critical thinking skills for a nurse

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?

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• 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?

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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, 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.

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Why Critical Thinking in Nursing Is Important

8 examples of critical thinking in nursing, improving the quality of patient care, the importance of critical thinking in nursing.

Jul 24, 2024

While not every decision is an immediate life-and-death situation, there are hundreds of decisions nurses must make every day that impact patient care in ways small and large.

“Being able to assess situations and make decisions can lead to life-or-death situations,” said nurse anesthetist Aisha Allen . “Critical thinking is a crucial and essential skill for nurses.”

The National League for Nursing Accreditation Commission (NLNAC) defines critical thinking in nursing this way: “the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief-based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research.”

An eight-year study by Johns Hopkins reports that 10% of deaths in the U.S. are due to medical error — the third-highest cause of death in the country.

“Diagnostic errors, medical mistakes, and the absence of safety nets could result in someone’s death,” wrote Dr. Martin Makary , professor of surgery at Johns Hopkins University School of Medicine.

Everyone makes mistakes — even doctors. Nurses applying critical thinking skills can help reduce errors.

“Question everything,” said pediatric nurse practitioner Ersilia Pompilio RN, MSN, PNP . “Especially doctor’s orders.” Nurses often spend more time with patients than doctors and may notice slight changes in conditions that may not be obvious. Resolving these observations with treatment plans can help lead to better care.

Key Nursing Critical Thinking Skills

Some of the most important critical thinking skills nurses use daily include interpretation, analysis, evaluation, inference, explanation, and self-regulation.

• Interpretation: Understanding the meaning of information or events.
• Analysis: Investigating a course of action based on objective and subjective data.
• Evaluation: Assessing the value of information and its credibility.
• Inference: Making logical deductions about the impact of care decisions.
• Explanation: Translating complicated and often complex medical information to patients and families in a way they can understand to make decisions about patient care.
• Self-Regulation: Avoiding the impact of unconscious bias with cognitive awareness.

These skills are used in conjunction with clinical reasoning. Based on training and experience, nurses use these skills and then have to make decisions affecting care.

It’s the ultimate test of a nurse’s ability to gather reliable data and solve complex problems. However, critical thinking goes beyond just solving problems. Critical thinking incorporates questioning and critiquing solutions to find the most effective one. For example, treating immediate symptoms may temporarily solve a problem, but determining the underlying cause of the symptoms is the key to effective long-term health.

Here are some real-life examples of how nurses apply critical thinking on the job every day, as told by nurses themselves.

Example #1: Patient Assessments

“Doing a thorough assessment on your patient can help you detect that something is wrong, even if you’re not quite sure what it is,” said Shantay Carter , registered nurse and co-founder of Women of Integrity . “When you notice the change, you have to use your critical thinking skills to decide what’s the next step. Critical thinking allows you to provide the best and safest care possible.”

Example #2: First Line of Defense

Often, nurses are the first line of defense for patients.

“One example would be a patient that had an accelerated heart rate,” said nurse educator and adult critical care nurse Dr. Jenna Liphart Rhoads . “As a nurse, it was my job to investigate the cause of the heart rate and implement nursing actions to help decrease the heart rate prior to calling the primary care provider.”

Nurses with poor critical thinking skills may fail to detect a patient in stress or deteriorating condition. This can result in what’s called a “ failure to rescue ,” or FTR, which can lead to adverse conditions following a complication that leads to mortality.

Example #3: Patient Interactions

Nurses are the ones taking initial reports or discussing care with patients.

“We maintain relationships with patients between office visits,” said registered nurse, care coordinator, and ambulatory case manager Amelia Roberts . “So, when there is a concern, we are the first name that comes to mind (and get the call).”

“Several times, a parent called after the child had a high temperature, and the call came in after hours,” Roberts said. “Doing a nursing assessment over the phone is a special skill, yet based on the information gathered related to the child’s behavior (and) fluid intake, there were several recommendations I could make.”

Deciding whether it was OK to wait until the morning, page the primary care doctor, or go to the emergency room to be evaluated takes critical thinking.

Example #4: Using Detective Skills

Nurses have to use acute listening skills to discern what patients are really telling them (or not telling them) and whether they are getting the whole story.

“I once had a 5-year-old patient who came in for asthma exacerbation on repeated occasions into my clinic,” said Pompilio. “The mother swore she was giving her child all her medications, but the asthma just kept getting worse.”

Pompilio asked the parent to keep a medication diary.

“It turned out that after a day or so of medication and alleviation in some symptoms, the mother thought the child was getting better and stopped all medications,” she said.

Example #5: Prioritizing

“Critical thinking is present in almost all aspects of nursing, even those that are not in direct action with the patient,” said Rhoads. “During report, nurses decide which patient to see first based on the information gathered, and from there they must prioritize their actions when in a patient’s room. Nurses must be able to scrutinize which medications can be taken together, and which modality would be best to help a patient move from the bed to the chair.”

A critical thinking skill in prioritization is cognitive stacking. Cognitive stacking helps create smooth workflow management to set priorities and help nurses manage their time. It helps establish routines for care while leaving room within schedules for the unplanned events that will inevitably occur. Even experienced nurses can struggle with juggling today’s significant workload, prioritizing responsibilities, and delegating appropriately.

Example #6: Medication & Care Coordination

Another aspect that often falls to nurses is care coordination. A nurse may be the first to notice that a patient is having an issue with medications.

“Based on a report of illness in a patient who has autoimmune challenges, we might recommend that a dose of medicine that interferes with immune response be held until we communicate with their specialty provider,” said Roberts.

Nurses applying critical skills can also help ease treatment concerns for patients.

“We might recommend a patient who gets infusions come in earlier in the day to get routine labs drawn before the infusion to minimize needle sticks and trauma,” Robert said.

Example #7: Critical Decisions

During the middle of an operation, the anesthesia breathing machine Allen was using malfunctioned.

“I had to critically think about whether or not I could fix this machine or abandon that mode of delivering nursing anesthesia care safely,” she said. “I chose to disconnect my patient from the malfunctioning machine and retrieve tools and medications to resume medication administration so that the surgery could go on.”

Nurses are also called on to do rapid assessments of patient conditions and make split-second decisions in the operating room.

“When blood pressure drops, it is my responsibility to decide which medication and how much medication will fix the issue,” Allen said. “I must work alongside the surgeons and the operating room team to determine the best plan of care for that patient’s surgery.”

“On some days, it seems like you are in the movie ‘The Matrix,’” said Pompilio. “There’s lots of chaos happening around you. Your patient might be decompensating. You have to literally stop time and take yourself out of the situation and make a decision.”

Example #8: Fast & Flexible Decisions

Allen said she thinks electronics are great, but she can remember a time when technology failed her.

“The hospital monitor that gives us vitals stopped correlating with real-time values,” she said. “So I had to rely on basic nursing skills to make sure my patient was safe. (Pulse check, visual assessments, etc.)”

In such cases, there may not be enough time to think through every possible outcome. Critical thinking combined with experience gives nurses the ability to think quickly and make the right decisions.

Nurses who think critically are in a position to significantly increase the quality of patient care and avoid adverse outcomes.

“Critical thinking allows you to ensure patient safety,” said Carter. “It’s essential to being a good nurse.”

Nurses must be able to recognize a change in a patient’s condition, conduct independent interventions, anticipate patients and provider needs, and prioritize. Such actions require critical thinking ability and advanced problem-solving skills.

“Nurses are the eyes and ears for patients, and critical thinking allows us to be their advocates,” said Allen.

Image courtesy of iStock.com/ davidf

Last updated on Jul 24, 2024. Originally published on Aug 25, 2021.

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How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples

Last updated on August 19th, 2023

Nurses play a critical role in making critical decisions that directly impact patient outcomes in the dynamic field of healthcare. Developing strong critical thinking skills is essential for success in this role.

In this article, we present a comprehensive list of 23 nursing-specific strategies aimed at improving critical thinking and improve the quality of patient care.

24 Strategies to improve critical thinking skills in nursing

You may also want to check out: 15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)

1. Reflective Journaling: Delving into Deeper Understanding

Reflective journaling is a potent tool for nurses to explore their experiences, actions, and decisions.

By regularly pondering over situations and analyzing their thought processes, nurses can identify strengths and areas for improvement.

This practice encourages the conscious development of critical thinking by comparing past experiences with current knowledge and exploring alternative solutions.

After a particularly challenging case, a nurse reflects on their decision-making process, exploring what worked well and what could have been done differently.

2. Meeting with Colleagues: Collaborative Learning for Critical Thinking

Regular interactions with colleagues foster a collaborative learning environment. Sharing experiences, discussing diverse viewpoints, and providing constructive feedback enhance critical thinking skills .

Colleagues’ insights can challenge assumptions and broaden perspectives, ultimately leading to more well-rounded clinical judgments.

A nursing team gathers to discuss a recent complex case, sharing their perspectives, insights, and lessons learned to collectively improve patient care strategies.

3. Concept Mapping: Visualizing Complexity

Concept mapping is an excellent technique to synthesize intricate patient information. By creating visual representations of patient problems and interventions, nurses can identify relationships and patterns that might not be apparent otherwise.

This strategy aids in comprehensive care planning and encourages nurses to think holistically about patient care.

Creating a concept map to connect patient symptoms, diagnostics, and interventions reveals patterns that help the nurse formulate a comprehensive care plan.

4. Socratic Questioning: Digging Deeper into Situations

The art of Socratic questioning involves asking probing questions that lead to deeper understanding.

Applying this technique allows nurses to uncover assumptions, examine inconsistencies, and explore multiple viewpoints.

This approach is especially valuable when reviewing patient history, discussing conditions, and planning care strategies.

When assessing a patient’s deteriorating condition, a nurse asks probing questions to uncover potential underlying causes and prioritize appropriate interventions.

5. Inductive and Deductive Reasoning: From Specifics to Generalizations

Developing skills in both inductive and deductive reasoning equips nurses to analyze situations from different angles.

Inductive reasoning involves drawing conclusions from specific observations, while deductive reasoning starts with general premises to arrive at specific conclusions.

Proficient use of these methods enhances nurses’ ability to make accurate clinical judgments.

When encountering a series of patients with similar symptoms, a nurse uses inductive reasoning to identify a common pattern and deduce potential causes.

6. Distinguishing Statements: Fact, Inference, Judgment, and Opinion

Clear thinking demands the ability to differentiate between statements of fact, inference, judgment, and opinion.

Nurses must critically evaluate information sources, ensuring they rely on evidence-based practice.

This skill safeguards against misinformation and supports informed decision-making.

While reviewing a patient’s history, a nurse differentiates factual medical information from inferences and subjective judgments made by different healthcare professionals.

7. Clarifying Assumptions: Promoting Effective Communication

Recognizing assumptions and clarifying their underlying principles is vital for effective communication. Nurses often hold differing assumptions, which can impact patient care.

By acknowledging these assumptions and encouraging open discussions, nursing teams can collaboratively create care plans that align with patients’ best interests.

Before suggesting a treatment plan, a nurse engages in a conversation with a patient to understand their cultural beliefs and preferences, ensuring assumptions are not made.

8. Clinical Simulations: Learning through Virtual Scenarios

Clinical simulations provide nurses with a risk-free environment to practice decision-making and problem-solving skills.

These virtual scenarios mimic real-life patient situations and allow nurses to test different approaches, assess outcomes, and reflect on their choices.

By engaging in simulations, nurses can refine their critical thinking abilities, learn from mistakes, and gain confidence in their clinical judgment.

Engaging in a simulated scenario where a patient’s condition rapidly changes challenges a nurse’s decision-making skills in a controlled environment.

9. Case Studies and Grand Rounds: Analyzing Complex Cases

Engaging in case studies and participating in grand rounds exposes nurses to complex patient cases that require in-depth analysis.

Working through these scenarios encourages nurses to consider various factors, potential interventions, and their rationale.

Discussing these cases with colleagues and experts fosters collaborative critical thinking and widens the spectrum of possible solutions.

Nurses participate in grand rounds, discussing a challenging case involving multiple medical specialties, encouraging a holistic approach to patient care.

10. Continuing Education and Lifelong Learning: Expanding Knowledge

Staying up-to-date with the latest advancements in nursing and healthcare is crucial for effective critical thinking.

Pursuing continuing education opportunities, attending conferences, and engaging in self-directed learning keeps nurses informed about new research, technologies, and best practices.

This continuous learning enriches their knowledge base, enabling them to approach patient care with a well-rounded perspective.

Attending a nursing conference on the latest advancements in wound care equips a nurse with evidence-based techniques to improve patient outcomes.

11. Debates and Discussions: Encouraging Thoughtful Dialogue

Organizing debates or participating in structured discussions on healthcare topics stimulates critical thinking.

Engaging in debates requires researching and presenting evidence-based arguments, promoting the evaluation of different perspectives.

Nurses can exchange insights, challenge assumptions, and refine their ability to defend their viewpoints logically.

Engaging in a debate on the pros and cons of a new treatment method encourages nurses to critically analyze different viewpoints and strengthen their own understanding.

12. Multidisciplinary Collaboration: Gaining Insights from Various Disciplines

Collaborating with professionals from diverse healthcare disciplines enriches nurses’ critical thinking.

Interacting with doctors, pharmacists, therapists, and other experts allows nurses to benefit from different viewpoints and approaches.

This cross-disciplinary collaboration broadens their understanding and encourages innovative problem-solving.

Collaborating with physical therapists, nutritionists, and pharmacists helps a nurse develop a holistic care plan that addresses all aspects of a patient’s recovery.

13. Ethical Dilemma Analysis: Balancing Patient Autonomy and Best Practice

Ethical dilemmas are common in nursing practice. Analyzing these situations requires nurses to weigh the principles of beneficence, non-maleficence, autonomy, and justice.

By critically examining ethical scenarios, nurses develop the capacity to navigate morally complex situations, prioritize patient welfare, and make ethically sound decisions.

When faced with a patient’s refusal of treatment due to religious beliefs, a nurse evaluates the ethical considerations, respects autonomy, and seeks alternatives.

14. Root Cause Analysis: Investigating Adverse Events

When adverse events occur, performing a root cause analysis helps identify the underlying causes and contributing factors.

Nurses engage in a systematic process of analyzing events, exploring the “5 Whys” technique , and developing strategies to prevent similar occurrences in the future.

This approach cultivates a thorough and analytical approach to problem-solving.

After a medication error, a nurse leads a root cause analysis to identify system failures and implement preventive measures to enhance patient safety.

15. Creative Thinking Exercises: Expanding Solution Repertoire

Encouraging creative thinking through brainstorming sessions or scenario-based exercises widens the range of possible solutions nurses consider.

By thinking outside the box and exploring innovative approaches, nurses develop adaptable problem-solving skills that can be applied to complex patient care challenges.

Brainstorming creative approaches to comfort a distressed pediatric patient empowers a nurse to find innovative methods beyond routine interventions.

16. Journal Clubs: Fostering Evidence-Based Discussion

Participating in journal clubs involves healthcare professionals coming together to dissect recent research articles.

This practice ignites critical thinking by allowing nurses to evaluate study methodologies, scrutinize findings, and consider the implications for their practice.

Engaging in evidence-based discussions not only cultivates a culture of critical inquiry but also reinforces continuous learning.

At the monthly journal club meeting, Nurse Mark engages in a discussion on a recent research article focusing on pain management strategies for post-operative patients.

The group analyzes the study design, scrutinizes the findings, and considers the potential implications for their practice.

During the discussion, Mark raises thought-provoking questions about the study’s methodology and suggests potential applications in their hospital’s patient care protocols.

This active participation in journal clubs not only refines Mark’s critical thinking but also instills evidence-based practices into his nursing approach.

17. Critical Reflection Groups: Collaborative Learning and Analysis

Similarly, establishing critical reflection groups, where nurses meet regularly to discuss experiences, cases, and challenges, fosters collective learning.

These sessions encourage the exchange of diverse perspectives, enriching the analysis process and ultimately enhancing patient care strategies.

Through shared insights and discussions, nurses can refine their clinical reasoning and broaden their problem-solving capabilities.

Nurse Emma actively participates in critical reflection groups in order to broaden her clinical knowledge. During a recent meeting, the group tackled a difficult patient case with complicated symptomatology.

Emma suggests alternative diagnostic pathways based on her own experiences. Emma’s critical thinking skills are honed as a result of the group’s dynamic interaction, which also emphasizes the importance of collaborative decision-making in complex scenarios.

18. Mindfulness and Reflection Practices: Enhancing Self-Awareness

Mindfulness techniques, such as meditation and deep breathing, encourage self-awareness and a clear mind.

Engaging in these practices helps nurses become more attuned to their thoughts and emotions, leading to better self-regulation and improved decision-making during high-pressure situations.

Engaging in mindfulness exercises before a demanding shift helps a nurse maintain focus, manage stress, and make clear-headed decisions.

19. Problem-Based Learning: Applying Knowledge in Real Scenarios

Problem-based learning involves presenting nurses with real-world patient cases and encouraging them to collaboratively solve the problems.

This approach bridges the gap between theoretical knowledge and practical application, fostering critical thinking through active problem-solving.

Working through a simulated patient case challenges nurses to apply theoretical knowledge to practical situations, refining their clinical reasoning.

20. Self-Assessment and Feedback: Evaluating Decision-Making Skills

Regularly assessing one’s own decision-making process and seeking feedback from peers and mentors is essential for improvement.

Reflecting on past decisions, considering alternative approaches, and understanding the rationale behind them contribute to the refinement of critical thinking skills.

A nurse evaluates their performance after a patient’s unexpected complication, seeking feedback from peers and mentors to identify areas for improvement.

21. Cultural Competence Training: Navigating Diverse Perspectives

Cultural competence training enhances critical thinking by enabling nurses to understand the diverse cultural beliefs and practices of patients.

This knowledge is vital for providing patient-centered care, as it encourages nurses to think critically about the unique needs of each individual.

A nurse attends cultural competence training to understand the dietary preferences of a diverse patient population, ensuring respectful and patient-centered care.

22. Active Listening and Empathetic Communication: Gathering Insights

Active listening and empathetic communication with patients and their families enable nurses to gather comprehensive information about their conditions, concerns, and preferences.

This data forms the basis for critical analysis and informed decision-making in patient care.

Through attentive listening, a nurse uncovers a patient’s underlying concerns, leading to an informed care plan that addresses both medical needs and emotional well-being.

23. Mentorship and Preceptorship: Learning from Experienced Professionals

Having a mentor or preceptor provides novice nurses with the opportunity to learn from experienced professionals.

Mentors guide critical thinking by sharing their insights, challenging assumptions, and offering guidance in complex situations. This relationship fosters growth and expertise development.

A novice nurse gains valuable insight from a mentor, who guides them through complex cases, offering real-world wisdom and refining critical thinking skills.

24. Self-Assessment and Feedback: Evaluating Decision-Making Skills

Reflecting on past decisions, considering alternative approaches, and understanding the rationale behind them contribute to the refinement of critical thinking skills .

Nurse Sarah regularly takes time to assess her decision-making skills by reviewing past patient cases. After a challenging case involving conflicting symptoms, she reflects on her initial approach, the outcomes, and what she could have done differently.

She seeks feedback from her senior colleague, who provides insights on alternative diagnostic paths. Sarah’s self-assessment and feedback-seeking process enable her to identify areas for improvement and refine her critical thinking in similar situations.

• Clinical Reasoning In Nursing (Explained W/ Example)
• 8 Stages Of The Clinical Reasoning Cycle
• What is Critical Thinking in Nursing? (Explained W/ Examples)

Enhancing critical thinking skills is an ongoing journey that transforms nursing practice.

Reflective journaling, collaborative learning, concept mapping, Socratic questioning , reasoning techniques, distinguishing statements, and clarifying assumptions all play integral roles in nurturing these skills.

By incorporating these strategies into their daily routines, nurses can improve their critical thinking skills.

Additionally, this will help nurses in navigating the complexities of the healthcare field with confidence, expertise, and the ability to make well-informed decisions that improve patient outcomes.

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Why Critical Thinking Is Important in Nursing

Most nursing professionals have natural nurturing abilities, a desire to give others support, and an appreciation for science and anatomy. Successful nurses also possess a skill that is often overlooked: they can think critically.

A critical thinker will identify the problem, determine the best solution, and choose the most effective method. Critical thinkers evaluate the execution of a plan to see if it was effective and if it could have been done better. 

The ability to think critically has multiple applications in your life, as you can see. But Why is critical thinking important in nursing? Learn why and how you can improve this skill by reading on.

Why Are Critical Thinking Skills in Nursing Important?

Critical thinking is an essential skill for nursing students to have. It’s not something that it can teach in a classroom, and it must be developed over time through experience and practice. 

Critical thinking is the process of applying logic and reason to make decisions or solve problems. The ability to think critically will help you make better decisions on your own and collaborate with others when solving problems – both are essential skills for nurses.

Nursing has always been a profession that relies on critical thinking. Nurses are constantly faced with new situations and problems, which they need to think critically about to solve. 

Critical thinking is essential for nurses because it helps them make decisions based on the available information and their past experiences and knowledge of the field. It also allows nurses to plan before making any changes to be most effective as possible.

It is an essential skill for nurses to have to provide the best care possible. Critical thinkers can comprehend a problem and think about how they can solve it, rather than reactively or automatically.

Critical thinking is a crucial skill for doctors, nurses, and other health care providers.

How can you develop your critical thinking skills?

As you know, learning doesn’t end when you graduate from nursing school. You must continue to grow as a professional and develop your critical thinking skills.

Critical thinkers are better problem solvers than others in the same situation because they examine all the facts before coming up with solutions. They can also take many different perspectives into account when solving problems.

It’s easy for people to come to conclusions too quickly, but those who think critically will avoid this trap by first looking at every possible angle.

When faced with difficult decisions, these nurses won’t just rely on their gut feelings or what seems right according to society’s norms; instead, they’ll analyze all available information carefully until they develop the best solution.

Critical thinking is also crucial because it helps nurses avoid making mistakes in their work by providing them with a way to examine each situation and identify any potential risks or problems that may arise from subsequent actions before they take place.

It’s not enough for you to have empathy if your compassion isn’t backed up by critical thought and understanding of how certain decisions might affect others in various circumstances, so keep learning ways to become more thoughtful about the world around you.

The skills involved in being a good nurse are many and varied, but one thing all nurses need, regardless of what specialty they choose, is critical solid thinking abilities.

Reasons Critical Thinking In Nursing Is Important

Nurses’ experiences often include making life-altering decisions, establishing authority in stressful situations, and helping patients and their loved ones cope with some of the most stressful and emotional times of their lives.  Critical thinking is an essential aspect of nursing.

Following are the reasons:

• Nurses’ critical thinking has a significant impact on patient care 
• Recognizing changes in patient status is essential 
• It’s essential to an honest and open exchange of ideas 
• It enables you to ensure patient safety 
• Nurses can find quick fixes with it 
• Improvements can be made through critical thinking 
• It Contributes to Rational Decision Making

Further critical thinking is essential to nursing because nurses can establish authority in a stressful situation, such as issuing orders or administering care when needed.

This can be difficult because it may require balancing medical expertise with empathy and compassion towards patients’ feelings, leading them to question your judgment at some point in time.

Another reason this skill set is crucial involves making decisions that will have life-changing effects on a patient’s health and well-being.

These are often irreversible choices that only you know how much weight they carry within the context of each situation, so you need to make sure all factors are carefully considered before deciding what action must be taken next without hesitation.

Skills that Critical Thinkers Need

When it comes to critical thinking, some skills are more important than others. Using a framework known as the Nursing Process, some of these skills are applied to patient care. The most important skills are:

Interpretation: Understanding and explaining a specific event or piece of information.

Analysis: Studying data based on subjective and objective information to determine the best course of action.

Evaluation: Here, you assess the information you received. Is the information accurate, reliable, and credible? The ability to determine if outcomes have been fully achieved requires this skill as well.

The nurse can then use clinical reasoning to determine what the problem is based on those three skills. 

The decisions need to be based on sound reasoning:

Provide a clear, concise explanation of your conclusions. Nurses should provide a rationale for their answers.

Self-regulation – You need to be aware of your thought processes. As a result, you must reflect on the process that led to your conclusion. In this process, you should self-correct as necessary. Keep an eye out for bias and incorrect assumptions.

Critical Thinking Pitfalls

It can fall by the wayside when it’s not seen as necessary or when there are more pressing issues.

• Critical thinking is important in nursing because it can fall by the wayside when it’s not seen as an essential or more pressing issue.
• It can be difficult to think critically about complex, ambiguous situations with a shortage of information and time in healthcare settings.
• If we don’t use critical thinking skills, problems might go undetected or unresolved, leading to further complications down the road.

Sometimes nurses can’t differentiate between a less acute clinical problem and one that needs immediate attention. When a large amount of complex data must be processed in a time-critical manner, errors can also occur.

Conclusion:

Nurses cannot overstate the importance of critical thinking. The clinical presentations of patients are diverse. To provide safe, high-quality care, nurses must make rational clinical decisions and solve problems. Nurses need critical thinking skills to handle increasingly complex cases.

• Why Is Research Important in Nursing?
• Why Is the Nursing Process Important?
• Why Compassion is Important in Nursing

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Why Critical Thinking Skills in Nursing Matter (And What You Can Do to Develop Them)

By Hannah Meinke on 07/05/2021

The nursing profession tends to attract those who have natural nurturing abilities, a desire to help others, and a knack for science or anatomy. But there is another important skill that successful nurses share, and it's often overlooked: the ability to think critically.

Identifying a problem, determining the best solution and choosing the most effective method to solve the program are all parts of the critical thinking process. After executing the plan, critical thinkers reflect on the situation to figure out if it was effective and if it could have been done better. As you can see, critical thinking is a transferable skill that can be leveraged in several facets of your life.

But why is it so important for nurses to use? We spoke with several experts to learn why critical thinking skills in nursing are so crucial to the field, the patients and the success of a nurse. Keep reading to learn why and to see how you can improve this skill.

Why are critical thinking skills in nursing important?

You learn all sorts of practical skills in nursing school, like flawlessly dressing a wound, taking vitals like a pro or starting an IV without flinching. But without the ability to think clearly and make rational decisions, those skills alone won’t get you very far—you need to think critically as well.

“Nurses are faced with decision-making situations in patient care, and each decision they make impacts patient outcomes. Nursing critical thinking skills drive the decision-making process and impact the quality of care provided,” says Georgia Vest, DNP, RN and senior dean of nursing at the Rasmussen University School of Nursing.

For example, nurses often have to make triage decisions in the emergency room. With an overflow of patients and limited staff, they must evaluate which patients should be treated first. While they rely on their training to measure vital signs and level of consciousness, they must use critical thinking to analyze the consequences of delaying treatment in each case.

No matter which department they work in, nurses use critical thinking in their everyday routines. When you’re faced with decisions that could ultimately mean life or death, the ability to analyze a situation and come to a solution separates the good nurses from the great ones.

How are critical thinking skills acquired in nursing school?

Nursing school offers a multitude of material to master and upholds high expectations for your performance. But in order to learn in a way that will actually equip you to become an excellent nurse, you have to go beyond just memorizing terms. You need to apply an analytical mindset to understanding course material.

One way for students to begin implementing critical thinking is by applying the nursing process to their line of thought, according to Vest. The process includes five steps: assessment, diagnosis, outcomes/planning, implementation and evaluation.

“One of the fundamental principles for developing critical thinking is the nursing process,” Vest says. “It needs to be a lived experience in the learning environment.”

Nursing students often find that there are multiple correct solutions to a problem. The key to nursing is to select the “the most correct” solution—one that will be the most efficient and best fit for that particular situation. Using the nursing process, students can narrow down their options to select the best one.

When answering questions in class or on exams, challenge yourself to go beyond simply selecting an answer. Start to think about why that answer is correct and what the possible consequences might be. Simply memorizing the material won’t translate well into a real-life nursing setting.

How can you develop your critical thinking skills as a nurse?

As you know, learning doesn’t stop with graduation from nursing school. Good nurses continue to soak up knowledge and continually improve throughout their careers. Likewise, they can continue to build their critical thinking skills in the workplace with each shift.

“To improve your critical thinking, pick the brains of the experienced nurses around you to help you get the mindset,” suggests Eileen Sollars, RN ADN, AAS. Understanding how a seasoned nurse came to a conclusion will provide you with insights you may not have considered and help you develop your own approach.

The chain of command can also help nurses develop critical thinking skills in the workplace.

“Another aid in the development of critical thinking I cannot stress enough is the utilization of the chain of command,” Vest says. “In the chain of command, the nurse always reports up to the nurse manager and down to the patient care aide. Peers and fellow healthcare professionals are not in the chain of command. Clear understanding and proper utilization of the chain of command is essential in the workplace.”

How are critical thinking skills applied in nursing?

“Nurses use critical thinking in every single shift,” Sollars says. “Critical thinking in nursing is a paramount skill necessary in the care of your patients. Nowadays there is more emphasis on machines and technical aspects of nursing, but critical thinking plays an important role. You need it to understand and anticipate changes in your patient's condition.”

As a nurse, you will inevitably encounter a situation in which there are multiple solutions or treatments, and you'll be tasked with determining the solution that will provide the best possible outcome for your patient. You must be able to quickly and confidently assess situations and make the best care decision in each unique scenario. It is in situations like these that your critical thinking skills will direct your decision-making.

Do critical thinking skills matter more for nursing leadership and management positions?

While critical thinking skills are essential at every level of nursing, leadership and management positions require a new level of this ability.

When it comes to managing other nurses, working with hospital administration, and dealing with budgets, schedules or policies, critical thinking can make the difference between a smooth-running or struggling department. At the leadership level, nurses need to see the big picture and understand how each part works together.

A nurse manager , for example, might have to deal with being short-staffed. This could require coaching nurses on how to prioritize their workload, organize their tasks and rely on strategies to keep from burning out. A lead nurse with strong critical thinking skills knows how to fully understand the problem and all its implications.

• How will patient care be affected by having fewer staff?
• What kind of strain will be on the nurses?

Their solutions will take into account all their resources and possible roadblocks.

• What work can be delegated to nursing aids?
• Are there any nurses willing to come in on their day off?
• Are nurses from other departments available to provide coverage?

They’ll weigh the pros and cons of each solution and choose those with the greatest potential.

• Will calling in an off-duty nurse contribute to burnout?
• Was this situation a one-off occurrence or something that could require an additional hire in the long term?

Finally, they will look back on the issue and evaluate what worked and what didn’t. With critical thinking skills like this, a lead nurse can affect their entire staff, patient population and department for the better.

Beyond thinking

You’re now well aware of the importance of critical thinking skills in nursing. Even if you already use critical thinking skills every day, you can still work toward strengthening that skill. The more you practice it, the better you will become and the more naturally it will come to you.

If you’re interested in critical thinking because you’d like to move up in your current nursing job, consider how a Bachelor of Science in Nursing (BSN) could help you develop the necessary leadership skills.

EDITOR’S NOTE: This article was originally published in July 2012. It has since been updated to include information relevant to 2021.

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28.2 Developing Critical Thinking Skills

Learning objectives.

By the end of this section, you will be able to:

• Analyze the types of thinking used in nursing
• Recognize when to use the different types of thinking in nursing
• Explore the application of knowledge to thinking in nursing
• Appy Critical Thinking Indicators (CTIs) to decision making

Thinking is something we usually do subconsciously, because we are not usually “thinking about thinking.” However, with the ever-increasing autonomy being afforded to nurses, there is also an increased need for nurses to be able to critically think effectively and intentionally. Being able to critically think helps nurses’ problem solve, generate solutions, and make sound clinical judgments that affect the lives of their patients. Keep reading to learn more about how nurses use critical thinking in practice and how you can develop your own critical thinking skills.

Types of Thinking Used in Nursing

Nurses make decisions while providing patient care by using critical thinking and clinical reasoning. In nursing, critical thinking is a broad term that includes reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” On the other hand, clinical reasoning is defined as a complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions. Each of these types of thinking is described in more detail in the following sections.

Cognitive Thinking

The term cognitive thinking refers to the mental processes and abilities a nurse uses to interpret, analyze, and evaluate information in their practice. Basically, it encompasses how nurses think about the practice decisions they are making. Cognitive thinking and critical thinking go hand in hand because nurses must be able to use their knowledge and mental processes to devise solutions and actions when caring for patients. Using critical thinking means that nurses take extra steps to maintain patient safety and do not just follow orders. It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research. Critical thinkers possess certain attitudes that foster rational thinking:

• confidence: believing in yourself to complete a task or activity
• curiosity: asking “why” and wanting to know more
• fair-mindedness: treating every viewpoint in an unbiased, unprejudiced way
• independence of thought: thinking on your own
• insight into egocentricity and sociocentricity: thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
• integrity: being honest and demonstrating strong moral principles
• intellectual humility: recognizing your intellectual limitations and abilities
• interest in exploring thoughts and feelings: wanting to explore different ways of knowing
• nonjudgmental: using professional ethical standards and not basing your judgments on your own personal or moral standards
• perseverance: persisting in doing something despite it being difficult

Cognitive thinking is significant to nursing because it provides a foundation on which nurses can make rapid and accurate decisions in clinical practice. Nurses must be able to think quickly and make informed decisions to promote optimal patient outcomes.

Effective Thinking

To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process. Effective thinking in nursing involves the integration of clinical knowledge and critical thinking to make the best decisions for patients. For example, if a nurse was caring for a patient who presents with hypertension and new-onset left-sided weakness, it is important that the nurse be able to quickly consider potential causes for the weakness and implement immediate stroke protocols. Without the ability to critically think, the nurse may overlook the weakness as being unrelated to the hypertension and not consider the possibility of stroke, leading to a poor patient outcome. Thus, it is imperative that nurses develop effective thinking skills.

Inductive Reasoning

The term inductive reasoning involves noticing cues, making generalizations, and creating hypotheses. Cues are data that fall outside of expected findings and give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A generalization is a judgment formed on the basis of a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes clearer. On the basis of generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. Remember, a hypothesis is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored. No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to act quickly, especially in emergency situations. They can see how certain objects or events form a pattern (or a generalization) that indicates a common problem.

Consider this example: A nurse assesses a patient who has undergone surgery and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.

Deductive Reasoning

Another type of critical thinking is deductive reasoning ; it is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.

Think about this example: On the basis of research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking, because the intervention is applied to all patients regardless of whether they have difficulty sleeping or not.

Identify the Purpose of Thinking

Rationalizing the purpose of thinking is probably not something you do often, but it is the foundational first step in critical thinking. To effectively use critical thinking in practice, the nurse must first identify the purpose of thinking. For example, the nurse is caring for a patient who presents with fever, tachycardia, and shortness of breath. The patient also has an open, infected wound on the left foot that is not healing. The nurse must recognize that the patient is exhibiting signs and symptoms that may be indicative of an underlying problem. At this point, the nurse must be able to identify that the purpose of thinking with regard to the patient is to consider what might be happening with the patient and formulate a plan of care. This begins the process of critical thinking, which involves several steps: thinking ahead, thinking in action, and reflection on thinking.

Thinking Ahead

Thinking ahead in nursing involves considering what may be going on with the patient to anticipate potential outcomes and complications that may arise. Remember competent nurses are proactive versus reactive. Reactive nursing is letting situations arise and then responding to the change, but proactive nursing is recognizing cues behaviors and patterns that are leading up to a complicated event. Additionally, the nurse will formulate goals of care and must try to anticipate specific needs the patient will have. Considering the patient discussed in the preceding paragraph, the nurse should begin the process of thinking ahead about potential outcomes and complications. The nurse may hypothesize that the patient is starting to develop sepsis from the open wound on the foot so severe sepsis and/or septic shock could be a complication to begin preparing for. The nurse thinks ahead about goals of care for the patient and determines that wound care to prevent infection spread and sepsis is the priority goal at this time.

Thinking in Action

Thinking in action encompasses the thought processes occurring while the nurse is performing interventions. So, if the nurse in our example begins performing wound care, they are thinking about the best dressing to use, how to clean the wound, and if antibiotics should be considered. All of these thoughts are likely occurring as the nurse is providing the care; thus, they are examples of how the nurse is using thinking in action.

Reflection on Thinking

After performing interventions or making decisions, the nurse should reflect on the thinking that occurred. The nurse will use this thinking process to determine if the decision was reactive or responsive. Reactive decision-making involves responding to situations after they have occurred, often in a hurried or unplanned manner. These decisions tend to be impulsive and are driven by immediate needs or crises. Responsive decisions, on the other hand, involve careful deliberation about how to address a situation based on careful consideration of information. In our example, the nurse’s decision appears to have been responsive. The patient was exhibiting some altered vital signs, but nothing indicated that the situation had become emergent yet. The nurse was able to think carefully about the patient’s situation and determine that wound care was the highest priority and begin to implement care in a calm, deliberate manner. In an ideal world, all nursing decisions would be responsive, but in a lot of cases, they must be reactive because of situation severity and medical emergencies.

Application of Knowledge

During the outset of the critical thinking process, nurses must judge whether their knowledge is accurate, complete, factual, timely, and relevant. This can be done by applying knowledge to nursing practice in a multitude of ways, including drawing from past education and experience in nursing and using professional resources and standards. Each of these is discussed in more detail in the following sections.

Knowledge Base

Becoming a nurse requires years of schooling, which contributes to the development of a robust knowledge base. Nurses receive formal education and training that provides them foundational knowledge in anatomy, physiology, pharmacology, and patient care techniques, among many others. Additionally, nurses are required to complete continuing education courses specific to their chosen practice setting, further developing their knowledge base. When applying knowledge in practice, nurses can draw from their knowledge base and make informed decisions about patient care.

Experience in Nursing

Nursing is considered a practice. Nursing practice means we learn from our mistakes and our past experiences and apply this knowledge to our next patient or to the next population we serve. As nurses gain more experience, they can use what they have learned in practice and apply it to new patient situations. Each new encounter with a patient presents unique challenge and learning opportunities that contribute to the development of clinical expertise. Reflecting on these experiences allows nurses to recognize patterns, anticipate patient outcomes, and refine their decision-making processes. Whether they are identifying effective nursing interventions for common conditions, adapting care plans to individual patient needs, or navigating complex situations with compassion, nurses draw upon their accumulated knowledge base from clinical experience to provide high-quality, patient-centered care. Through reflection and continuous learning from past experiences, nurses enhance their clinical skills, ultimately improving patient outcomes.

Professional Resources and Standards

In addition to foundational knowledge bases and experience, nurses can also use professional resources and standards to gain and apply knowledge in practice. Nurses can refer to clinical practice guidelines that have been established by professional organizations and healthcare institutions to help provide a framework for implementing nursing interventions based on the best evidence. By following the guidelines, nurses are ensuring that their care aligns with established standards and promotes optimal patient outcomes. Additionally, nurses should remain up to date about new and emerging research in their practice area, which can be obtained by reading professional journals and publications and attending conferences, workshops, and other trainings. Nurses can use the information learned from these resources to influence practice and ensure the highest standards of care are being performed in their practice setting. By staying informed about the latest developments in nursing and health care, nurses enhance their knowledge base and can adapt their practice to incorporate new evidence and innovations. Along with professional development and staying current with professional practices, nursing students should actively seek and join professional organizations such as critical care nursing or oncology nursing societies because this will lead the student to become expert in that subject and stay relevant with current evidence and practice guidelines.

Clinical Safety and Procedures (QSEN)

Qsen competency: evidence-based practice.

Definition: Providing quality patient care based on up-to-date, theory-derived research and knowledge, rather than personal beliefs, advice, or traditional methods.

Knowledge: The nurse will describe how the strength and relevance of available evidence influences the choice of intervention in provision of patient-centered care.

Skill: The nurse will:

• subscribe to professional journals that produce original research and evidence-based reports related to their specific area of practice
• become familiar with current evidence-based clinical practice topics and guidelines
• assist in creating a work environment that welcomes new evidence into standards of practice
• question the rational for traditional methods of care that result in sub-par outcomes or adverse events

Attitude: The nurse will appreciate the importance of regularly reading relevant professional journals.

Critique of Decision

After determining the best course of action based on the application of knowledge, the nurse can critique the decisions that were made. Specifically, the nurse will use self-reflection to review their actions and thoughts that led them to the decision. The nurse will consider the outcomes of their chosen interventions, reflect on the effectiveness of their approach, and identify areas of improvement. Additionally, the nurse may seek feedback from colleagues to obtain different perspectives about decisions made. Soliciting input from others helps the nurse gain insight and learn from their peers to further inform their future practice. Reflection questions that the nurse may ask themselves to critique their decision include the following:

• Was the patient goal or outcome met?
• Could the intervention have been done differently? Could it have been done better?
• What are alternative decisions that could have been made? What are the merits of each?

Critical Thinking Indicators

Certain behaviors that demonstrate the knowledge, skills, and attitudes that promote critical thinking are called critical thinking indicators (CTIs) . Critical thinking indicators are tangible actions that are performed to assess and improve your thinking skills.

4-Circle CT Model

There are many models and frameworks within nursing and other disciplines that attempt to explain the process of critical thinking. One of the most popular is Alfaro-LeFevre’s 4-Circle CT Model (Alfaro-LeFevre, 2016). This model breaks critical thinking into four components: personal characteristics, intellectual and cognitive abilities, interpersonal abilities and self-management, and technical skills. These four components overlap, forming interconnections in critical thinking.

Link to Learning

Learn more here about the 4-Circle CT Model and see an illustration of it.

Personal Critical Thinking Indicators

Personal CTIs are behaviors that are indicative of critical thinkers. Some of these behaviors that are most relevant to nursing include:

• confidence and resilience: showing ability to reason and learn and overcoming problems
• curiosity and inquisitiveness: asking questions and looking for the “why” behind things
• effective communication: listening well, showing understanding for others thoughts and feelings, and speaking and writing with clarity
• flexibility: changing approaches as needed to obtain the best results
• honesty: looking for the truth and demonstrating integrity while adhering to moral and ethical standards
• self-awareness: being able to identify one’s own knowledge gaps and acknowledge when thinking may be negatively influenced by emotions or self-interests.

Personal Knowledge and Intellectual Skills

Personal knowledge and intellectual skills encompass the knowledge gained from nursing school and clinical experiences. Examples of each of these kinds of skills are listed in Table 28.3 .

Interpersonal and Self-Management Skills

Interpersonal and self-management skills encompass the knowledge and skills needed for effective collaboration. These include:

• addressing conflicts fairly
• advocating for patients, self, and others
• dealing with complaints constructively
• establishing empowered partnerships
• facilitating and navigating change
• fostering positive interpersonal relationships and promoting teamwork
• giving and taking constructive criticism
• leading, motivating, and managing others
• managing stress, time, and energy
• promoting a learning and safety culture
• upholding healthy workplace standards
• using skilled communication in high-stake situations

Technical Skills

Technical skills in nursing refer to the practical abilities and competencies that nurses use in the delivery of patient care. These skills are typically learned through education, training, and hands-on experience. Some common technical skills in nursing include:

• administering medications
• assisting with personal hygiene and activities of daily living
• documentation and charting
• inserting intravenous catheters
• inserting urinary catheters and nasogastric tubes
• performing tracheostomy care
• performing wound care
• taking vital signs

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Critical Thinking in Nursing

• First Online: 02 January 2023

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• Şefika Dilek Güven 3  

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Critical thinking is an integral part of nursing, especially in terms of professionalization and independent clinical decision-making. It is necessary to think critically to provide adequate, creative, and effective nursing care when making the right decisions for practices and care in the clinical setting and solving various ethical issues encountered. Nurses should develop their critical thinking skills so that they can analyze the problems of the current century, keep up with new developments and changes, cope with nursing problems they encounter, identify more complex patient care needs, provide more systematic care, give the most appropriate patient care in line with the education they have received, and make clinical decisions. The present chapter briefly examines critical thinking, how it relates to nursing, and which skills nurses need to develop as critical thinkers.

Graphical Abstract/Art Performance

Critical thinking in nursing.

This painting shows a nurse and how she is thinking critically. On the right side are the stages of critical thinking and on the left side, there are challenges that a nurse might face. The entire background is also painted in several colors to represent a kind of intellectual puzzle. It is made using colored pencils and markers.

(Adapted with permission from the Association of Science and Art (ASA), Universal Scientific Education and Research Network (USERN); Painting by Mahshad Naserpour).

Unless the individuals of a nation thinkers, the masses can be drawn in any direction. Mustafa Kemal Atatürk

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Güven, Ş.D. (2023). Critical Thinking in Nursing. In: Rezaei, N. (eds) Brain, Decision Making and Mental Health. Integrated Science, vol 12. Springer, Cham. https://doi.org/10.1007/978-3-031-15959-6_10

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

Affiliations.

• 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.

© 2020 John Wiley & Sons Ltd.

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Critical thinking definition

Critical thinking, as described by Oxford Languages, is the objective analysis and evaluation of an issue in order to form a judgement.

Active and skillful approach, evaluation, assessment, synthesis, and/or evaluation of information obtained from, or made by, observation, knowledge, reflection, acumen or conversation, as a guide to belief and action, requires the critical thinking process, which is why it's often used in education and academics.

Some even may view it as a backbone of modern thought.

However, it's a skill, and skills must be trained and encouraged to be used at its full potential.

People turn up to various approaches in improving their critical thinking, like:

• Developing technical and problem-solving skills
• Engaging in more active listening
• Actively questioning their assumptions and beliefs
• Seeking out more diversity of thought
• Opening up their curiosity in an intellectual way etc.

Is critical thinking useful in writing?

Critical thinking can help in planning your paper and making it more concise, but it's not obvious at first. We carefully pinpointed some the questions you should ask yourself when boosting critical thinking in writing:

• What information should be included?
• Which information resources should the author look to?
• What degree of technical knowledge should the report assume its audience has?
• What is the most effective way to show information?
• How should the report be organized?
• How should it be designed?
• What tone and level of language difficulty should the document have?

Usage of critical thinking comes down not only to the outline of your paper, it also begs the question: How can we use critical thinking solving problems in our writing's topic?

Let's say, you have a Powerpoint on how critical thinking can reduce poverty in the United States. You'll primarily have to define critical thinking for the viewers, as well as use a lot of critical thinking questions and synonyms to get them to be familiar with your methods and start the thinking process behind it.

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Critical thinking ability of new graduate and experienced nurses

Laura j. fero.

Doctoral Candidate, University of Pittsburgh School of Nursing, Pennsylvania, USA

Catherine M. Witsberger

Clinical Nurse Educator, Nursing Education and Research, University of Pittsburgh Medical Center, Pennsylvania, USA

Susan W. Wesmiller

Director, Nursing Education and Research, University of Pittsburgh Medical Center, Pennsylvania, USA

Thomas G. Zullo

Professor Emeritus, Dental Public Health, University of Pittsburgh, Pennsylvania, USA

Leslie A. Hoffman

Professor and Chair, Department of Acute/Tertiary Care, University of Pittsburgh School of Nursing, Pennsylvania, USA

This paper is a report of a study to identify critical thinking learning needs of new and experienced nurses.

Concern for patient safety has grown worldwide as high rates of error and injury continue to be reported. In order to improve patient safety, nurses must be able to recognize changes in patient condition, perform independent nursing interventions, anticipate orders and prioritize.

In 2004–2006, a consecutive sample of 2144 newly hired nurses in a university-affiliated healthcare system completed the Performance Based Development System Assessment consisting of 10 videotaped vignettes depicting change in patient status. Results were reported as meeting or not meeting expectations. For nurses not meeting expectations, learning needs were identified in one of six sub-categories.

Overall, 74.9% met assessment expectations. Learning needs identified for nurses not meeting expectations included initiating independent nursing interventions (97.2%), differentiation of urgency (67%), reporting essential clinical data (65.4%), anticipating relevant medical orders (62.8%), providing relevant rationale to support decisions (62.6%) and problem recognition (57.1%). Controlling for level of preparation, associate ( P = 0.007) and baccalaureate ( P < 0.0001) nurses were more likely to meet expectations as years of experience increased; a similar trend was not seen for diploma nurses ( P = 0.10). Controlling for years of experience, new graduates were less likely to meet expectations compared with nurses with ≥10 years experience ( P = 0.046).

Patient safety may be compromised if a nurse cannot provide clinically competent care. Assessments such as the Performance Based Development System can provide information about learning needs and facilitate individualized orientation targeted to increase performance level.

Introduction

Concern for patient safety has grown worldwide as high rates of error and injury continue to be reported. A recent Commonwealth Fund international survey of six nations showed that between one-quarter and one-third of patients with health problems experienced medical, medication, or testing errors. A number of countries, including the United States of America, Australia, Canada, Germany, New Zealand and the United Kingdom, have identified a need for improvement in the coordination and delivery of care ( Schoen et al. 2005 ) and a reduction in preventable medical errors ( Kohn & Donaldson 2000 ).

Patient safety can be directly affected by the critical thinking ability of a nurse. Nurses must have the ability to recognize changes in patient condition, perform independent nursing interventions, anticipate orders and prioritize ( Buerhaus et al. 2005 ). These actions require critical thinking ability, advanced problem-solving skills and the ability to communicate clearly ( NACNEP 1996 ). Using root cause analysis, the Joint Commission on the Accreditation of Healthcare Organizational Standards (JCAHO) identified orientation, training, and competence assessment as top factors contributing to patient safety errors over the past 10 years (1995–2005) ( JCAHO 2006 ).

New graduate nurses practise at the novice or advanced beginner level ( Benner 1984 ). They are at the early stage of developing a skill set and applying critical thinking. Nursing shortages and budgetary issues may mean that initial orientation periods for new graduates are shortened ( AORN 2006 ), a potential factor prompting the increase in errors. One means of determining whether new graduates and more experienced nurses can demonstrate the critical thinking ability necessary to ensure patient safety involves asking them to complete a performance-based evaluation.

Patient safety

Patient safety is at the center of today’s healthcare system reform. According to the Institute of Medicine (IOM), more than 98,000 people in the United States of America (USA) die and more than one million patients suffer injuries each year ( Kohn & Donaldson 2000 ). Thirty to 40 percent of every US dollar spent on healthcare is lost to inappropriate use, poor communication, and inefficiency ( Proctor et al. 2005 ). The IOM aims for the 21st century healthcare system include providing safe, effective, patient-centered care that is timely, efficient, and equitable ( IOM 2001 ).

Nursing competence plays a large role in assuring patient safety ( IOM 2004 ). A majority of sentinel events occur in acute care settings, where new graduate nurses traditionally begin their professional careers ( JCAHO 2006 ). According to the Joint Commission International Center for Patient Safety, over 70% of sentinel events reported resulted in a patient’s death and 10% resulted in loss of function ( JCRINC 2007 ). The inability of a nurse to set priorities and work effectively and efficiently may delay patient treatment in a critical situation and result in serious life-threatening consequences ( Redfern et al. 2002 ).

The definition of nursing competence has been extensively debated ( Redfern et al. 2002 ). Competence can be the subject of objective evaluation which includes standardized measurement or subjective observational reporting. In the USA, the only universally accepted method of evaluating competence occurs at entry to practise via the National Council Licensure Examination-Registered Nurse or NCLEX-RN© ( NCSBN 2007 ). This examination does not, however, address ongoing assessment, and there is no agreement on how continued assessment should be accomplished. Current measurement tools do not take into account the evolution of practice with experience or identify areas of weakness in which healthcare organizations should focus orientation or remediation efforts ( NCSBN 2005 ). Therefore, the IOM has encouraged the development of more effective methods to identify and take action when providers are unsafe ( Kohn & Donaldson 2000 ).

Benner (1984) argues that competency assessment should be grounded in actual practice, under pressure, and over time. She further argues that assessment should be related to patient outcome and be context-specific ( Benner 1984 ). The Performance Based Development System (PBDS) assessment is an attempt to evaluate actual performance and remediate deficiencies within the orientation period.

Critical thinking

Critical thinking has been discussed since the time of Socrates and its dimensions have been explored by numerous scholars from Thomas Aquinas to John Dewey ( Facione 1990 ). However, it was not until the late 1980s that the nursing profession began to question how critical thinking relates to clinical practice and to evaluate ways to measure how effectively the educational system achieves critical thinking competence through its curriculum. This movement was started, in part, to address the directive of the US National League of Nursing to measure critical thinking as an outcome criterion for the accreditation of nursing programmes ( AACN 1998 ; Rubenfeld & Scheffer 1999 , Scheffer & Rubenfeld 2000 , Simpson & Courtney 2002 ).

There is no widely accepted definition of critical thinking in the field of nursing, psychology, or education ( Simpson & Courtney 2002 ). Scholars have found the concept very difficult to quantify and therefore to measure, leading to a wide array of interpretations ( Hynes & Bennett 2004 ). In 1988, a Delphi panel was established at the request of the American Philosophical Association to synthesize expert opinion on the concept of critical thinking. The panel identified interpretation, analysis, evaluation, inference, explanation, and self-regulation as necessary components ( Facione 1990 ).

The term critical thinking is often used interchangeably with problem-solving, clinical decision-making, and creative thinking in the nursing literature ( Simpson & Courtney 2002 ). Problem-solving focuses on identification and resolution, whereas critical thinking goes beyond this and incorporates asking questions and critiquing solutions. The notion of clinical decision-making focuses attention on the clinical nature of a problem but falls short of facilitating understanding of the broader spectrum of the issue. Decision-making and critical thinking need to occur concurrently to produce reasoning, clarification, and potential solutions. Creative thinking is a combination of imagination and knowledge ( Simpson & Courtney 2002 ). It helps one to understand solutions that have failed and is certainly part of the subset of skills necessary to be an effective critical thinker.

In order to advance practice, it is necessary to develop and evaluate strategies to help nurses develop essential skills. Most studies show that there is a progression in nursing students’ ability to critically think through their education tenure ( Colucciello 1997 , Thompson & Rebeschi 1999 , Giddens & Gloeckner 2005 ). However, the literature does not identify specific areas of needed attention. In addition, most studies take place in the context of a nursing education programme, rather than following graduation ( Colucciello 1997 , May et al. 1999 , Thompson & Rebeschi 1999 , Beckie et al. 2001 , Chau et al. 2001 , Giddens & Gloeckner 2005 ). To develop in new graduates the responsibilities inherent in clinical practice most effectively, new approaches are needed, and these approaches should be objectively evaluated to determine their effectiveness prior to implementation.

The Performance Based Development System

The PBDS is designed to provide such an assessment ( Performance Management Services, Inc. 2006 ). The Clinical Judgment portion of the PBDS assessment consists of 10 videotaped vignettes which depict common clinical problems that nurses may encounter on a medical-surgical unit (e.g. onset of dyspnea, anxiety, or change in mental status). Respondents are asked to view each vignette and then state, in writing, what they think the problem is, actions they would take in response, and their rationale. The PBDS assessment is designed to identify critical thinking learning needs and assist in the development of an individualized orientation action plan to prepare better nurses for safe clinical practice ( Performance Management Services, Inc. 2006 ). Although the PBDS assessment has been in use since 1985 in over 500 healthcare organizations, reports of its use are limited to descriptive studies ( del Bueno 2001 , 2005 , Performance Management Services, Inc. 2006 ).

Conceptual framework

The purpose of this study was to identify critical thinking learning needs of new and experienced nurses with varying levels of preparation (diploma, associate, baccalaureate degree). The expectation was that nurses having more years of experience and those prepared at the baccalaureate level would have a higher rate of meeting expectations on the PBDS assessment. The theoretical framework guiding this expectation was Patricia Benner’s Novice to Expert Model ( Benner 1984 ). This model was developed through descriptive research using the Dreyfus Model of Skill Acquisition, which identified five levels of competence. These levels are novice, advanced beginner, competent, proficient and expert ( Dreyfus 1980 ). The novice level applies to nurses who have no experience in the environment in which they are expected to perform ( Benner 1984 ). For the purpose of this study, a novice was defined as a new nursing graduate with limited exposure to independently managing a critical situation who operates in a limited and prescribed way. An advanced beginner performs at a marginally acceptable level. At this level, nurses recognize the meaning of a critical situation but may not understand or anticipate the care needed. A competent practitioner begins to see their actions in terms of long-range planning ( Benner 1984 ). A competent nurse is able to determine which aspects of a situation are considered more relevant. This practice level entails planning, considering, analyzing, and contemplating which action to take. After reaching the proficient level, a nurse begins to perceive the meaning of a situation through reflection on previous experience, and often modifies plans based on the response to the event. At the expert level, a nurse has an intuitive grasp of a critical situation and understands deeply what is needed to ensure resolution ( Benner 1984 ).

The novice to expert framework is the basis for a number of clinical ladders in healthcare and is often used to formalize promotional structures and drive work role competencies ( Benner 1984 ). In addition, it has served as a catalyst for staff development programmes with the aim of facilitating nursing excellence. The novice to expert framework has been applied to gain insight into managing clinical problems, practice skills, and communication through innovative teaching methods ( Larew et al. 2006 ).

The aim of the study was to identify critical thinking learning needs of new and experienced nurses.

The specific objectives were to (1) describe the overall rate at which nurses meet expectations on the PBDS assessment; (2) examine the relationship between meeting PBDS expectations and years of nursing experience controlling for preparation level; and (3) examine the relationship between meeting PBDS expectations and nurses’ preparation level (diploma, associate, baccalaureate) controlling for years of nursing experience.

The study was a post hoc retrospective analysis of PBDS assessment data collected prospectively during the initial 2 weeks of employment of 2144 newly hired nurses.

Participants

All nurses employed by the same university healthcare system from 1 January 2004 to 30 September 2006 were eligible for inclusion in the study. The healthcare system which provided the de-identified data included 19 acute care, specialty, community and regional hospitals located in southwestern Pennsylvania, USA. All newly hired nurses were assessed using the PBDS in order to customize their orientation at the beginning of their employment tenure.

The sample included nurses prepared at the diploma, associate or baccalaureate level. Diploma programmes offer hospital-based nursing preparation that is typically 2 years in length; courses in the programme are taught by hospital-based educators and may include some college credit. Graduates receive a nursing diploma and are prepared to function at the staff nurse level in hospitals or inpatient facilities. Associate degree programmes are provided by a community college and are typically 2 years in length. Graduates receive an associate degree and are prepared to function at the staff nurse level in hospitals or inpatient facilities. Baccalaureate-prepared nurses attend a 4-year programme offered by a college or university. Graduates receive a baccalaureate degree and are prepared to assume leadership roles in hospitals, inpatient facilities and community settings ( All Star Directories, Inc. 2002–2008 ).

We achieved a power of 90% to detect an effect size (W) of 0.0813 using a chi-square test of independence with 3 d.f. (Specific Aim 2) and 90% power to detect an effect size (W) of 0.0768 using a chi-square test of independence with 2 d.f. (Specific Aim 3) for two-sided hypothesis testing at a statistical significance level of 0.05. Specific Aim 1 was descriptive and not included in sample size estimates.

Data collection

Data were obtained from files of the Nursing Education Department and included demographic data and hard copy summaries of the PBDS assessments. Data regarding the number of individuals who took the PBDS, years of experience, level of preparation and ratings (met, did not meet expectations) were obtained ( Table 1 ). Hard copy records of nurses who did not meet expectations on the assessment were identified. All personal identifiers were removed and de-identified hard copies of the assessment were forwarded to the research team for analysis.

Frequency counts and percentages by degree and years of experience in nursing ( n = 2144) Characteristic Newly hired nurses, n = 2144

Performance Based Development System Assessment were administered and rated based on the process developed by Performance Management Services, Inc. (2006) . Responses were rated by nurses who, by comparing respondents’ answers to model answers, determined if they met or did not meet expectations in the following six subcategories: problem recognition, reports essential clinical data, initiates independent nursing interventions, differentiation of urgency, anticipates relevant medical orders, and provides relevant rationale to support decisions ( Table 2 ). For example, if a nurse was presented with a clinical case in which the patient was recovering from surgery and receiving blood products and experienced an elevated temperature, hives, and chills, it would be expected that they would recognize that the patient was having a blood transfusion reaction, report essential clinical findings to the physician, and prepare to treat the patient based on the orders received.

Subcategory rating matrix for model Performance Based Development System Assessment

The PBDS overall assessment rating (met or did not meet expectations) was developed using a three-step process. Those taking the assessment were first given a preset amount of time to view a series of 10 videotaped vignettes depicting common clinical problems and write their responses. The nurse rater next determined if the nurse met expectations for each vignette using the method illustrated in Table 2 . Using an organizational algorithm reflecting patterns of inconsistency and safety in the answers that was based on the ability to meet expectations in each of the subcategories, the nurse rater then determined an overall assessment rating (met/did not meet expectations) for each nurse. When learning needs were identified, they were included in a summary given to the preceptor, along with an action plan to guide clinical orientation activities. The individual summary and action plan was sent to the unit manager and nurse educator to share with the orientee and preceptor. The nurse raters ( n = 5) all had Master’s degrees and over 10 years of clinical experience, and completed 9–12 months of PBDS rater training. Annual assessments were performed to determine inter-rater reliability and to validate rater competence. One nurse was assigned to rate all subcategories of each assessment. The department rates over 1000 PBDS assessments per year.

Validity and reliability

Reliability and validity of the PBDS assessment have been reported in previous publications ( del Bueno 1990 , 1994 , 2001 , 2005 ). Reliability estimates for the clinical vignettes, obtained using an equivalence approach, averaged 94% for individuals tested in parallel situations ( del Bueno 1990 ).

Ethical considerations

Approval for the study was obtained from a university institutional review board. Study data were de-identified; therefore participant consent was not required.

Data analysis

Descriptive statistics were calculated using SPSS, version 14.0. Descriptive data were available for the entire sample and included years of experience, academic preparation, and the overall assessment rating. Of the 539 nurses who did not meet expectations, 103 (19.1%) did not have complete subcategory scores and therefore were excluded when analyzing these scores. The chi-square test for independence likelihood ratio and Pearson chi-square were used to analyze differences in years of experience and level of preparation. The likelihood ratio was used because of the large sample size. The level of statistical significance was set a priori at 0.05.

Of the sample, 31.4% were diploma graduates, 41.0% associate degree graduates and 27.6% baccalaureate graduates ( Table 1 ). The majority (56.5%) were new graduates, defined as having ≤1 year of experience, while 24.5% had 10 or more years of experience.

Meeting PBDS expectations and areas of deficiency

The majority of newly hired nurses (74.9%) met expectations on the PBDS assessment. Of those who did not meet expectations, 436 (81%) had complete subcategory information. PBDS results indicated that 97.2% did not initiate appropriate nursing interventions, 67.0% did not differentiate urgency, 65.4% did not report essential clinical data, 62.8% did not anticipate relevant medical orders, 62.6% did not understand their decision rationale and 57.1% were deficient in problem recognition. Figure 1 summarizes the percentage of newly hired nurses not meeting expectations by subcategory and level of preparation.

Percentage of the sample ( n = 436) not meeting expectations by subcategory and level of preparation.

Meeting PBDS expectations and years of experience

New graduates comprised 56.5% ( n = 1211) of the sample. The remaining nurses were categorized into >1 but <5 years of experience ( n = 197), ≥5 but <10 years of experience ( n = 211) and ≥10 years of experience ( n = 525). Years of experience differed statistically significantly in those meeting or failing to meet expectations (χ 2 = 21.631, d.f. = 3, P < 0.0004): those with the least experience had the highest rate of not meeting expectations, while those with the most experience had the lowest rate.

Controlling for level of preparation (diploma, associate, baccalaureate), rates at which nurses met expectations differed statistically significantly in those prepared at associate (χ 2 = 12.085, d.f. = 3, P = 0.007) and baccalaureate levels (χ 2 = 18.498, d.f. = 3, P < 0.0001) based on years of experience. Of these, 29.6% of the new graduates prepared at the baccalaureate level did not meet expectations on the PBDS, whereas only 11.5% with ≥10 years did not meet expectations ( Figure 2 ). At the associate level 31.0% of the new graduates did not meet expectations whereas 18.3% with ≥10 years did not meet expectations. In contrast, there were no statistically significant differences in the rate of meeting expectations for nurses prepared at the diploma level based on years of experience (χ 2 = 6.259, d.f. = 3, P = 0.100).

Percentage of the sample ( n = 539) not meeting expectations on the Performance Based Development System by years of experience and degree.

Meeting PBDS expectations and level of preparation

There was no statistically significant difference in the rate of meeting or not meeting expectations with regard to level of preparation when the data were analyzed for the total sample (χ 2 = 4.886, d.f. = 2, P = 0.087). However, on controlling for years of experience, new graduates (χ 2 = 6.158, d.f. = 2, P = 0.046) and nurses with ≥10 years of experience (χ 2 = 6.179, d.f. = 2, P = 0.046) differed statistically significantly in pass rates (in those with ≥10 years of experience, the likelihood ratio was statistically significant at P = 0.046, but the Pearson chi-square was not ( P = 0.055). New graduates prepared at the associate level did not meet expectations 31.0% of the time as compared with the baccalaureate (29.6%) and the diploma (23.6%) prepared graduates ( Figure 3 ). In nurses with ≥10 years of experience, those prepared at the diploma level did not meet expectations 22.0% of the time as compared with the associate (18.3%) and baccalaureate (11.5%).

Percentage of the sample ( n = 539) not meeting expectations on the Performance Based Development System by degree and years of experience.

Study limitations

This study had a number of limitations. The analysis was limited to data collected at the time of the PBDS assessment, i.e. level of preparation and years of nursing experience. Additional information on age, gender, prior healthcare experience in addition to nursing, employment location, and length of employment was not available. These and other potential predictor variables should be considered in future studies. The six subcategories delineating the reasons that newly hired nurses did not meet expectations on the assessment did not have complete data in 19.1% of cases. It is possible that these individuals differed from others with complete subcategory data. Finally, the assessment was based on simulated vignettes, and it is possible that actual clinical decision-making may have differed from the stated actions.

Discussion of results

The results suggest that a substantial minority of these newly hired nurses had identified learning needs with regard to their ability to make appropriate decisions when asked to assess a clinically focused vignette. Overall, approximately 25% of nurses participating in the assessment were not able to recognize the clinical problem, safely prioritize care and implement independent nursing interventions. They appeared to have difficulty reporting relevant clinical data and anticipating medical orders, and were not able to convey clearly a rationale for their decision-making. It is unclear from the assessment process whether this resulted from lack of knowledge, lack of sufficient time to respond, or not completely presenting their rationale in writing. Nevertheless, it emphasizes the importance of continued assessment, mentoring and coaching to improve and validate decision-making skills.

The percentage of new graduates not meeting expectations in the present study did not fall within the range of previously published results ( del Bueno 2005 ). In a study by del Bueno (2005) , from a sample size of 10,988 inexperienced nurses (<1 year of experience) sampled between 1995 and 2004, between 65% and 76% did not meet expectations on the PBDS assessment. Of the 20,413 experienced nurses sampled in the same study, those not meeting expectations ranged between 8% and 69%. Experienced nurses not meeting expectations in the present study ranged from 18.3% to 25.1%. Areas of deficiency on subcategories from their reports were consistent with the present study.

Our findings suggest that, as would be anticipated, nurses with more years of experience were more likely to meet expectations on the PBDS assessment. However, there were differences related to level of preparation. Specifically, those with more experience who were prepared at the baccalaureate or associate level fared better on the assessment than experienced nurses with diploma level preparation. This finding may have resulted from differences in the scope of experience and/or commitment to continuing education fostered by the educational programme. Whether these or other reasons explain the differences are speculative, as our data did not suggest an explanation. This finding is not consistent with previous studies reporting PBDS results. In a study published in 2005, del Bueno reported that after 10 years of analysis there are no consistent findings which indicate differences in clinical judgment ability based on educational preparation or credentialing. Our findings, nevertheless, support a difference in testing outcome based on level of preparation. Further exploration is needed to determine the potential reasons for our results. Possible explanations include the value of and access to advancement via nursing education, the organizational emphasis placed on continuing education, or previous clinical experience.

What is already known about this topic

• Critical thinking, advanced problem-solving, and expert communication skills are an integral part of nursing practice and should be developed through nursing education programmes.
• Many nurses with a year or less of experience fail to meet expectations on the Performance Based Development System Assessment.

What this paper adds

• Approximately 25% of newly hired nurses had deficiencies in critical thinking ability, including problem recognition, reporting essential clinical data, initiating independent nursing interventions, anticipating relevant medical orders, providing relevant rationale to support decisions, and differentiation of urgency.
• Nurses prepared at the baccalaureate and associate level were more likely to meet expectations on the assessment as years of experience increased; a similar trend was not seen for diploma nurses.
• New graduates were less likely to meet assessment expectations compared with nurses with 10 years’ experience or more.

Implications for practice and/or policy

• PBDS can assist in providing information about critical thinking learning needs and facilitate individualized orientation.
• Further study is needed to identify areas of critical thinking deficiency and begin to test objective, innovative educational strategies that enhance critical thinking in the nursing population.

Our findings support Benner’s conceptualization in her novice to expert framework ( Benner 1984 ). Nurses with more experience were better able to identify appropriate actions when viewing the clinical vignettes, as would be expected. While it is of concern that a substantial minority of newly hired nurses did not meet expectations, it is important to emphasize that 75% were able to state actions that indicated their ability to manage critical situations independently and anticipate the care needed. They were able to prioritize clinical needs, consider potential actions and modify the plan of care based on prior experience. As might be anticipated, new graduates had a higher rate of not meeting expectations and struggled with the ability to make and implement independent nursing interventions in these same clinical scenarios.

Alternative critical thinking assessment methods are coming into vogue, e.g. high fidelity human simulation (HFHS) ( Henrichs et al. 2002 , Nehring et al. 2002 , Parr & Sweeney 2006 ). HFHS may be a better option for assessing critical thinking and decision-making as it provides evaluation activities that are more interactive and offers the added benefit of debriefing to facilitate learning ( Henrichs et al. 2002 , Feingold et al. 2004 , Bearnson & Wiker 2005 , O’Donnell et al. 2005 , Trossman 2005 ). Like the PBDS assessment, the HFHS can be used as a group learning tool without patient risk ( Schwid et al. 2002 ). HFHS provides a more realistic assessment that includes the ability to assess blood pressure, palpable pulses, heart sounds, breath sounds. In addition, it offers the ability to programme responses that mimic physiological actions and patient responses to the timing and selection of interventions ( Euliano 2001 , Lupien & George-Gay 2001 , Kozlowski 2004 ). Accordingly, HFHS may facilitate assessment of critical thinking and decision-making ( Duchscher 2003 ). Studies comparing the various methods of assessment remain few in number and therefore it is not possible to determine objectively which approach is the most valid and cost-effective for assessing the learning needs of new graduates and experienced nurses.

Assessments such as PBDS can provide information about learning needs and facilitate individualized orientation targeted to increase performance level. Evaluation of clinical competence is difficult, as there are few measures that capture how a nurse will perform in an actual clinical emergency when rapid decisions must be made in a complex and emotionally charged environment. Further research is needed to identify further specific areas of deficiency and begin to test objective, innovative educational strategies to enhance the critical thinking ability of both new graduates and experienced nurses. Although a time-intensive endeavor, the outcome has the potential to contribute greatly to the advancement of nursing practice and safe patient care.

Acknowledgments

The lead author was recipient of the T-32 Technology Grant: Research in Chronic and Critical Illness (T32 NR008857) Pre-Doctoral Fellowship for Doctoral Study at the University of Pittsburg, PA, USA.

Author contributions

Contributor Information

Laura J. Fero, Doctoral Candidate, University of Pittsburgh School of Nursing, Pennsylvania, USA.

Catherine M. Witsberger, Clinical Nurse Educator, Nursing Education and Research, University of Pittsburgh Medical Center, Pennsylvania, USA.

Susan W. Wesmiller, Director, Nursing Education and Research, University of Pittsburgh Medical Center, Pennsylvania, USA.

Thomas G. Zullo, Professor Emeritus, Dental Public Health, University of Pittsburgh, Pennsylvania, USA.

Leslie A. Hoffman, Professor and Chair, Department of Acute/Tertiary Care, University of Pittsburgh School of Nursing, Pennsylvania, USA.

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