ 25 ]. Grey cases present the dilemma of whether to admit, keep for observation, or discharge. This decision is problematic because it entails not only technical aspects of the clinical status of the patient but also social, political, economic, and administrative factors along with the availability of supportive resources.

The initial brainstorm regarding imminent threats to life, organs, and limbs (C) continues to play a major role in the emergency provider’s decision-making. Discharging patients to their home carries risks related to a lack of clinical care and formal monitoring compared to admitted patients [ 26 ]. Hence, this step is pivotal in the emergency care of patients with significant implications in terms of outcome. Incorporating this step in the model is essential for the emergency care provider to have an integrative and holistic view of the case.

G: (groups of particular interest)

Certain groups of patients warrant particular concern while being managed in emergency care settings [ 27 ]. There are different reasons to consider these groups as high risk. Often, it is because they have underlying pathologies and/or physiologies that make them more prone for complications, acute exacerbations, and/or they are less likely to withstand the stress of acute illness. These groups include the elderly, pregnant women, children, psychiatric patients, and patients with a significant past medical history. These patients should cause particular concern that may justify a different and/or altered path of management at any step during the emergency care process.

H: (highlights)

Lack of informative feedback is one of the major drawbacks in emergency medicine that hinders learning and maintaining of cognitive and practical emergency care skills [ 28 ]. Feedback and highlighting of learning points is a crucial step in medical education and can be done in a variety of methods [ 29 ]. This is an ongoing step that starts at the case encounter and never ends during a practitioner’s career. Here, the practitioner reflects on the care and management provided during the encounter and makes a case for learning and advancing his knowledge, skills, and attitudes in emergency care. This step is usually done unconsciously. However, exposing this process to scrutiny and making it a formal step in the process of emergency care is likely to enhance experiential learning of the provider and, more importantly, offer feedback for the first step in the model that further augments situational awareness (A). This will add to the reservoir of understanding and attentiveness for future cases.

Thinking about thinking, also called metacognition, in emergency care is likely to reveal the strengths and weaknesses in current approaches and open doors for further development and improvement of emergency care. It is also likely to aid in recognizing opportunities for interventional thinking strategies [ 18 ]. This could be a step forward in preparing a broad-based, critical thinking pattern for physicians, who may save lives, organs, and limbs based on undifferentiated cases without having to depend on a diagnosis to do so.

The presented conceptual model attempts to contribute to the exposition and development of the forgotten skill of clinical reasoning with a particular reference to emergency and acute care. Moreover, it dissects the usually overlooked process of decision-making in emergency care [ 28 ]. The arrangement of the model components in alphabetical mnemonics may act as a reminder of a decision process that will reduce omission errors in clinical settings. Furthermore, functional categorization of the steps involved in decision-making, as well as in actual practice, will provide and develop further insight and awareness of cognitive strengths and weaknesses at different stages.

A significant advantage of the proposed conceptual mental model for emergency care is that it combines both analytic as well as non-analytic (also called naturalistic decision-making, NDM) strategies to aid medical emergency management. This model does not eliminate the need for the hypothetico-deductive analytic method but rather incorporates it within a more comprehensive approach and utilizes it when it is situationally appropriate along with the non-analytic method (Fig. 3 ). Combining different clinical reasoning strategies helps novice practitioners have greater diagnostic accuracy, improve performance, and avoid giving misleading information [ 30 , 31 ].

Situationally combined analytical and non-analytical decision-making methods

In addition, emergency care has been described as chaotic. Chaotic contexts are characterized by dominance of the unknowables, indeterminate relationships between the cause and effect, and a lack of existing manageable patterns [ 32 ]. In such contexts, the best approach to management is to act to establish order, then sense where stability is present and where it is not, and then respond to transform the situation from chaos to complexity [ 32 ]. The described model addresses those activities in order where the emergency care provider first acts (B), then senses (C), and finally responds (D, E) to establish a more stable context.

The suggested approach can be utilized by various groups of practitioners, such as physicians, nurses, and paramedics, hence the use of the term emergency care. Moreover, novices and trainees learn better by being exposed to the decision-making process involved, rather than just mimicking the actions of experts [ 3 ].

Medical education is required to produce a “broad-based physician, geared to solving undifferentiated clinical problems” [ 33 ]. Emergency medicine, as a generalist discipline, has probably high potential for that. The presented model could be used in several contexts. It could be used as a mental model that guides the practice of emergency care for novice practitioners or it could be used as a teaching tool for medical students and trainees, in not only emergency care, but also other specialties that may have exposure to emergency cases. In addition to novice providers, it has implications for physicians in emergency departments, paramedics in emergency medical services, general practitioners in rural clinics, nurse practitioners, or anyone else practicing emergency care. This may lead to the development of training and educational methods that suit each stage separately, as well as recognizing cognitive biases and avoiding them.

The model may also be used for audits and reviews of emergency case management, including self-audits, departmental or institutional audits, or peer reviews. Moreover, clinical decision-making aids could be further developed and tailored to the needs of the practice. For example, algorithms and pattern recognition are suitable for steps B and C teaching and decision-making, while event-driven and hypothetico-deductive approaches are more suitable for step D. This model is very broad-based. It is hoped that this conceptual model will help practitioners develop a more focused approach, a broader perspective, and a better ability to detect critical signals when managing undifferentiated emergency cases.

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Al-Azri, N.H. How to think like an emergency care provider: a conceptual mental model for decision making in emergency care. Int J Emerg Med 13 , 17 (2020). https://doi.org/10.1186/s12245-020-00274-0

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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?

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, DNP, APRN, ACNS-BC, CNE

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, Ph.D., RN

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, BSN, RN, CCRN

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.

• Pre-Nursing
• Nursing School
• After Graduation

How to Apply Critical Thinking in Nursing

Harnessing the power of critical thinking can be the key to becoming a successful and competent nurse. 

Developing and refining your critical thinking skills is crucial as you embark on your nursing journey. By doing so, you’ll enhance your ability to provide high-quality care, advance your professional growth, and contribute to the ever-evolving nursing field.

What is critical thinking in nursing?

Critical thinking is an essential cognitive process that enables nurses to analyze, evaluate, and synthesize information to make informed decisions. In the context of nursing, it involves observing, interpreting, and responding to patient needs effectively. 

Critical thinking allows nurses to go beyond memorized facts and apply logical reasoning to address patient problems holistically.

As a nurse, you’ll encounter multifaceted healthcare scenarios, each presenting its unique challenges. Critical thinking enables you to approach these situations systematically, evaluate the available data, identify relevant factors, and understand the patient’s condition comprehensively.

By employing critical thinking skills, you can differentiate between urgent and non-urgent issues, prioritize care, anticipate potential complications, and adapt your interventions accordingly. This analytical approach helps minimize errors, promote patient safety, and achieve positive patient outcomes.

Why is critical thinking important in nursing?

Critical thinking serves as the backbone of nursing practice. You’ll encounter various uncertainties, changing conditions, and ethical dilemmas as a nurse. Developing critical thinking abilities empowers you to navigate these challenges confidently and provide optimal patient care.

In nursing, critical thinking is crucial for the following reasons:

• Enhanced Clinical Judgment: Critical thinking enables assessing complex situations, analyzing available information, and drawing logical conclusions. It enhances your clinical judgment, allowing you to make informed decisions based on the best available evidence and expert consensus.
• Effective Problem Solving: Nursing involves encountering problems and finding effective solutions. Critical thinking equips you with the tools to identify underlying issues, explore alternative options, and implement interventions that address the root cause of the problem.
• Patient Advocacy: Critical thinking empowers you to advocate for your patients’ needs. By actively engaging in critical inquiry, you can challenge assumptions, question policies, and promote patient-centered care.
• Adapting to Changing Environments: Healthcare is constantly evolving, with new research findings, technologies, and treatments emerging regularly. Developing critical thinking skills helps you adapt to these changes, ensuring you stay updated and deliver evidence-based care.

Examples of Critical Thinking in Nursing

Let’s dive into some real-life examples that highlight how critical thinking plays a crucial role in nursing practice:

• Prioritization: Imagine working in an emergency department where multiple patients arrive simultaneously with varying degrees of severity. Utilizing critical thinking, you can assess each patient’s condition, prioritize care based on the urgency of their needs, and allocate resources effectively.
• Medication Administration: When administering medication, critical thinking prompts you to cross-check the prescribed dose, assess potential drug interactions or allergies, and evaluate the patient’s response to the medication. This proactive approach ensures patient safety and minimizes medication errors.
• Ethical Dilemmas: Critical thinking helps you navigate complex ethical dilemmas by analyzing the values at stake, considering legal and ethical principles, and collaborating with the healthcare team to make decisions that align with the patient’s best interests.

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Boost your confidence and excel in your nursing studies with SimpleNursing’s innovative study resources.

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Positive troponins

• (NRSNG=0.035… check your institutions ranges)
• Troponins are proteins that initiate contraction of muscle fibers. Troponin I is specific to heart muscle .
• Use your judgement.
• Is there a cardiac history?
• A couple hours in the patient realizes that they forgot to tell you they did a heavy upper arm workout or they have had a cough for a week and it hurts after they cough…
• People get things in their mind and think that might be what is pertinent to tell you “I have chest pain, that means heart” but YOUR job is to look at the other factors, ask the questions that could seem not related from the patients understanding of the situation.
• Comparison, has there been a change since the trops were drawn
• How long has it been since that lab value was drawn?
• Make sure the 2 hour troponin is ON TIME.
• Because trops aren’t always released right away
• Can be up to 3 hours before release.
• Can stay elevated for up to a week before returning to normal
• EBR: out of the weeds after 3 negative trops.
• Why are we drawing serial trops?
• What if they have 2 neg trops and the chest pain resolves?

Shortness of breath:

• Thinking beyond the lungs- OR- thinking about what deficient lung function does within the body!
• Hypoxemia causing stress on the heart
• But what if their pulse ox is wnl?
• Helps to eliminate the heart which is in the same area
• Brady or tachy
• How many RBCs have oxygen attached to them?
• IE their hemoglobin
• But what else attaches to an RBC that can take place of oxygen? :::::CO
• 93% Oxygen is good if it is all oxygen.
• Carbon monoxide molecules, even in a small amount, can attach to the patient’s hemoglobin replacing oxygen molecules. A pulse oximeter cannot distinguish the differences and the reading will show the total saturation level of oxygen and carbon monoxide. If 20% of hemoglobin has carbon monoxide and 73% has oxygen, the reading would be 93%.
• This can be dangerous. A pulse oximeter should not be used on people with smoke inhalation, carbon monoxide poisoning, and heavy cigarette smoking.
• Causes of SOB: Don’t just think lungs. Go beyond the lungs too.
• Heart disease or heart attack (in this case, shortness of breath may be accompanied by swelling of the feet/ankles).
• Lung disease.
• Pneumonia (breathlessness often accompanied by high fever, cough and mucus).
• Asthma or allergies.
• Anemia (other symptoms characterized by fatigue and pale skin color).
• Panic attacks.
• Airway obstructions, exposure to cigarette smoke or extreme exposure to dust or fumes.
• Obesity or lack of exercise.
• High altitudes.
• Blood flow disruption in getting oxygen to the brain.
• Intense emotional anxiety or stress.
• Some chest pain can feel like pressure, causing breathing issues

MVA with back pain

• To make sure that the kidneys weren’t injured and have blood in the urine
• It could be related to the MVA it could be coincidence, perhaps a UTI or kidney stone that started to be pesky and pain full OH and the patient got into a car accident…
• Immobilizing spine, we are concerned about bones, but don’t stop there, if we are concerned about the spine, think spinal cord, think neuro.

Don’t get caught focusing on just the story, make the connections, that is the idea behind critical thinking .

Abnormal vital sign

• Look at the patient first
• Check equipment
• Do manual checks

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• Margaret McCartney:...

Nurses are critical thinkers

Rapid response to:

Margaret McCartney: Nurses must be allowed to exercise professional judgment

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Rapid Response:

The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice. Nurses’ ability to recognize and respond to signs of patient deterioration in a timely manner plays a pivotal role in patient outcomes (Purling & King 2012). Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events (Tomlinson, 2015). The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement. Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010). At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction.

The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.

As lifelong learners, nurses are constantly accumulating more knowledge, expertise, and experience, and it’s a rare nurse indeed who chooses to not apply his or her mind towards the goal of constant learning and professional growth. Institute of Medicine (IOM) report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice. American Nurses Association (ANA), Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice (p.26)

Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier

The future of nursing: Leading change, advancing health, (2010). https://campaignforaction.org/resource/future-nursing-iom-report

Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today. 30(6), 515-520.

NMC (2010) New Standards for Pre-Registration Nursing. London: Nursing and Midwifery Council.

Purling A. & King L. (2012). A literature review: graduate nurses’ preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23–24), 3451–3465

Thompson, C., Aitken, l., Doran, D., Dowing, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50 (12), 1720 - 1726 Tomlinson, J. (2015). Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Medical Education, 15(103)

Competing interests: No competing interests

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• Indian J Crit Care Med
• v.20(10); 2016 Oct

Examining the relationship between critical-thinking skills and decision-making ability of emergency medicine students

Mohammad heidari.

From: 1 Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran

Parvin Ebrahimi

2 Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran

Background and Aims:

Critical-thinking ability would enable students to think creatively and make better decisions and makes them make a greater effort to concentrate on situations related to clinical matters and emergencies. This can bridge the gap between the clinical and theoretical training. Therefore, the aim of the present study is to examine the relationship between critical-thinking ability and decision-making skills of the students of Emergency Medicine.

Materials and Methods:

This descriptive and analytical research was conducted on all the students of medical emergency students ( n = 86) in Shahrekord, Iran. The demographic information questionnaire, the California Critical Thinking Skills Test, and a decision-making researcher-made questionnaire were used to collect data. The data were analyzed by SPSS software version 16 using descriptive and analytical statistical tests and Pearson's correlation coefficient.

The results of the present study indicate that the total mean score for the critical thinking was 8.32 ± 2.03 and for decision making 8.66 ± 1.89. There is a significant statistical relationship between the critical-thinking score and decision-making score ( P < 0.05).

Conclusions:

Although critical-thinking skills and decision-making ability are essential for medical emergency professional competence, the results of this study show that these skills are poor among the students.

Introduction

The increase in number and range of the incidents during the recent years has led the personnel of medical emergency encountering complex problems and issues, which are the result of the advancement in technology and cultural and ethical factors. It is, therefore, necessary to replace the traditional methods with decentralized emergency management systems. One of these techniques uses decision-making, creative-thinking, and problem-solving skills in today's world of management.[ 1 ] Decision-making is one of the most important and vital parts of the managers of emergency rooms. They must make a decision quickly most of the times even if they do not have sufficient information about the matter in hand.[ 2 ] In addition to the problems which are common among everyone, these employees encounter unique difficulties such as working with numerous employees and individuals on the treatment team in the hospital, the families who are facing a crisis, happy and sad moments of life and death, accidents, disasters, etc.[ 3 ]

Clinical decision-making is a complex process. The fact that emergency units are potentially very stressful and unpredictable and quick diagnosis and communication with the companions of the patient are vital in these units. Proper triage is a complex decision-making process which includes evaluation of the patient and other factors of the treatment system.[ 4 ]

Patients’ families, expect the students of medical emergency, to make the best decisions. This is while the students of medical sciences are unable to take decisions independently to solve the patients’ problems.[ 5 ] The students mostly execute the orders of their mentors which if done mechanically could lead to adverse consequences. Critical-thinking skills are considered the ultimate aim of training in medical education, to draw correct judgments which can reduce the gap between theoretical and clinical training.[ 6 ]

Unfortunately, the traditional method of training provides a mixture of information and concepts to the students and leaves them unprepared when it comes to analyzing, prioritizing, and organizing.[ 7 ] Understanding the present conditions of critical-thinking and decision-making abilities among the medical emergency students and the degree to which the contemporary teaching and training methods improve these skills could lead to improvement of the clinical decision-making abilities of the students in crisis.[ 8 ] The need for this skill is emphasized in medical emergency due to the complexity of the current system and the rapid changes in the field of health care. The personnel of medical emergency must use critical analytical skills to present safe and proper medical emergency care.[ 9 ]

The experts in the field of education agree that critical thinking should be the inseparable part of education at any level. Critical thinking by the use of analysis, evaluation, selection, and utilization would lead us to the best possible solution. Educationists should design training programs that promote critical thinking. Research, however, indicate that the students of medical sciences are not sufficiently skilled in critical thinking.[ 10 ] With regard to the current conditions, the aim of the present study is to examine the relationship between critical-thinking skills and decision-making abilities among the medical emergency students.

Materials and Methods

This is a descriptive and analytical study which was conducted on all the students of medical emergency (a total number of 86) in Shahrekord in 2014. After the researcher's explanations, the demographic information questionnaire, the California Critical Thinking Skills Test, and a decision-making questionnaire were distributed among the students, and they were asked to fill up the forms, in case they are interested in participating in the study. The completed questionnaires were then collected by a researcher.

After receiving Ethics committee approval consent was obtained from all participants. The researchers undertook that all the information of the participants will be confidential and will only be presented in the form of statistical information. The demographic questionnaire included items such as age, marital status, the year the student entered the university and the semester.

The California Critical Thinking Skills Test includes various sections for assessing the critical-thinking skills of children and adults, students of different educational levels, and different professions, including medicine, law, and trading. The questionnaire's questions are divided into two groups: Three critical-thinking skills, including analysis, evaluation, and inference, are in one group, and deduction and inductions are assessed in another group.[ 11 ]

The questionnaire which was used in the present study contained 34 questions with four or five options and only one correct answer. The given time to fill out this questionnaire was approximately 45 min. Answering some of the questions required deduction based on a series of presumptions and some other require logical reasoning. This questionnaire is suitable for assessing critical thinking of students as well as assessing people who need to solve problems and take decisions about their jobs. The scores assess the general skills of critical thinking and its five subsets. The scores ranged between 0 and 34.[ 11 ] The validity and reliability of the Persian translation of this form were examined in Khalili and Hosseinzadeh's study, which was conducted on 405 nursing students of Shahid Beheshti, Iran, and Tehran Medical Sciences University. The reliability coefficient of the above-mentioned study, which was obtained through KR-20 (0.62), is strongly correlated with the reliability coefficient obtained during the standardization process of this test in America (0.68–0.70). Furthermore, the construct validity, which is the most important type of validity in translated tests, shows that the construct of this test correlates with its theoretical basis.[ 12 ]

Decision-making skills of the students were evaluated by a decision-making questionnaire. The questionnaire comprised twenty questions. Each question was scored at four levels and had values between 0.25 and 1 score, based on Likert scale. The minimum score was 5, and the maximum score was 20 ( Appendix 1 ).

This questionnaire was presented to a panel of ten experts to examine its content validity, and the questionnaire was approved by them. Cronbach's alpha was used to calculate the reliability of this test, which turned out to be 0.87 in a pilot study in which the test was administered to 15 students who were taking the fourth semester of medical emergency in the Nursing University of Shahrekord. Moreover, the reliability of this test was measured and its Cronbach's alpha was 0.74 when the test was administered to 15 students of the 2 nd year of medical emergency in Shahrekord. The reliability of the test was also examined through the pretest-posttest method. The posttest was administered 2 weeks after the pretest, and the correlation between the mean score of the students on the first test and the second test was 0.66. Statistical analyses were performed using the Statistics Package for Social Scientists 16.0 (SPSS Inc. Released 2009. PASW Statistics for Windows, Version 16.0. Chicago: SPSS Inc.) And the use of descriptive and analytical statistical tests such as Chi-square and Pearson correlation coefficient.

The present study was conducted on 86 students of medical emergency. All the participants were male. It is worth mentioning that only men are admitted to medical emergency in Iran. The average age of the participants was 20.35 ± 0.82.

These students were first to fourth-semester students of medical emergency. There were 22 (25.58%) first-semester students, 25 (29.06%) second-semester students, 19 (23.25%) third-semester students, and 20 (23.25%) fourth-semester students. The mean total average of the students was 15.84 ± 1.12 and 14 students (16.27%) were married and 72 (83.73%) were single.

The total mean score of students was 8.323 ± 2.031 on critical thinking and 8.66 ± 1.89 on decision-making ability. The scores of critical-thinking and decision-making abilities of the students have been separated based on the semester and presented in Table 1 .

Comparison of mean and standard deviation of critical thinking and problem-solving ability scores and subgroups on critical-thinking, using ANOVA separated based on the semester

The relationship between the age, marital status, and the mean total average of the students and their critical-thinking and decision-making abilities was not statistically significant ( P > 0.05).

The results of the study revealed that there was a statically significant relationship ( P < 0.001) between the total score of critical-thinking skill (8.323 ± 2.031) and decision-making ability (8.66 ± 1.89) which is presented in Table 2 .

The relationship between the mean score of critical thinking and that of decision-making ability

Critical thinking is an essential part of clinical decision-making and professional competence.[ 9 ] Despite all that, not a lot of researches have been conducted on the critical-thinking abilities among the students and personnel of medical emergency.[ 13 ] However, with regard to the fact that more than half of the prehospital emergency centers’ staff are nurses, the researches which have been conducted on them are used in this study.

The result of the present study is, therefore, consistent with other studies, which have been conducted in Iran. Paryad et al reported that most of the students (86%) were poor at critical thinking.[ 14 ] Khodamoradi study, which was conducted in the Tehran University of Medical Sciences, did not show any significant increase in the critical-thinking skills of the last semester students, and the total score on the test was low.[ 15 ] The current study is also consistent with Lotfi et al study regarding the decision-making scores; the scores were low in both studies.[ 11 ]

Akhondzade also reviewed the studies related to critical thinking conducted in an 8-year long period. He reported that the range of the scores of the medical sciences student was between 8.88 and 14.75.[ 16 ] The test score was reported to be 11.96 in a Jamshidian study in Isfahan.[ 17 ]

The mean score of critical thinking was noticeably lower in comparison to other countries. Yuan's research in Canada indicated that 98.2% of the nursing students had acceptable levels of critical-thinking skills. In a research in Taiwan, the mean score of the test of nursing students was calculated to be 19.39.[ 18 ] In Hodge's study, the mean score of critical thinking was 20.2, which was obtained through California Critical Thinking Skills Test.[ 19 ]

In a research, Gunnarsson conducted in Sweden, the factors influencing the decision-making abilities of the medical emergency staff were examined in emergency rooms. The report stated that numerous factors influenced the decision-making ability of these employees; factors relating to patient, environment, colleagues, interpersonal issues, performance of the team supervisor, knowledge of other employees, and moral conflicts. These issues make it difficult for students to make decisions leading to poor choices in some cases.[ 20 ]

Sands examined clinical decision-making in psychological health triage in Australia. The study conducted on 15 employees of medical emergency reported that most of the decisions were made based on their experiences. Most of them had not received special training courses of psychological health triage, and, importantly, there is not always a positive relationship between proper decisions and years of experience of the employees.[ 21 ]

Franklin et al . conducted a study which examined the manner in which the emergency room's staff makes decisions, and they reported that the employees’ decision-making is closely related to psychological processes, cognitive abilities, the importance of the decision, identification abilities, problem-solving abilities, and organizational conditions under which they worked. Therefore, the advanced courses of decision-making must be held to improve their abilities, and their training must go beyond the clinic's atmosphere.[ 4 ]

Furthermore, the results of the studies by Dy and Purnell showed that there are many factors such as the skills of the individuals, culture, communication skills, problem solving abilities which influence the complexity of the decision-making process of the individuals who work in health and treatment centers, and they must improve these to make the best decisions.[ 5 ]

The results of numerous studies have repeatedly expressed that it is vital to improve the competencies of the emergency room personnel.[ 1 , 2 , 20 ] The personnel of the emergency room must utilize many cognitive strategies when making a decision. The personnel must especially improve their problem-solving, communication, and decision-making skills.[ 22 , 23 ] It is clear based on the above-mentioned specifications of critical thinking that training the medical students through didactic methods alone and not utilizing learning methods based on clinical scenarios, field practice, computer simulation, and clinical problem-solving cannot improve the students’ critical-thinking abilities.[ 15 , 17 ] Further using assessment methods, which are based on retaining large volumes of theoretical information, may lead to rote learning which do not involve analysis and deduction.[ 16 ]

Roberts et al indicated that using innovative educational models can have a significant effect on the improvement of decision-making skills of the emergency room personnel.[ 23 ] Based the results of the present study it is clearly important to hone the problem-solving abilities of the associate degree students of medical emergency, Contrary to the belief that these students can make simple and complex decisions based on their their traditional courses,[ 24 ] additionally problem-solving and decision-making skills must be taught to students to make the best decisions.[ 25 ]

The findings showed that the critical-thinking scores of senior nursing students who participated in this study were poor. This is while the results of the study conducted by Profetto-McGrath on the Canadian nursing students revealed a high score.[ 26 ] The same result is observable in a study by Bowles conducted in America.[ 27 ] The researcher believes that the performance at schools before entering universities and also university programs may not empower students in critical thinking. Since we do not know the critical thinking scores of the participants of this study at the start of their university education, it cannot be ascertained that university training has failed in fostering the critical thinking of the students. Besides, the programming of the 4-year academic period of nursing in Iran has not been designed to address students’ critical-thinking skill, who in most cases, try to cope with their clinical problems by trial and error. From this perspective, reviewing the existing educational programs and redesigning them on the basis of increasing critical-thinking ability can be the outcome based on the findings of this study.

One of the limitations of the present research was that completing the California Critical Thinking Skills Test was time-consuming and complex requiring explanations.

Conclusions

Despite the importance of decision-making ability, the results indicate that the students lack decision making and critical thinking skills. Considering the fact that the present study was conducted on medical emergency students, the results are not generalizable to the students of other departments. It is advisable to replicate the present study with more students and in other fields.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Appendix 1: Decision-making questionnaire

Dear students,

The questionnaire, before you, has been designed with the purpose of examining the level of your decision-making skill. Please answer the questions regarding the reality and the knowledge you have about yourself. Your complete and correct answer to the questions will help us achieve the goals of the study.

Decision-making questionnaire

Critical-thinking performance scoring rubric.