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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.

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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.

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

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

What is Critical Thinking in Nursing?

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

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

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

Critical Thinking in Nursing

• First Online: 02 January 2023

Cite this chapter

• Şefika Dilek Güven 3  

Part of the book series: Integrated Science ((IS,volume 12))

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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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Bilgiç Ş, Kurtuluş Tosun Z (2016) Birinci ve son sınıf hemşirelik öğrencilerinde eleştirel düşünme ve etkileyen faktörler. Sağlık Bilimleri ve Meslekleri Dergisi 3(1):39–47

Article   Google Scholar  

Kantek F, Yıldırım N (2019) The effects of nursing education on critical thinking of students: a meta-analysis. Florence Nightingale Hemşirelik Dergisi 27(1):17–25

Ennis R (1996) Critical thinking dispositions: their nature and assessability. Informal Logic 18(2):165–182

Riddell T (2007) Critical assumptions: thinking critically about critical thinking. J Nurs Educ 46(3):121–126

Cüceloğlu D (2001) İyi düşün doğru karar ver. Remzi Kitabevi, pp 242–284

Google Scholar  

Kurnaz A (2019) Eleştirel düşünme öğretimi etkinlikleri Planlama-Uygulama ve Değerlendirme. Eğitim yayın evi, p 27

Doğanay A, Ünal F (2006) Eleştirel düşünmenin öğretimi. In: İçerik Türlerine Dayalı Öğretim. Ankara Nobel Yayınevi, pp 209–261

Scheffer B-K, Rubenfeld M-G (2000) A consensus statement on critical thinking in nursing. J Nurs Educ 39(8):352–359

Article   CAS   Google Scholar  

Rubenfeld M-G, Scheffer B (2014) Critical thinking tactics for nurses. Jones & Bartlett Publishers, pp 5–6, 7, 19–20

Gobet F (2005) Chunking models of expertise: implications for education. Appl Cogn Psychol 19:183–204

Ay F-A (2008) Mesleki temel kavramlar. In: Temel hemşirelik: Kavramlar, ilkeler, uygulamalar. İstanbul Medikal Yayıncılık, pp 205–220

Birol L (2010) Hemşirelik bakımında sistematik yaklaşım. In: Hemşirelik süreci. Berke Ofset Matbaacılık, pp 35–45

Twibell R, Ryan M, Hermiz M (2005) Faculty perceptions of critical thinking in student clinical experiences. J Nurs Educ 44(2):71–79

The Importance of Critical Thinking in Nursing. 19 November 2018 by Carson-Newman University Online. https://onlinenursing.cn.edu/news/value-critical-thinking-nursing

Suzanne C, Smeltzer Brenda G, Bare Janice L, Cheever HK (2010) Definition of critical thinking, critical thinking process. Medical surgical nursing. Lippincott, Williams & Wilkins, pp 27–28

Profetto-McGrath J (2003) The relationship of critical thinking skills and critical thinking dispositions of baccalaureate nursing students. J Adv Nurs 43(6):569–577

Elaine S, Mary C (2002) Critical thinking in nursing education: literature review. Int J Nurs Pract 8(2):89–98

Brunt B-A (2005) Critical thinking in nursing: an integrated review. J Continuing Educ Nurs 36(2):60–67

Carter L-M, Rukholm E (2008) A study of critical thinking, teacher–student interaction, and discipline-specific writing in an online educational setting for registered nurses. J Continuing Educ Nurs 39(3):133–138

Daly W-M (2001) The development of an alternative method in the assessment of critical thinking as an outcome of nursing education. J Adv Nurs 36(1):120–130

Edwards S-L (2007) Critical thinking: a two-phase framework. Nurse Educ Pract 7(5):303–314

Rogal S-M, Young J (2008) Exploring critical thinking in critical care nursing education: a pilot study. J Continuing Educ Nurs 39(1):28–33

Worrell J-A, Profetto-McGrath J (2007) Critical thinking as an outcome of context-based learning among post RN students: a literature review. Nurse Educ Today 27(5):420–426

Morrall P, Goodman B (2013) Critical thinking, nurse education and universities: some thoughts on current issues and implications for nursing practice. Nurse Educ Today 33(9):935–937

Raymond-Seniuk C, Profetto-McGrath J (2011) Can one learn to think critically?—a philosophical exploration. Open Nurs J 5:45–51

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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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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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• Authors: Christy Bowen
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• Book title: Clinical Nursing Skills
• Publication date: Jun 26, 2024
• Location: Houston, Texas
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Enhancing Critical Thinking in Clinical Practice

Implications for critical and acute care nurses.

Shoulders, Bridget MS, ACNP-BC, CCRN-CMC; Follett, Corrinne MS, FNP-BC, CCRN, RN-BC, RCIS; Eason, Joyce MS, ANP-BC, RN-BC

Bridget Shoulders, MS, ACNP-BC, CCRN-CMC , is a nurse practitioner in the cardiology department at the James A. Haley VA Hospital in Tampa, Florida.

Corrinne Follett, MS, FNP-BC, CCRN, RN-BC, RCIS, is a nurse practitioner in the cardiology department at the James A. Haley VA Hospital in Tampa, Florida.

Joyce Eason, MS, ANP-BC, RN-BC, is a nurse practitioner in the cardiology department at the James A. Haley VA Hospital in Tampa, Florida.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

Address correspondence and reprint requests to: Bridget Shoulders, MS, ACNP-BC, 31047 Whitlock Dr, Wesley Chapel, FL 33543 ( [email protected] ).

The complexity of patients in the critical and acute care settings requires that nurses be skilled in early recognition and management of rapid changes in patient condition. The interpretation and response to these events can greatly impact patient outcomes. Nurses caring for these complex patients are expected to use astute critical thinking in their decision making. The purposes of this article were to explore the concept of critical thinking and provide practical strategies to enhance critical thinking in the critical and acute care environment.

The complexity of patients in the critical and acute care settings requires that nurses be skilled in early recognition and management of rapid changes in patient condition. The interpretation and response to these events can greatly impact patient outcomes. The purpose of this article is to explore the concept of critical thinking and provide practical strategies to enhance critical thinking in the critical and acute care environment.

The complexity of patients in the critical and acute care settings requires that nurses be skilled in early recognition and management of rapid changes in patients’ condition. Caring for patients with complex conditions, decreased length of stay, sophisticated technology, and increasing demands on time challenges new and experienced nurses alike to use astute critical thinking in clinical decision making. The decisions made directly affect patient care outcomes. 1 Bedside nurses, preceptors, and nurse leaders play a pivotal role in the development of critical thinking ability in the clinical setting. The purposes of this article were to explore the concept of critical thinking and to provide nurses with practical strategies to enhance critical thinking in clinical practice.

WHAT IS CRITICAL THINKING?

Critical thinking is a learned process 2 that occurs within and across all domains. There are numerous definitions of critical thinking in the literature, often described in terms of its components, features, and characteristics. Peter Facione, an expert in the field of critical thinking, led a group of experts from various disciplines to establish a consensus definition of critical thinking. The Delphi Report, 3 published in 1990, characterized the ideal critical thinker as “habitually inquisitive, well-informed, trustful of reason…, diligent in seeking relevant information, and persistent in seeking results.” Although this definition was the most comprehensive attempt to define critical thinking 4 at the time, it was not nursing specific.

Scheffer and Rubenfeld 4 used the Delphi technique to define critical thinking in nursing. An international panel of expert nurses in practice, education, and research provided input into what habits of the mind and cognitive skills were at the core of critical thinking. After discussion and analysis, the panel provided the following consensus statement: “Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge.” This definition expanded on the consensus definition in the Delphi Report to include the additional components of creativity and intuition.

Skilled critically thinking nurses respond quickly to changes in patients’ conditions, changing priorities of care based on the urgency of the situation. They accurately interpret data, such as subtle changes in vital signs or laboratory values. 5 They are not just looking at the numbers but also assessing the accuracy and relevancy of the findings. Critical thinking helps the nurse to recognize events as part of the bigger picture and center in on the problem.

Lack of critical thinking is evident when nurses depend heavily on structured approaches, such as protocols, to make clinical decisions. These guidelines should not be viewed as mandates because the practice is always more complex than what can be captured by pathways and protocols. 6 Without critical thinking, nurses are merely performing task-oriented care.

One example of how nurses use critical thinking is with medication administration. This task may appear to be primarily a technical process, but it requires astute critical thinking. Eisenhauer and Hurley 7 interviewed 40 nurses to illustrate their thinking processes during medication administration. The nurses described communicating with providers, sharing their interpretation of patient data to ensure safe administration of medication. They used their judgment about the timing of as-needed medication (eg, timing pain medication before physical therapy). Nurses integrated their knowledge of the patient’s laboratory values or pattern of response to medication to determine the need for a change in the drug dose or time. They assessed whether a medication was achieving the desired effect and took precautionary measures in anticipating potential side effects. It is evident in these examples that safe administration of medication involves critical thinking beyond the 5 rights that nurses are taught in the academic setting .

INTEGRATING RESEARCH, EVIDENCE-BASED PRACTICE, AND CRITICAL THINKING

Nursing research is a scientific process that validates and refines existing knowledge and generates new knowledge that influences nursing practice. 8 Evidence-based practice integrates the best available research with clinical expertise and patient’s needs and values. Different types of evidence have different strengths and weaknesses in terms of credibility. The typical evidence hierarchy places meta-analysis of randomized clinical trials at the top and expert opinion at the bottom of what counts as good evidence. 6

It is important to recognize that nursing knowledge is not always evidence based. Nurses have historically acquired knowledge through a variety of nonscientific sources such as trial and error, role modeling, tradition, intuition, and personal experiences. 8 Although these sources have been “handed down” over the years and continue to influence nursing practice, nurses are expected to use the best available evidence to guide their decision making. Evidence-based practice redirects nursing from making decisions based on tradition to practicing based on the best research evidence.

Barriers for nurses to implement evidence-based practices include lack of knowledge of research, difficulty interpreting findings and applying to practice, lack of time, and lack of autonomy to implement changes. 9 Universities can overcome these barriers by incorporating nursing research throughout all clinical and nonclinical courses. Joint endeavors between hospitals and universities to educate nurses in the use of research will increase the level of comfort with evidence-based practice. 10 Specialized research departments devoted to promotion and education of staff nurses in research evaluation, utilization, and implementation would allow nursing staff to experience an increased level of support and awareness of the need for research utilization.

Nurse leaders need to create an environment that supports transformation from outdated practices and traditions. Nurses must feel empowered to question nursing practice and have available resources to support the search for evidence. Critical thinking and evidence-based practice must be connected and integrated for nurses, starting in their basic education programs and fostered throughout their lifetime. 11

THE NURSING PROCESS AND CRITICAL THINKING

The nursing process is the nurse’s initial introduction to a thinking process used to collect, analyze, and solve patient care problems. The steps of the nursing process are similar to the scientific method. In both processes, information is gathered, observations are made, problems are identified, plans are developed, actions are taken, and processes are reviewed for effectiveness. 8 The nursing process, used as a framework for making clinical judgments, helps guide nurses to think about what they do in their practice.

Chabeli 12 described how critical thinking can be facilitated using the framework of the nursing process. During the assessment phase, the nurse systematically gathers information to identify the chief complaint and other health problems. The nurse uses critical thinking to examine and interpret the data, separating the relevant from the irrelevant and clarifying the meaning when necessary. During the diagnosis phase, nurses use the diagnostic reasoning process to draw conclusions and decide whether nursing intervention is indicated. The planning and implementation of interventions should be mutual, research based, and realistic and have measurable expected outcomes. The evaluation phase addresses the effectiveness of the plan of care and is ongoing as the patient progresses toward goal achievement. The author concludes that when the nursing process is used effectively for the intended purpose, it is a powerful scientific vehicle for facilitating critical thinking.

HOW DO WE LEARN CRITICAL THINKING IN NURSING?

Nurses initially learn to think critically in the academic environment, using assessments designed to measure critical thinking. It is conceivable that a nurse could pass an examination in the classroom but have difficulty making the transition to think critically in the clinical setting. Improving critical thinking ability should be viewed as a process and, as with the development of any skill, requires practice. 13

Most nurses develop their critical thinking ability as they gain clinical expertise. Patricia Benner 14 described the development of clinical expertise, as nurses transition from novice to expert. The beginning, or novice nurse, has theoretical knowledge as a foundation and minimal practical experiences to draw from. As similar situations are encountered, experience is accrued over time as the nurse evolves toward competency. As proficiency is developed, the nurse is able to perceive situations as a whole and recognize the significant aspects. As the proficient nurse reaches toward expertise, decision making becomes automatic, drawing from the enormous background of experience acquired over the years. Experience is more than the passage of time and is required at each stage before progressing to the next level of clinical expertise. As nurses progress along the novice-to-expert continuum and gain competence, they develop their ability to think critically. 15

Preceptors play a significant role in transitioning nurses into professional practice. It is essential that preceptors have the necessary skills to facilitate the critical thinking development of new nurses. Forneris and Peden-McAlpine 16 investigated the impact of the preceptor’s coaching component of a reflective learning intervention on novice nurses’ critical thinking skills. The following coaching strategies were used to educate preceptors: context (eg, understanding the big picture), dialogue, reflection, and time (eg, the use of past experiences to discern change over time). After completing the educational intervention, the preceptors used these strategies to coach the novice nurses in the development of their critical thinking skills. This study found that these strategies stimulated the novice nurses to engage in an intentional, reflective dialogue. The preceptors acknowledged a change in their preceptor style, moving from describing critical thinking as prioritizing and organizing task to a dialogue to share thinking and understand rationale.

Nurses must have the necessary dispositions (eg, attributes, attitudes, habits of the mind) to be effective critical thinkers. 11 Finn 17 defined thinking dispositions that influence critical thinking. Open mindedness was described as the willingness to seek out and consider new evidence or possibilities. Fair mindedness referred to an unprejudiced examination of evidence that might question beliefs or a viewpoint contrary to the nurse’s own beliefs. Reflectiveness was described as the willingness to gather relevant evidence to carefully evaluate an issue, rather than making hasty judgments. Counterfactual thinking referred to the willingness to ponder what could or would happen if the facts were considered under different conditions or perspectives. The opposite thinking styles directed toward maintaining the status quo included being close minded, biased, and rigid.

Rung-Chaung et al 18 investigated the critical thinking competence and disposition of nurses at different rankings on the clinical ladder. Using Benner’s novice to expert model as their theoretical framework, a stratified random sampling of 2300 nurses working at a medical center were classified according to their position on the clinical ladder. Ten to fifteen percent of this population were randomly selected for each ladder group, with the final sample size totaling 269. Data were collected using a modified version of the Watson-Glaser Critical Thinking Appraisal tool, designed to assess critical thinking competence in the categories of inference, recognition of assumptions, deduction, interpretation, and evaluation. The participants’ cumulative average score for critical thinking competence was 61.8 of a possible score of 100, ranking highest in interpretation and lowest in inference. Participants completed a modified version of the California Critical Thinking Disposition Inventory, designed to measure the following characteristics of critical thinking: inquisitiveness, systematic analytical approach, open mindedness, and reflective thinking. Participants scored highest in reflective thinking and lowest in inquisitiveness.

Analysis of the data indicated that older nurses with more years of experience and a more prominent position on the clinical ladder were predictive of a higher critical thinking disposition. Overall, critical thinking was shown to be only partially developed. The authors recommended training programs, such as problem-based learning, group discussion, role-playing, and concept mapping be adopted to enhance nurse critical thinking skills.

Chang el al 19 examined the relationship between critical thinking and nursing competence, using the Watson-Glaser Critical Thinking Appraisal and the Nursing Competence Scale. A total of 570 clinical nurses participated in the study. These nurses scored highest in interpretation ability and lowest in inference ability. These findings were consistent with the results reported in the Rung-Chuang study. Analysis of the data indicated that critical thinking ability was significantly higher in older nurses and nurses with more than 5 years of experience. The findings of this study indicated that critical thinking ability, working years, position/title, and education level were the 4 significant predictors of nursing competence. There were significantly positive correlations between critical thinking ability and nursing competence, indicating that the higher the critical thinking ability, the better the nursing competence is.

STRATEGIES TO ENHANCE CRITICAL THINKING ABILITY

To improve critical thinking, the learning needs of nurses must first be identified. The Performance Based Development System, a scenario-based tool, was used in a study to identify critical thinking learning needs of 2144 new and experienced nurses. 20 Results were reported as either meeting (identifying the appropriate actions) or not meeting the expectations. Most participants (74.9%) met the expectations by identifying the appropriate actions. Of the approximately 25% who did not meet the expectations, the learning needs identified included initiating appropriate nursing interventions (97.2%), differentiating urgency (67%), reporting essential clinical data (65.4%), anticipating relevant medical orders (62.8%), understanding decision rationale (62.6%), and problem recognition (57.1%). As expected, nurses with the most experience had the highest rate of identifying the appropriate actions on the Performance-Based Development System assessment. These findings were consisted with Benner’s novice to expert framework. These types of assessment tools can be used to identify learning needs and help facilitate individualized orientation. The authors acknowledged that further research is needed to identify areas of critical thinking deficiency and to test objective, educational strategies that enhance critical thinking in the nursing population.

The Institute of Medicine report on the future of nursing 21 emphasized the importance of nursing residency programs to provide hands-on experience for new graduates transitioning into practice. According to the report, these programs have been shown to help new nurses develop critical competencies in clinical decision making (eg, critical thinking) and autonomy in providing patient care. Implementing successful methods to expedite the development of critical thinking in new nurses has the potential to improve patient safety, nurse job satisfaction, and recruitment and retention of competent nurse professionals. 22

Although critical thinking skills are developed through clinical practice, there are many experienced nurses who possess less than optimal critical thinking skills. 5 As part of an initiative to elevate the critical thinking of nurses on the frontline, Berkow et al 23 reported the development of the Critical Thinking Diagnostic, a tool designed to assess critical thinking of experienced nurses. The tool includes 25 competencies, identified by nursing leaders as core skills at the heart of critical thinking. These competencies were grouped into 5 components of critical thinking: problem recognition, clinical decision making, prioritization, clinical implementation, and reflection. The potential application of this tool may enable nurse leaders to identify critical thinking strengths and individualize learning activities based on the specific needs of nurses on the frontline.

The critical thinking concepts, identified in the Delphi study of nurse experts, were used to teach critical thinking in a continuing education course. 24 The objective of the course was to help nurses develop the cognitive skills and habits of the mind considered important for practice. The course focused on the who, what, where, when, why, and how of critical thinking, using the case study approach. The authors concluded that critical thinking courses should include specific strategies for application of knowledge and opportunities to use cognitive strategies with clinical simulations.

Journal clubs encourage evidence-based practice and critical thinking by introducing nurses to new developments and broader perspectives of health care. 11 Lehna et al 25 described the virtual journal club (VJC) as an alternative to the traditional journal club meetings. The VJC uses an online blog format to post research-based articles and critiques, for generation of discussion by nurses. Recommendations for practice change derived from the analysis are forwarded to the appropriate decision-making body for consideration. The VJC not only exposes the nursing staff to scientific evidence to support changing their practice but also may lead to institutional policy changes that are based on the best evidence. The VJC overcomes the limitations of the traditional journal clubs by being available to all nurses at all times.

The integration of simulation technology in nursing exposes nursing students and nurses to complex patient care scenarios in a safe environment. Kirkman 26 reported a study to investigate nursing students’ ability to transfer knowledge and skill learned during high-fidelity simulations to the clinical setting, over time. The sample of 42 undergraduate students were rated on their ability to perform a respiratory assessment, using observation and a performance evaluation tool. The findings indicated there was a significant difference in transfer of learning demonstrated by participants over time. These results provide evidence that students were able to transfer knowledge and skills from high-fidelity simulations to the traditional clinical setting.

Jacobson et al 27 reported using simulated clinical scenarios to increase nurses’ perceived confidence and skill in handling emergency situations. During a 7-month period, the scenarios were conducted a total of 97 times with staff nurses. Each scenario presented a patient’s evolving story to challenge nurses to assess and synthesize the clinical information. The scenarios included a critical point at which the nurses needed to recognize and respond to significant deterioration in the patient’s condition. Postproject survey data found that most of the nurses perceived an improvement in their confidence and skill in managing emergency situations. More than half of the nurses reported that their critical thinking skills improved because of participation in this project.

Individual nurses can enhance critical thinking by developing a questioning attitude and habits of inquiry, where there is an appreciation and openness to other ways of doing things. Nurses should routinely reflect on the care provided and the outcomes of their interventions. Using reflection encourages nurses to think critically about what they do in everyday practice and learn from their experiences. 28 This strategy is beneficial for nurses to validate knowledge and examine nursing practice. 5 Nurses must be comfortable with asking and being asked “why” and “why not.” Seeking new knowledge and updating or refining current knowledge encourage critical thinking by practicing based on the evidence. “We’ve always done it that way” is no longer an acceptable answer. A list of other useful strategies for enhancing critical thinking is included in Table 1 .

USING THE INTERACTIVE CASE STUDY APPROACH TO ENHANCE CRITICAL THINKING

Case studies provide a means to attain experience in high-risk and complex situations in a safe environment. The purpose of a case study is to apply acquired knowledge to a specific patient situation, using actual or hypothetical scenarios. Waxman and Telles 32 discussed using Benner’s model to develop simple to complex scenarios that match the learning level of the nurse. The case study should ideally provide all the relevant information for analysis, without directing the nurse’s thinking in a particular direction. Participants are encouraged to use thinking processes similar to that used in a real situation.

A well-developed case study defines objectives and expected outcomes. The questions should be geared toward the outcomes to be met. 30 The focus of the questions should be on the underlying thought processes used to arrive at the answer, rather than the answer alone. This helps nurses identify the reasons behind why a decision is made. In some cases, the case study may build on the information shared, instead of presenting all the information at one time. At the very least, case studies should have face validity or represent what they were developed to represent. 33

Case studies can be developed for specific purposes, such as analyzing data or improving the nurse’s skill in responding to specific clinical situations. 30 This strategy can be useful in building nurses’ confidence in managing complex or emergency situations. The case can be tailored to specific patient populations or clinical events. Covering the course of care that a patient receives over time is effective in putting together the whole picture. 31 For the purpose of improving patient outcomes, the case study should represent the overall patient experience. Case studies may be used to review specific actions that led to positive outcomes or the processes that led to negative outcomes. This can help determine if the care was the most appropriate for the situation. 34

The use of case studies with simulation technology provides nurses with the opportunity to critically think through a critical situation in a controlled setting. The latest human patient simulators (HPSs) are programmed to respond to the nurse’s intervention, with outcomes determined as a result of the intervention. Howard et al 35 compared the teaching strategies of HPSs and the traditional interactive case study (ICS) approach, using scenarios with the same subject matter. A sample of 49 senior nursing students were given pretest and posttest designed to measure the students’ knowledge of the content presented and their ability to apply that content to clinical problems. Participants in the HPS group scored significantly higher on the posttest than the ICS group did. Students reported that the HPS assisted them in understanding concepts, was a valuable learning experience, and helped to stimulate their critical thinking. There was no significant difference between the HPS and ICS groups’ responses to the statement that the educational intervention was realistic.

The Figure depicts an example of a heart failure case study with the objective of applying critical thinking to a common problem encountered in practice. Expert clinical nurses would be ideal to serve as facilitators of this learning experience. Their role would be to present the scenario, describe the physiological findings, ask open-ended questions that require thinking and analysis, and guide the discussion and problem-solving process. Discussion and questioning strategies that are helpful in eliciting reflective responses during the learning experience are included in Table 2 . This case study could be tailored to meet the learning needs of the target audience.

THE INFLUENCE OF THE WORKPLACE ENVIRONMENT

The workplace environment can enhance or hinder nurses’ motivation to develop their critical thinking abilities. Cornell and Riordan 36 reported an observational study that assessed workflow barriers to critical thinking in the workplace. A total of 2061 tasks were recorded on an acute care unit during 35.7 hours of observation. The activities found to consume nearly 70% of the nurses’ time included verbal communication, walking, administering medications, treatments, and documentation. Nurse workflow was characterized by frequent task switching, interruptions, and unpredictability. The authors recommended reallocating duties, delegating appropriate task to nonnursing personnel, reducing waste, deploying technology that reduces repetitive task, and continuing education and training to help nurses cope with the complex demands of nursing.

Factors in the work environment conducive to the development of critical thinking include an atmosphere of team support, staffing patterns that allow continuity of care, and exposure to a variety of patient care situations. Creating an environment where contributions are valued, nurses feel respected, and there is comfort with asking probing questions is very important in enhancing the development of critical thinking skills.

Critical thinking is an essential skill that impacts the entire spectrum of nursing practice. Studies have shown that the higher the critical thinking ability, the better the nursing competence is. It is essential that critical thinking of new and experienced nurses be assessed and learning activities developed based on the specific needs of the nurses. The concept of critical thinking should be included in orientation, ongoing education, and preceptor preparation curriculums. These educational offerings should be designed to help nurses develop the cognitive skills and habits of the mind considered important for practice.

Bedside nurses can integrate a critical thinking approach by developing clinical expertise, making a commitment to lifelong learning, and practicing based on the evidence. Nurses should routinely reflect on the care provided and the outcomes of their interventions.

Further research is needed to identify areas of critical thinking deficiency and evaluate strategies aimed at enhancing critical thinking. These strategies will ultimately lead to improved clinical decision making and patient outcomes. Bedside nurses, preceptors, and nurse leaders are encouraged to work together collaboratively to create a culture where critical thinking is an integral part of nursing practice.

Acute care; Critical thinking; Decision making

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Nurse practitioners gather considerable amounts of patient data through evaluations, tests and conversations. Each patient's information can be interpreted and analyzed to determine the best courses of action for their health. A growing emphasis on critical thinking in nursing stems from the increasing importance of nurse practitioners in primary care.

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Growing need for critical thinking in nursing.

There is a significant shortage of primary care services throughout the United States. GoodRx identified 80% of counties as "health care deserts" or locations without easy access to necessary services. This data includes the following categories relevant to family nurse practitioners:

• 9% of counties lack enough primary care providers to serve the local population
• Residents in 20% of counties are at least 30 minutes away from hospitals
• Residents in 45% of counties are at least 20 minutes away from community health centers

"Health care deserts" are worsening because of a shortage of primary care physicians. The Association of American Medical Colleges ( AAMC ) estimates up to 48,000 more primary care providers are needed to meet patient care needs by 2034. This shortfall translates to a lack of preventive care and increased reliance on emergency care facilities.

The U.S. Bureau of Labor Statistics ( BLS ) projects a 52% growth in nurse practitioner roles by 2030. This growth is fueled not only by "health care deserts" but an aging population and public health threats like COVID-19. Critical thinking by nurse practitioners can overcome these challenges even with limited resources and stressful situations.

The Critical Thinking Process

The first step in incorporating critical thinking into patient care is understanding the critical thinking process. The National League for Nursing Accreditation Commission ( NLNAC ) defines critical thinking as:

"the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief based."

Critical thinking in nursing does not move in a straight line because each patient is unique. There isn't a one-size-fits-all diagnosis for patients because there isn't a single type of patient. Nurse practitioners can apply the following steps in the Clinical Reasoning Cycle as they evaluate patient care decisions.

Consider the Situation

First impressions of new patients can distract from effective evaluations. Personal experiences and assumptions may lead to hasty conclusions about patient needs. The first step to critical thinking in nursing involves a dispassionate consideration of the facts.

Nurse practitioners often have the basic facts about their patients' conditions before stepping into exam rooms. A simple repetition of the patient's age and reported illness counters assumptions that can negatively impact patient care.

Collect Information

Critical thinking requires the synthesis of existing and new information for effective analysis. Nurse practitioners can pull useful details from patient charts and histories when they are available. An evaluation of visual appearance, speech, blood pressure and other metrics builds on this previous work.

Skilled practitioners automatically apply their knowledge of physiology, pharmacology and other areas during the collection process. They also keep best practices, cultural competence and ethics in mind while working with patients. This recall makes it easier to process information during diagnosis.

Process Information

There is a multi-step process for turning raw information into useful insights for patient care. Nurse practitioners effectively process patient data by:

• Analyzing information within the context of normal and abnormal ranges
• Separating relevant and irrelevant data while finding information gaps
• Focus on relationships between symptoms and cues
• Deduce potential causes of health problems
• Compare similar situations between current and past patients
• Predict potential outcomes and complications from treatment

Nurse practitioners are ready to diagnose patient conditions following this process. Depending on symptoms, they'll have considered and eliminated multiple diagnoses based on careful consideration of the facts. This step also takes into consideration risks for other health issues without treatment.

Set Goals and Act

A patient's course of treatment should follow the SMART model for goal-setting. The best treatment plans are Specific, Measurable, Achievable, Realistic and Timely to support the measurement of their efficacy. This model creates a repeatable process that is effective across patient demographics and conditions.

Critical thinking in nursing produces clear goals that are essential to patient adherence to treatment. Treatment plans may include prescribed medications, therapies and visits with specialists. Nurse practitioners collaborate with their patients and colleagues on supportive frameworks for effective treatment.

Evaluate and Reflect

Follow-up appointments provide opportunities for evaluation of treatment plans. Nurse practitioners compare past and present metrics when determining improvements in patient conditions. A useful method for evaluating success is whether the following rights of clinical reasoning were applied:

• Right patient
• Right action
• Right reason

Frequent reflection on this process is essential for improvement as a nurse practitioner. Self-directed explorations of what should have been done and what could have happened in each case sharpen critical thinking skills. An understanding of what was learned in each case creates points of comparison for future patients.

Improving Your Critical Thinking

Critical thinking in nursing improves through thoughtful deliberation and frequent use. Nurse practitioners should speak with their colleagues and mentors about their applications of critical thinking. Frequent collaboration on patient care also places the focus on evidence-based care rather than personal assumptions.

Updated knowledge of nursing resources and tools makes it easier to implement critical thinking in nursing. Medical journals and continuing education courses reinforce what nurse practitioners have learned throughout their careers. Carson-Newman University provides a strong foundation for improved critical thinking through its Online MSN-FNP.

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Every course in the program is taught by an experienced nurse educator who also practices in their community. Carson-Newman reinforces the importance of critical thinking in nursing with courses on topics including:

• Advanced Health Assessment
• Advanced Pathophysiology
• Advanced Primary Care Nursing for Adults

FNP students receive full support from Carson-Newman to identify clinical placements in their communities. They also receive one-on-one guidance from Student Success Advisors throughout their time at the University. This commitment to nursing education helped Carson-Newman reach the top third of graduate nursing programs in U.S. News & World Report's rankings.

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• Critical Thinking

Q&A: What is critical thinking and when would you use critical thinking in the clinical setting?

(Write 2-3 paragraphs)

In literature ‘critical thinking’ is often used, and perhaps confused, with problem-solving and clinical decision-making skills and clinical reasoning. In practice, problem-solving tends to focus on the identification and resolution of a problem, whilst critical thinking goes beyond this to incorporate asking skilled questions and critiquing solutions.

Critical thinking has been defined in many ways, but is essentially the process of deliberate, systematic and logical thinking, while considering bias or assumptions that may affect your thinking or assessment of a situation. In healthcare, the clinical setting whether acute care sector or aged care critical thinking has generally been defined as reasoned, reflective thinking which can evaluate the given evidence and its significance to the patient’s situation. Critical thinking occasionally involves suspension of one’s immediate judgment to adequately evaluate and appraise a situation, including questioning whether the current practice is evidence-based. Skills such as interpretation, analysis, evaluation, inference, explanation, and self-regulation are required to interpret thinking and the situation. A lack of critical thinking may manifest as a failure to anticipate the consequences of one’s actions.

Critical thinking is that mode of thinking – about any subject, content, or problem — in which the thinker improves the quality of his or her thinking by skillfully taking charge of the structures inherent in thinking and imposing intellectual standards upon them.

The Paul-Elder framework has three components:

• The elements of thought (reasoning)
• The intellectual standards that should be applied to the elements of reasoning
• The intellectual traits associated with a cultivated critical thinker that result from the consistent and disciplined application of the intellectual standards to the elements of thought.

Critical thinking can be defined as, “the art of analysing and evaluating thinking with a view to improving it”. The eight Parts or Elements of Thinking involved in critical thinking:

• All reasoning has a purpose (goals, objectives).
• All reasoning is an attempt to figure something out, to settle some question, to solve some problem .
• All reasoning is based on assumptions (line of reasoning, information taken for granted).
• All reasoning is done from some point of view.
• All reasoning is based on data, information and evidence .
• All reasoning is expressed through, and shaped by, concepts and ideas .
• All reasoning contains inferences or interpretations by which we draw conclusions and give meaning to data.
• All reasoning leads somewhere or has implications and consequence.

Q&A: To become a nurse requires that you learn to think like a nurse. What makes the thinking of a nurse different from a doctor, a dentist or an engineer?

It is how we view the health care consumer or aged care consumer, and the type of problems nurses deal with in clinical practice when we engage in health care patient centred care. To think like a nurse requires that we learn the content of nursing; the ideas, concepts, ethics and theories of nursing and develop our intellectual capacities and skills so that we become disciplined, self-directed, critical thinkers.

As a nurse you are required to think about the entire patient/s and what you have learnt as a nurse including; ideas, theories, and concepts in nursing. It is important that we develop our skills so that we become highly proficient critical thinkers in nursing.

In nursing, critical thinkers need to be:

Nurses need to use language that will clearly communicate a lot of information that is key to good nursing care, for handover and escalation of care for improving patient safety and reducing adverse outcomes, some organisations use the iSoBAR (identify–situation–observations–background–agreed plan–read back) format. Firstly, the “i”, for “identify yourself and the patient”, placed the patient’s identity, rather than the diagnosis, in primary position and provided a method of introduction. (This is particularly important when teams are widely spread geographically.) The prompt, “S” (“situation”) “o” for “observations”, was included to provide an adequate baseline of factual information on which to devise a plan of care. and “B” (“background”), “A” “agreed plan” and “R” “read back” to reinforce the transfer of information and accountability.

In clinical practice experienced nurses engage in multiple clinical reasoning episodes for each patient in their care. An experienced nurse may enter a patient’s room and immediately observe significant data, draw conclusions about the patient and initiate appropriate care. Because of their knowledge, skill and experience the expert nurse may appear to perform these processes in a way that seems automatic or instinctive. However, clinical reasoning is a learnt skill.

Key critical thinking skills – the clinical reasoning cycle / critical thinking process

To support nursing students in the clinical setting, breakdown the critical thinking process into phases;

• Decide/identify

This is a dynamic process and nurses often combine one or more of the phases, move back and forth between them before reaching a decision, reaching outcomes and then evaluating outcomes.

For nursing students to learn to manage complex clinical scenarios effectively, it is essential to understand the process and steps of clinical reasoning. Nursing students need to learn rules that determine how cues shape clinical decisions and the connections between cues and outcomes.

Start with the Patient – what is the issue? Holistic approach – describe or list the facts, people.

Collect information – Handover report, medical and nursing, allied health notes. Results, patient history and medications.

• New information – patient assessment

Process Information – Interpret- data, signs and symptoms, normal and abnormal.

• Analyse – relevant from non-relevant information, narrow down the information
• Evaluate – deductions or form opinions and outcomes

Identify Problems – Analyse the facts and interferences to make a definitive diagnosis of the patients’ problem.

Establish Goals – Describe what you want to happen, desired outcomes and timeframe.

Take action – Select a course of action between alternatives available.

Evaluate Outcomes – The effectiveness of the actions and outcomes. Has the situation changed or improved?

Reflect on process and new learning – What have you learnt and what would you do differently next time.

Scenario: Apply the clinical reasoning cycle, see below, to a scenario that occurred with a patient in your clinical practice setting. This could be the doctor’s orders, the patient’s vital signs or a change in the patient’s condition.

(Write 3-5 paragraphs)

Important skills for critical thinking

Some skills are more important than others when it comes to critical thinking. The skills that are most important are:

• Interpreting – Understanding and explaining the meaning of information, or a particular event.
• Analysing – Investigating a course of action, that is based upon data that is objective and subjective.
• Evaluating – This is how you assess the value of the information that you have. Is the information relevant, reliable and credible?

This skill is also needed to determine if outcomes have been fully reached.

Based upon those three skills, you can use clinical reasoning to determine what the problem is.

These decisions have to be based upon sound reasoning:

• Explaining – Clearly and concisely explaining your conclusions. The nurse needs to be able to give a sound rationale for their answers.
• Self-regulating – You have to monitor your own thought processes. This means that you must reflect on the process that lead to the conclusion. Be on alert for bias and improper assumptions.

Critical thinking pitfalls

Errors that occur in critical thinking in nursing can cause incorrect conclusions. This is particularly dangerous in nursing because an incorrect conclusion can lead to incorrect clinical actions.

Illogical Processes

A common illogical thought process is known as “appeal to tradition”. This is what people are doing when they say it’s always been done like this. Creative, new approaches are not tried because of tradition.

All people have biases. Critical thinkers are able to look at their biases and not let them compromise their thinking processes.

Biases can complicate decision making, communication and ultimately effect patient care.

Closed Minded

Being closed-minded in nursing is dangerous because it ignores other team members points of view. Essential input from other experts, as well as patients and their families are also ignored which ultimately impacts on patient care. This means that fewer clinical options are explored, and fewer innovative ideas are used for critical thinking to guide decision making.

So, no matter if you are an intensive care nurse, community health nurse or a nurse practitioner, you should always keep in mind the importance of critical thinking in the nursing clinical setting.

It is essential for nurses to develop this skill: not only to have knowledge but to be able to apply knowledge in anticipation of patients’ needs using evidence-based care guidelines.

American Management Association (2012). ‘AMA 2012 Critical Skills Survey: Executive Summary’. (2012). American Management Association. http://playbook.amanet.org/wp-content/uploads/2013/03/2012-Critical-Skills-Survey-pdf.pdf   Accessed 5 May 2020.

Korn, M. (2014). ‘Bosses Seek ‘Critical Thinking,’ but What Is That?,’ The Wall Street Journal . https://www.wsj.com/articles/bosses-seek-critical-thinking-but-what-is-that-1413923730?tesla=y&mg=reno64-wsj&url=http://online.wsj.com/article/SB12483389912594473586204580228373641221834.html#livefyre-comment Accessed 5 May 2020.

School of Nursing and Midwifery Faculty of Health, University of Newcastle. (2009). Clinical reasoning. Instructors resources. https://www.newcastle.edu.au/__data/assets/pdf_file/0010/86536/Clinical-Reasoning-Instructor-Resources.pdf  Accessed 11 May 2020

The Value of Critical Thinking in Nursing + Examples. Nurse Journal social community for nurses worldwide. 2020.  https://nursejournal.org/community/the-value-of-critical-thinking-in-nursing/ Accessed 8 May 2020.

Paul And Elder (2009) Have Defined Critical Thinking As: The Art of Analysing And Evaluating …

https://www.chegg.com/homework-help/questions-and-answers/paul-elder-2009-defined-critical-thinking-art-analyzing-evaluating-thinking-view-improving-q23582096 Accessed 8 May 2020 .

Cody, W.K. (2002). Critical thinking and nursing science: judgment, or vision? Nursing Science Quarterly, 15(3), 184-189.

Facione, P. (2011). Critical thinking: What it is and why it counts. Insight Assessment , ISBN 13: 978-1-891557-07-1.

McGrath, J. (2005). Critical thinking and evidence- based practice. Journal of Professional Nursing, 21(6), 364-371.

Porteous, J., Stewart-Wynne, G., Connolly, M. and Crommelin, P. (2009). iSoBAR — a concept and handover checklist: the National Clinical Handover Initiative. Med J Aust 2009; 190 (11): S152.

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Applying critical thinking to nursing, bob price healthcare education and practice development consultant, surrey, england.

Critical thinking and writing are skills that are not easy to acquire. The term ‘critical’ is used differently in social and clinical contexts. Nursing students need time to master the inquisitive and ruminative aspects of critical thinking that are required in academic environments. This article outlines what is meant by critical thinking in academic settings, in relation to both theory and reflective practice. It explains how the focus of a question affects the sort of critical thinking required and offers two taxonomies of learning, to which students can refer when analysing essay requirements. The article concludes with examples of analytical writing in reference to theory and reflective practice.

Nursing Standard . 29, 51, 49-60. doi: 10.7748/ns.29.51.49.e10005

[email protected]

All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

Received: 23 February 2015

Accepted: 10 April 2015

education - students - study skills - studying - academic assignments - continuing professional development - CPD - clinical reasoning - critical appraisal - learning outcomes - reflection - reflective practice

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Reflective and critical thinking in nursing curriculum

O pensamento crítico-reflexivo nos currículos de enfermagem, el pensamiento reflexivo y crítico en los currículos de enfermería, maría antonia jiménez-gómez.

1 Universidad Nacional de Colombia, Facultad de Enfermería, Bogotá, Colombia.

Lucila Cárdenas-Becerril

2 Universidad Autónoma del Estado de México, Facultad de Enfermería, Toluca, México.

Margarita Betzabé Velásquez-Oyola

3 Universidad Nacional José Faustino Sánchez Carrión, Facultad de Medicina Humana, Huacho, Lima, Peru.

Marcela Carrillo-Pineda

4 Universidad de Antioquia, Facultad de Enfermería, Medellín, Colombia.

Leyvi Yamile Barón-Díaz

5 Universidad Nacional de Colombia, Facultad de Medicina, Bogotá, Colombia.

to evaluate the teaching of transversal competence of the Reflective and Critical Thinking that is fundamental in the decision-making and solution of nursing problems, in degree programs of public and private institutions in the Andean region.

multi-center, cross-sectional, exploratory-descriptive study, with mixed approach in 5 countries.

76 nursing programs participated in the study. The Reflective and Critical Thinking was found as a subject, subject content and didactic strategies. Of the 562 subjects reviewed, this type of thinking is found in 46% of the humanities area and 42% in the area of research and professional discipline. It is important to train teachers to achieve coherence between the pedagogical model approach, teaching strategies and evaluations.

Conclusion:

nursing programs in the Andean region contemplate the critical thinking as cognitive and personals skills of communication. They also use real situations analysis, supervised practice, simulation labs and specifically learning based in problems to develop the capacity to solve them, decision-making and develop communication skills, including analysis, synthesis and evaluation.

avaliar o ensino da competência transversal do pensamento crítico-reflexivo, fundamental na tomada de decisões e solução de problemas de enfermagem, nos programas de graduação de instituições públicas e privadas da região Andina.

Método:

estudo multicêntrico, transversal, exploratório-descritivo, com abordagem mista em cinco países.

Resultados:

76 programas de Enfermagem participaram do estudo. O pensamento crítico-reflexivo foi constatado como disciplina, conteúdo de disciplina e estratégias didáticas. Das 562 disciplinas revisadas, este tipo de pensamento se encontra em 46% da área de humanidades e 42% na área de pesquisa e profissional-disciplinar. Existe a necessidade de capacitar os docentes para obter coerência entre a proposta do modelo pedagógico, as estratégias didáticas e a avaliação.

Conclusão:

os programas de enfermagem da região Andina contemplam o pensamento crítico como habilidades cognitivas, de comunicação e pessoais. Da mesma forma, utilizam a análise de situações reais, estágio supervisionado, laboratórios de simulação e, principalmente, a aprendizagem baseada em problemas, com a finalidade de desenvolver a capacidade para solucionar problemas, tomar decisões e desenvolver habilidades comunicativas, incluindo análise, síntese e avaliação.

evaluar la enseñanza de la competencia transversal del Pensamiento Reflexivo y Crítico, fundamental en la toma de decisiones y en la solución de problemas de enfermería, en los programas de grado de instituciones públicas y privadas de la región Andina.

estudio multicéntrico, transversal, exploratorio-descriptivo, con abordaje mixto en 5 países.

76 programas de Enfermería participaron en el estudio. El Pensamiento Reflexivo y Crítico se encontró como asignatura, contenido de asignatura y estrategias didácticas. De las 562 asignaturas que han sido revisadas, este tipo de pensamiento se encuentra en el 46% del área de humanidades y el 42% en el área de investigación y profesional disciplinar. Está la necesidad de capacitar a los docentes para lograr coherencia entre el planteamiento del modelo pedagógico, las estrategias didácticas y la evaluación.

Conclusión:

los programas de enfermería de la región Andina contemplan el pensamiento crítico como habilidades cognitivas, de comunicación y personales. Asimismo, utilizan el análisis de situaciones reales, la práctica supervisada, los laboratorios de simulación y, principalmente, el aprendizaje basado en problemas, con la finalidad de desarrollar la capacidad para solucionar los problemas, tomar decisiones y desarrollar habilidades comunicativas, incluyendo el análisis, la síntesis y la evaluación.

Introduction

Globalization brought with it changes in all aspects of life: social, political, economic and cultural. Moreover, the nursing profession is evolving, so that it is increasingly moving away from the biomedical model of care, focused on the instrumental, to focus on people’s health care, with primacy of dialogue and agreements between the professional and the person under care. As part of a multiprofessional team, this requires changes in the curricular proposal and, in turn, a qualifying teacher for a new profile of graduate, whereby reflection, self-criticism and professional responsibility are developed ( 1 ) .

Therefore, it is necessary to work intensely to reduce the dichotomies that are present in nursing programs, namely: between theory-practice; training and the reality of professional practice; and the student as a passive part of the teaching-learning process and the professional who is required, active, proactive, creative, analytical, with contextual perspective, flexible, with logical thinking, able to carry out a permanent and continuous search for information, able to contribute with his profession to the solution of health problems.

The General Conference of the United Nations Educational, Scientific and Cultural Organization (UNESCO), at its 38th session, held in Paris from 3 to 18 November 2015, “Recommendation about Adult Learning and Education” states in one of its objectives the need to develop people’s capacity to think critically and to act with autonomy and a sense of responsibility ( 2 ) .

Critical thinking (CT) is a process and a learning outcome ( 3 - 4 ) and the clinical judgment is the result of this process. The development of the clinical judgment (clinical reasoning skills) is one of the most important and challenging tasks of being a nurse. Clinical reasoning precedes clinical judgment and the decision-making that is important in professional and personal life.

In order to achieve professionals with reflective and critical thinking (RACT), it is necessary to make deep changes in the educational dynamics, in the teaching and student roles, in the use of pedagogy and didactics to transmit knowledge, the curricular structure, the strategies of teaching-learning. These changes are expected to be centered on the student, who must actively participate in the learning process in order to achieve greater development of his or her capacities for reasoning, self-learning, self-evaluation, self-management and self-regulation. Likewise, it is expected that teachers to be critical and creative, attending to individual ways of learning, encouraging the development of good thinking in the student ( 3 ) .

Literature points out that critical thinking is the “essential foundation for education, since it is the basis for adaptation to the individual, social and professional demands of daily life in the 21st century and beyond” ( 4 ) . The world changes fast and new realities arise, so there is a fundamental need of people to develop capabilities that allow them to respond and adapt themselves to these changes.

Critical thinking is “the process of seeking, obtaining, evaluating, analyzing, synthesizing and conceptualizing information as a guide, to develop self-conscious thinking and the ability to use this information by adding creativity and taking risks” ( 4 ) .

Authors pointed out one of the first definitions of critical thinking: “knowledge, skills and attitudes” ( 5 ) and, since the end of 1980, various strategies for its teaching have been discussed at all school levels ( 4 ) . On the other hand, authors point out the importance of generating opportunities to develop RACT in students. Therefore, some authors emphasize the importance of developing it in all health situations in favor of the patient ( 4 , 6 - 7 ) . The nursing professional developing RACT will know where, when and how to use their knowledge, skills, values and attitudes.

The motivation for nurse training in the Andean region became evident in the 1960s. In particular, Colombia generated the first degree program in 1958, which was approved in 1961. In the same period, Venezuela, Ecuador, and Peru initiated undergraduate programs; in the case of Bolivia, it happened only until 1970 ( 8 ) .

The 1980s were marked by the rise of postgraduate programs, increased development of research and the generation of knowledge. The 1990s saw a boom in graduate, specialization, masters, and doctoral programs, the latter especially in education. However, there were also more options for the qualification of nursing professionals for the teaching role. On the other hand, the Higher Education Quality Assurance System ( Sistema de Aseguramiento de la Calidad de la Educación Superior ) was implemented, as well as the Accreditation of the programs and the own regulations or nursing law emerged in each country of the region.

The first decade of the 21st century brought the development of the highest level of nursing education, the doctorate, and, with it, the generation of nursing knowledge in the region and its progress towards consolidation as a discipline ( 8 ) .

Throughout this journey, there was a permanent motivation for balance and congruence between the graduation profiles and the reality of the job, based on the permanent motivation for the adaptation of the curriculum, the teaching-learning strategies, the evaluation processes, and the teacher qualification to respond to this constantly changing context.

The literature ( 9 - 11 ) shows the need to expand the research in the area of education, to achieve greater development of research and to work in education and nursing policies and practices. On the other hand, the latter shows the need to implement and evaluate pedagogical and didactic strategies that help the student to develop a critical judgment, justified decision making, comprehensive memory and communicative competence ( 11 ) .

For its part, the Ibero-American Network for Research in Nursing Education ( Red Iberoamericana de Investigación en Educación en Enfermería - RIIEE), in 2011, identified as a research priority, “The development of RACT in nursing students”, within the tree of the problems detected in its research line Higher Education and Nursing. For the development of this research purpose, the Network suggested a multicenter macroproject with the theme “Strategies to develop the RACT in nursing students: situation in Latin America”. In fact, the conceptual paradigm refers to “critical theory and constructivism, since RACT is an analytical, cyclical, broad and systematic process, but not rigid; its analysis and interpretation allows to have elements for decision-making, as well as to make informed choices” ( 8 - 12 ) .

The project involves five of the six regions that make up the RIIEE: the Andean region (Bolivia, Colombia, Ecuador, Peru and Venezuela), Brazil, the Southern Cone, Europe, and Mexico and the Caribbean. The investigation is planned in three stages: 1. Diagnose; 2. Planning and implementation of interventions; and 3. Evaluation. The diagnostic stage includes: 1. The state of the art on scientific production in RACT and teaching strategies for its development; 2. Characterization of educational strategies for teaching the RACT collected in nursing literature; 3. To determine the development of the RACT competence in the different nursing curriculum; 4. To identify the educational strategies used by teachers to develop the competence of reflective critical thinking in nursing students; 5. To identify levels of critical thinking in nursing students according to the classification of Paul and Elder (unreflective thinker - master thinker). Objectives 4 and 5 are currently being developed.

The analysis of the “Scientific Production in RACT in Nursing in 1990-2012 in Ibero-America” produced among others the following conclusion: the formation of a critical reader and the investigative process are strategies that help university students to be critical and autonomous and to access more critically to the knowledge of the disciplinary area. For this, teachers are required to make of each moment and situation in the teaching-learning relationship an open forum for reflection, debate, questioning and contrasting of the different perspectives around the area of professional training and society’s problems ( 8 ) .

After reviewing the literature on the web of science by using the descriptors critical thinking and nursing, education and curriculum, it was not possible to find studies that analyzed the presence of RACT in the curriculum of nursing degree programs. However, it is very striking the motivation to analyze the importance of its development and studies that demonstrate its value, as well as the use of different and combined teaching-learning strategies to achieve the formation of RACT in nursing students.

This study was done with the purpose of to evaluate the teaching of transversal competence of the Reflective and Critical Thinking that is fundamental in the decision-making and solution of nursing problems, in degree programs of public and private institutions in the Andean region.

The coordinating group of RIIEE developed the research project from which the research groups of each country and region of the Network were made up, integrated by members of the Network and researchers in education and nursing, who are also teachers in Higher Education Institutions (HEI), and mostly with PhD academic level. The HEI in Nursing (HEIN) were identified through the Ministries of Education, the Associations of Schools and Universities of Nursing of each country and the Latin American Association of Schools and Universities of Nursing ( Asociación Latinoamericana de Escuelas y Facultades de Enfermería - ALADEFE).

The project was benefited from the Declaration of Helsinki (Ethical principles for medical research on human subjects) and the current ethics legislation in each country, was approved by the Ethics Committee of the University of Antioquia, Colombia, by Act No. CEI-FE 2015-25 on July 31, 2015. The respect for privacy and confidentiality were ensured to each Program Director, with the informed consent signed by each participant. The project was also sent to them and their understanding was guaranteed. In turn, we conceded the right to choose what information they wanted to share. Confidentiality was maintained by institutional coding. Finally, was given a deadline of 15 days to obtain the response of acceptance to participate.

The target population of this research were 187 undergraduate nursing programs in the Andean region: Bolivia (47), Colombia (47), Ecuador (21), Peru (62) and Venezuela (10). We considered only the nursing curriculum of the HEI, recognized by the Associations of Schools and Colleges of Nursing of each country or its counterpart, regardless of whether they were public or private. Resulting in the nursing curriculum of 76 Institutions that correspond to the 40.64% HEIN that teach undergraduate nursing in the Andean region: Bolivia (7), Colombia (38), Ecuador (11), Peru (14), and Venezuela (6). Due to the difficulty in obtaining the information, we checked web pages, contacted HEIN members, made contacts by telephone, in some cases, we made personal visits and, finally, the complete program was requested in PDF format for the complete the instrument of the research group. In addition, the HEIN did not refused to participate, but some institutions did not respond to the invitation. The result of this process: 30 institutions accepted to participate and provided the complete information, and out of 46 partial results were obtained. An HEIN database of the names, telephone numbers and e-mail addresses of the authorities in charge of managing the programs was created in order to follow up on their responses.

After identifying, during 2011 and 2012, the theoretical and conceptual framework of RACT from different authors and different perspectives (education, pedagogy, psychology and nursing), despite the abundance of literature about the subject, we concluded that the concept is very unclear from a nursing point of view ( 13 - 14 ) .

However, it was necessary to establish a concept that was accepted by the research group of the Network, that allowed to determine a starting point or consensus to carry out this work and, without detriment to seek some level of fidelity to the multiple approaches of the scholars of this research object, that was understandable for the group and reflected what was intended to be done in its research phases and stages.

The Network took as a theoretical framework the approaches made by Paul ( 15 ) and Paul; Elder ( 16 ) , the elements of the CT and the attitudes of the Critical Thinker proposed by these authors. With the material analyzed, RIIEE constructed the following concept: “Reflective and critical thinking is a complex, systematic and deliberate process of reasoning, self-directed and action-oriented. It is primary purpose to choose, based on intellectual and affective processes (cognitive, experiential and intuitive), the best response options that favor the solution of nursing problems, in well-defined contexts and in accordance with the ethical postulates of the profession that allow it to act with rationality and professional autonomy” ( 8 ) .

The research process included the conceptual and theoretical analysis of the curriculum, the updating of the context of research development in nursing education in each country of the region, the characterization of the HEIN and, finally, the results of the state of the art on teaching strategies for the development of the RACT 1990-2012, Andean region.

Once the exhaustive bibliographic review was carried out, the instrument was designed based on the concept of Stenhouse ( 17 ) , the curriculum as a macro concept that encompasses the socializing function of the school is at the same time pedagogical ideas, structure of contents in a particular form, precision of them, reflection of educational aspirations more difficult to translate in concrete terms and skills to promote in the students ( 16 ) . In Posner ( 18 ) , who raised the great number of phenomena involved in the curriculum; Gimeno-Sacristán; Pérez-Gómez ( 19 ) , there is five categories in which the definitions of curriculum can be articulated: as an organized knowledge structure, production technology system, instructional plan, set of learning experiences and problems solution.

Based on the aforementioned, the specific instrument for this investigation was constructed with three parts. The first with 10 items, with general information from the HEI or University. Each University is subdivided into Centers that are parted into Colleges and these are divided into programs: name, geographic location, type of institution, accreditation data, mission, vision, objectives, curricular guidelines for degree programs, web page, and data about who completed the instrument. The second, 28 items, for the College, School, Department or Nursing Program (typology to identify HEIN in the region), with the following subsections: general aspects of the nursing program, character within the institution, number of sites where the program is offered, accreditation data (date, resolution, and time of accreditation), program justification, mission, vision and objectives of the program, evaluation process, graduation profile, pedagogical model, number of hours and credits, curricular structure (nursing program subjects that correspond to each area or component). Finally, the general characteristics of the teachers: kind of affiliation with the institution, time worked, and maximum educational level achieved. The third, 9 items, for specific information about each of the subjects: name, component or area to which it belongs, number of hours and credits, type of subject (theoretical, practical and theoretical-practical), contents, teaching-learning methodologies and evaluation process.

The members of the research group carried out an analysis of the validity of the content of the instrument. Afterwards, the pilot test was conducted, starting with its implementation in each of the HEI in which the researchers worked; the results were analyzed and the corresponding adjustments were made in its structure. Subsequently, the adjusted instrument was tested with five members from the region, one from each country, but different from the research group. Because of this test, we decided to design a guide to facilitate the completion of the instrument and ensure objectivity in the collection of information, because of the language differences. It is possible to obtain the final version of the instrument from the authors of the project.

Each participant received the letter of invitation, the project, the informed consent, the instrument to collect the information and the corresponding guide for its completion in hands and by e-mail.

The information obtained was reviewed and, in some cases, it was necessary to request the complementation of some aspects of the instrument. Then we proceeded to codify the HEI or Universities and the HEIN. The information was included in Excel tables designed with the predetermined categories and subcategories, which were later incorporated into the SPSS statistical analysis program, version 19. The information was processed using descriptive statistics, with frequency distributions and average analysis, and analyzed by institution, by country and as an Andean region, according to the categories and subcategories determined, allowing comparisons between countries and conclusions to be drawn as a region.

The analysis of the information was carried out using the deductive-inductive method, considering the objectives of the project and the revised conceptual theoretical framework, with the aim of determining the presence of the RACT, explicit and implicit, in each categories, the coherence of the approaches between University-College-Program, the coherence between the objectives, contents, teaching-learning strategies and the evaluation process in each subject. In this sense, we analyzed the linearity or coherence with respect to what was proposed, developed and evaluated in relation to the RACT and, finally, the contradictions and inconsistencies found in the aforementioned approaches were pointed out. We considered national and international studies about the subject for the analysis and discussion of the results obtained, in addition to the documents mentioned above.

According to the information obtained by the research group, the Andean region has 2,552 HEI; 410 with character of universities and 160 are public, 220 are private and 14 are in special regime. There are 167 universities with nursing programs, 146 affiliated and recognized by the respective Associations of Schools and Colleges of Nursing in each country. The number of accredited nursing programs in the Andean region is 43: Colombia (20), Peru (20) and Bolivia (3). Precisely, of the 20 accredited institutions in Colombia, 11 already have their certifications renewed, which are of 8, 6 and 4 years; 5 and 6 years for Ecuador and 3 years for Peru. Bolivia is just beginning the process and Venezuela has no information about it.

The total population of HEIN by country was Bolivia 47, Colombia 42, Ecuador 21, Peru 62 and Venezuela 10. A total of 76 HEIN answered: Bolivia 7; Colombia 38; Ecuador 11; Peru 14 and Venezuela, 6. These institutions constituted the sample of the study.

Twenty-one of these institutions are certified: in Colombia 20 and in Bolivia 1; 12 did not include this information and 41 were not yet certificated. Of the total number of institutions that provided the information, 47 are public, 26 private and three do not know the information. Administratively, 36 are programs; 22 Colleges; 21 Schools and one Department.

The number of hours and credits of the programs showed considerable heterogeneity: the average number of hours was 5,552.3, corresponding on average to 232.11 credits. Regarding the number of hours per credit, the lowest is in Peru, which has 13 hours per credit, and the highest is in Colombia, with 48 hours corresponding to one credit. There are institutions that do not work with credits, especially in Bolivia; others did not included this information, among them Ecuador and Venezuela.

The main characteristics of the 912 teachers developing nursing programs in the Andean region are: 501 (54.9%) with a Specialist degree; 634 (69.51%) with a Master’s degree and 58 (6.35%) with a PhD; 249 (27.3%) with a postgraduate degree in Education.

From a general perspective, it should be noted that of the five countries in the region only Venezuela and Peru explicitly present the RACT in their Organic Law (OL) or Higher Education Law in terms of integral and permanent formation of reflective critical citizens (LOE, 2009, or Organic Law of Education, in Venezuela) ( 20 ) and (Law 30220, 2014, or University Law, in Peru) ( 21 ) .

The results of RACT’s presence are presented below: Universities or HEI; in Colleges, Programs, Schools and Departments, that is, in HEIN; and in the subjects.

When analyzing the information of the Universities or HEI, we found the RACT as direct mention, indirect mention and evidence of traditional positions was found. Directly, it was found as a training purpose in Bolivia, Colombia and Peru: receptor and analytical constructor, with critical conscience; as methodology to achieve it, in Colombia and Peru: “ promoting reasoning, the CT and creative”; as a result of learning in Ecuador and Venezuela: capable of solving problems, CT promoter.

The indirect mention was found as result in the five countries of the Region, as a strategy in Bolivia, Ecuador, Peru and Venezuela: integral formation, relation practical theory; and as objective in Colombia: future graduates with ethical conscience, autonomy, democratic spirit and highly qualified.

There are still traditional postures: teaching, evaluation as a final product, training in instrumental action, the educational process as providing knowledge.

By going a little deeper into the HEI, we found that 88% (38) consider the RACT: 63% (27) in the mission; 7% (3) in the vision; 51% (22) in the objectives and 30% (13) in the curricular guidelines. Among these, three defining categories were identified. The first, as a training purpose: prepare professionals and leaders with CT and social conscience . The second, as a methodological strategy to achieve its development: to develop and implement pedagogical methods that encourage reasoning, CT and creativity, and that encourage habits of discipline and productive work . And the third, as a result of the formation process that includes the subject: Training of critical, self-managed, creative and proactive men and women; and, moreover, refers to the projection and utility: with the promotion of CT and the generation of knowledge, thanks to the strengthening of critical analysis, anticipation and vision of the future and development of viable alternatives to the problems.

At HEIN, RACT is expressed in the graduation profile, objectives, curricular guidelines and mission. Table 1 shows the data summarized in relation to the number and percentage in which the RACT is presented in the subcategories and with regard to the total. The information recovered allows us to identify that the RACT ranks first with 38.3% in the graduation profile, followed by 35% both in the curricular guidelines and in the objectives; thirdly, is in the mission, 26.7%, and finally, with 11.7% it is in the vision. Bolivia has the highest percentage of presence in its curricular guidelines, followed by Colombia in its graduation profile, objectives, and mission, while Venezuela is in one before the last place with a 28% of presence in its mission and is not present in the profile or in the curricular guidelines. Peru has the last place and presents it only in the objectives of the programs.

In a cross-sectional view of what is proposed by curricular programs, three categories were identified to be highlighted. The first, the development of cognitive and personal skills, expressed as the training of professionals with scientific, technical, critical, analytical and reflective knowledge, as well as communication, oral and written expression skills; and referred to a critical, creative, participative, supportive, innovative and sensitive attitude towards social change.

The second, the way in which its development could be achieved, among which the research stands out: promote and develop research, generating knowledge in the different areas of nursing that contribute to universal science and the solution of health problems; and the use of technologies: learns permanently developing the capacity of abstraction, analysis, synthesis and using information technologies . The third, its finality, related to the ability of individuals, families and community groups to interfere and make decisions in the solution of health problems, to provide comprehensive care with the capacity to solve health problems in changing and emerging environments.

Concerning the pedagogical models expressed in the HEIN, a variety was found in the denomination. First of all, the constructivist approaches are highlighted in eight (8) Institutions, with some connotations as the model social-critical-constructivist and second, the cognitive - humanistic in four (4). Other models or approaches were also identified, among them: dialectic, technological, psychological, the problematic schools, the Active, Reflective, Dialectic, Innovative and Critical . Finally one institution works with the model based on the pillars of education , in which learning to know, learning to do, learning to be and learning to live together, which includes, educating for life, educating for life, educating for work, educating in society and for society ( 22 ) .

The RACT in the subjects of the programs of Nursing in the Andean region

Only 29 of the 76 HEIN participants in the study were able to obtain information on subjects (38.15%), and 22 (75.86%) of these in nursing programs, RACT was present in different elements of the subjects. 562 subjects were reviewed, 159 (29%) of which have no information about teaching strategies or evaluation. Moreover, some programs record the same teaching and assessment strategies for all subjects in the program, 45 (8%).

Table 2 presents the results by subcategory and the total presence of RACT in the different groups of subjects, basic area or foundation subjects (which introduce and contextualize the student in the field of knowledge), Research, Humanities (the study of the behavior, conditions and performance of the human being), disciplinary professional area (gives the basic grammar of the profession and discipline) and those of the flexible area (the student chooses them according to personal interests, allow to the learner to approach, contextualize and study in depth aspects of the profession and discipline, allowing to learn tools and other kinds of knowledge, leading to develop interdisciplinarity, flexibility and diversity).

The information provided makes it possible to indicate RACT as a subject: Workshop of Critical Thinking and Introduction to CT ; second, as a subject content: CT in Nursing, and, third, RACT is evidenced in teaching-learning strategies.

The highest percentage of subjects in which RACT is evident correspond to the area of humanities, with 46% (55), in which analysis of real situations, group work, concept maps, role playing and seminars are predominant.

In second place, it is in the professional-disciplinary area with 42% (307) subjects with the predominance of the following strategies: supervised clinical practice, clinical case, problem-based learning, simulation laboratories, and the nursing process. The research is in the same place, 42% (41) subjects. The most commonly used strategies are: critical discussions of research reports and articles, project development, workshops, and problem-based learning.

In the last place, subjects from the basic or foundation area 144 (24%). Including discussion workshops, concept maps and case studies.

A great variety of strategies have been identified, among them are: presentation and discussion of clinical case, group work, clinical practice, flipchart, observation guides, debates, discussion about specific topics, resolution of case studies, support of the nursing care plan, investigative reports , workshop development.

What is evaluated: the development of competencies, the acquisition of skills, the development of superior cognitive processes, the professional spirit and the development of processes and independence.

Finally, in some of the subjects, the intentionality of the evaluation of the RACT is explicitly presented: written works about the topics of each seminar in which the proper handling of the bibliography is evidenced, the capacity for criticism, analysis and synthesis, evidence of problem solving, case analysis and Nursing Based in Evidences , didactic relationship analysis and fundamental elements of the RACT, conceptual knowledge, written and oral reflections, group work, practical reflections and group discussions.

It is evident that traditional evaluation techniques still exist: evaluating procedural aspects, dexterity, motivation and initiative in the procedures, memory evaluation, participation in class, oral and written interventions and, finally, the replication of the topics studied in classes.

Therefore, the analyzed programs show interest in including as an important element in their future graduates the development of the RACT. This aspect is vanishing in the development of the subjects. It is evident in the pedagogical strategies, but it is lost until disappearing in most of the evaluative processes.

The analysis results of the plans and programs of the HEI and HEIN allow to conclude that the proposes of the Law of Higher Education to develop the RACT in the students does not guarantee that it is included in the subjects and evaluations.

What is stated in HEI and HEIN allows us to infer that epistemological and theoretical contradictions are present in the Institutions and among them. It makes necessary an epistemological, theoretical and methodological consideration in order to achieve alignment and coherence between the purposes in the curricular guidelines and what is programmed in the curricular plans for the concrete work with the students. This matter goes against comprehensive training, since it is demonstrated that critical and reflective skills contribute to train professionals with greater ability to care for patients ( 23 ) .

It should be noted that it is the University or HEI that determines the philosophical bases that will guide the academic units that compose it, so that they, in turn, incorporate these principles into their academic programs. The results show that there is no linearity between the proposals of the university with respect to its mission, vision, objectives, graduation profile, curricular guidelines, and what is proposed in the nursing degree programs. There is more linearity in Institutions with a longer trajectory and development, private and public ones.

The analysis of the areas in which the subjects are grouped made it possible to identify that the subjects of the humanities area have the highest percentage of presence of the RACT. This result can be explained by the strategies used, but even more by the subjects under study, since it has been demonstrated that the teaching-learning strategies based on the humanities have a significant impact on the development of skills such as clinical reasoning ( 24 ) . The subjects in the professional area use strategies such as case study, supervised clinical practice and other relatively new ones as problem-based learning and simulation laboratories. Strategies that, by involving simulation or potential practical actions, contribute to enhance critical skills and make decisions that lead to the future professional committing fewer errors during the care of patients ( 25 - 26 ) .

By contrast, it is not the same with the subjects of the foundation or basic area in which it is necessary to return to some knowledge aspects that already exists, such as anatomy, physiology, anthropology, psychology, statistics, among many others. For some students these topics are very difficult and involve, on several occasions, an excellent dose of memory. However, the teaching strategies that develop the RACT are not so frequent. It is important doing more research on this point to sustain if it is true.

On the other hand, for the majority of HEIN, training is conceived as qualification and progress achieved by people and as a principle of theories, concepts, methods, models, strategies and courses of pedagogical action that aim to understand and qualify the teaching. In some cases, the transfer of knowledge is approached, but it still underlies the concept of learning as acquisition of knowledge built and finished; the teacher is the one who has the knowledge and the student is who learns what teacher knows.

The curricula of the Andean region include explicit elements that contribute to the development of the RACT, such as reading, writing and reasoning, allowing to the future professional to know how to learn, reason, think creatively, generate and evaluate ideas, make decisions and solve problems ( 24 ) . It includes as proposals the development of social skills, with emphasis on oral and written communication, cognitive skills including problem solving, establish different alternatives, understand the consequences of actions, make decisions and critical thinking ( 16 ) . Also, intend to achieve in the student some characteristics of the critical thinker like to be creative, innovative, proactive, analytical, participatory, entrepreneurial, self-critical, supportive, humanistic, ethical and scientific ( 27 ) .

Regarding the pedagogical models proposed by the HEIN, inconsistencies between the approach of constructivist approach and meaningful learning are evident. The axis is the student and the repetitive approach in the subjects with master class methodology, reading guides and analysis made by teacher, but not by the student. It shows a traditional model centered on the teacher, with an emphasis on memory, comprehension and the application of concepts. Some subjects focus learning on the acquisition of concepts, despite using the integrating project as a teaching-learning strategy, workshops and practice as evaluation. The pretense for the development of the RACT is not in line with the evaluation, with the examination, in the application of contents, since it is centralized in aspects of memory and knowledge, in an asymmetric theory-practice relationship.

Although significant learning is intended and the importance of integrating it into the formation of learning approaches with the intention of promoting critical thinking, added with successful learning experiences ( 28 ) , it is not really concrete how it could be achieved. Strategies such as simple repetition and teaching for the acquisition of concepts show the persistence of the traditional educational models.

This study found there is no a clear structure to operationalize the theories of the proposed pedagogical models, even though there are expressions that point to RACT. Thus, the elements important for its development are presented in the teaching and learning strategies in a more remarkable way.

The curricular guidelines express the intention to transcend technical rationality and behavioral objectives ( 29 ) , from the positivist, rationalist or empirical analyst paradigm, to the humanist and critical curriculum ( 30 ) to the socio-critical paradigm and critical thinking based on hermeneutic processes ( 31 ) . The social and contextual (political, economic and cultural) aspects that influence and determine the health behaviors of the people are still incipient in the curricula ( 32 ) .

According to what has been demonstrated, it is possible to state that there is no predominance of a pedagogical model, but a mixture of several models in the same program with varied influences. The presence of the following models was identified: Traditional Pedagogical, Behavioral, Cognitive, and Social Pedagogical, the latter being very tenuous ( 33 ) .

There are four fundamental elements to forming critical thinkers: first, the question; second, the creation of continuous opportunities to participate in dialogue, debate, research, and critique; third, self-evaluation and hetero-evaluation; and fourth, teachers as models of critical thinkers ( 32 ) . Considering these elements, we can assure that the creation of opportunities is present with more intensity in some curricula, and self-evaluation and hetero-evaluation have begun to be implemented especially in public institutions.

Mentioning the subjects, it is not evident that the thought is motivated by complex kind of questions that encourage exploration, generate evaluation, create concepts and knowledge ( 33 ) .

The literature points out that the Socratic questions stimulate the student to use existing knowledge, since they promote a greater understanding and integration of new knowledge, they foment the habit of thinking critically ( 8 , 34 ) . Other authors suggest, for the reports, questions about the purpose, information, concepts, assumptions, implications, points of view and the questions, as elements that favor analysis, the evaluation of ideas and reasoning ( 24 , 35 ) .

Like other researches, this study found that the most used strategies in the progress of the professional area that promote the development of RACT are the case study ( 24 , 36 ) , problem-based learning ( 24 ) , supervised clinical practice ( 37 ) , the nursing process ( 4 , 38 ) and simulation laboratories ( 34 , 37 - 38 ) . In this article, we only refer to two of these strategies, which were selected because of the great advance of information and communications technologies. The growing need to access this kind of infrastructure as a fundamental part in the training of future professionals and as an example of a single teaching and learning strategy is not sufficient to achieve the RACT, rather, the use of different techniques enhance its development, as we will see below.

We agree with the conclusion of authors who suggest that Problem-Based Learning and simulation labs are active strategies that develop RACT in nursing students ( 37 ) .

The case study, moreover, promotes active learning, helps to solve clinical problems, promotes the development of critical thinking skills ( 34 - 35 ) , in addition, it allows to integrate knowledge, to think as a professional, to analyze individual situations in specific contexts from different angles, to use theoretical concepts in the delimitation of a concrete problem ( 36 ) . It also stimulates collaborative and team work, the work with different points of view. The question-problem is the motivator in the search for alternative solutions, is useful in simple and complex situations, allows to apply theory in practice, promotes the exchange of ideas, teaches students to learn to control their own thinking and promote the exchange of ideas and intellect ( 37 ) . In addition, it helps to incorporate time management and take responsibility. It also facilitates the integration of the four elements of the Nursing metaparadigm: the person receiving the care, health as purpose, the nature of the nursing and the context or environment.

The case study allows the simultaneous implementation of other strategies that further enhance the development of RACT, such as concept maps, the analysis and selection of scientific evidence, the nursing process, nursing history, role-playing, argued discussion and debate.

In contradiction to all the positive aspects of the case study in the development of RACT, the dichotomy between theory and practice in a large number of the curricula reviewed is an obstacle to achieving all the benefits pointed out. Since some teachers are in charge of the development of the theoretical subject in the classroom, others are in charge of their practical part in other spaces that require this care.

Regarding the practice based on simulation models, a study ( 38 ) shows how the promotion of RACT is relevant. In this connection, it highlights the importance of including simulation as a key element in curricula, because it ensures skills in this kind of thinking ( 38 ) and gives students the opportunity to show their ability in decision-making, critical thinking and other skills ( 39 ) . Other authors emphasize its importance when students reflect it on their thinking process and show how it guided their actions ( 34 ) .

There is efficiency of simulation laboratories when accompanied by active strategies, such as the conceptual map before each laboratory session, a visual aid that allows the concepts, objectives, justification, expected results and possible complications to be described in a logical manner if the procedure is not carried out in the appropriate manner ( 34 ) . The same author suggests the use of high-level questions to stimulate reason more than memory. He also suggests assigning an observer, who will ensure analysis and reflection on patient safety, communication, teamwork and leadership, among others ( 34 ) . The reflection of the group around the whole process carried out will be the end of the laboratory ( 15 , 34 ) .

Another study concluded that simulation as a pedagogical method allows students to recognize, interpret and integrate new information with previous knowledge in order to make decisions about the best direction to follow. The authors state that simulation, as an educational method, provides an opportunity to systematically structure learning to help students acquire deep content knowledge and to facilitate the development of thought processes; that simulation experiences stimulate students’ RACT skills and help them become more competent in caring for patients in complex conditions ( 37 ) .

We agree with what has been found in other studies emphasizing that simulation laboratories by themselves do not guarantee the development of RACT skills, but if combined with other strategies and implemented with adequate pedagogy, the results will be much more effective in terms of CT skills ( 34 , 37 - 38 ) .

It is also possible to find correspondence with that was discovered in the State of the Art of scientific production in RACT in the Andean region. The students perceive that “Clinical simulation is a valuable strategy for the acquisition, complementation and integration of the theoretical part with the practical part, because it seeks to make decisions according to the CT” ( 38 ) .

The evaluation of the subjects is cumulative and formative. In some cases, a diagnosis of the level of the student’s participation in the subject is made; it is evaluated in the intermediate and at the end with the objective of promotion to another level. In other cases, a teaching-learning balance is done to verify the fulfillment of the objectives and competences. Self-evaluation and heteroevaluation are increasingly used, implying a process of reflection, analysis and self-criticism.

Precisely, evaluation appears as one of the weakest points when analyzing the presence of RACT in curricula. Therefore, we agree that the “best teaching practice begins by establishing learning outcomes and continues with a focus on helping the student to achieve satisfactory results”. If the proposal is to achieve a higher order thinking, the evaluation will be oriented towards the synthesis, analysis and evaluation of knowledge ( 40 ) .

Overall, the strong approaches to RACT training formulated at HEI, HEIN, as evidenced by some of the teaching and learning strategies presented in the subjects, become much weaker in the evaluation process, with predominance of traditional evaluation models, and in some cases, the intention to evaluate RACT is outlined.

The curricula of Colleges and Schools of Nursing in the Andean region explicitly contemplate reflective and critical thinking in their mission, vision, objectives, graduation profile and didactic strategies, and implicitly as integral formation. However, there is a tension between what is proposed by the HEI and HEIN and what is implemented and evaluated in the subjects. The presence of RACT in the proposed didactic strategies is much more evident, but it is not sufficiently objective or explicit in the evaluation processes.

Despite the great diversity of pedagogical models, there is a clear intention to facilitate the development of RACT. In addition, although a constructivist model is proposed centered on the student, dialogical, active, reflexive, innovative and critical, this model is more centered on the teacher than on the student; on knowledge over a relationship between equals; more on results than on the learning process. Likewise, knowledge is considered as something finished, fixed and the ultimate truth.

In order to be able to teach the RACT to the nursing student it is necessary to include it in the nursing curriculum, teachers who are professionals in the areas of Education and Nursing and with RACT in their training. Teachers should create spaces for the development of RACT, know and implement the different and complementary didactic strategies that facilitate its learning and that analyze the students in relation to the level of RACT achieved.

The authors of this article suggest that the projects currently developed with teachers and students in Ibero-America should be finalized and retaken with the implementation and evaluation of strategies that value the development of RACT.

RACT is considered an indispensable element in personal and professional development, in order to have autonomy, confidence, the ability to make decisions, reach clinical judgment and, the most important, provide individualized, comprehensive and human nursing care. In summary, graduates should be able to work as members of the health team with sufficient clarity of the role and identity they should have, because they have to integrate and experience the four paradigms of the Nursing.

The limitations of the study are

The complexity of the project due to the number of participating countries and the different research groups;

The large number of public and private nursing schools and colleges in the Andean region;

The limitation in accessibility to the complete information of the curricula of each institution;

The minimal presence of information on the official web pages of each institution, school or nursing college;

No response and lack of interest from different schools and nursing colleges, public and private, to participate of this project;

Limited access of current and recent updates of the curricula of nursing colleges to develop this project.

The research group made efforts to reduce these limitations and devised multiple options that were proposed to the institutions, in order to facilitate the provision of information and its complementation when necessary.

Applications for practice

The innovation and contributions expected with this research are based fundamentally on documenting and analyzing of the diverse existing evidences about if RACT is contemplated in the nursing curricula or not, the strategies used by teachers to create and promote it in nursing students and the evaluation processes employed. It provides insights about how RACT’s competence in nursing is addressed in the context of the Andean region and other regions of Ibero-America, its weaknesses and strengths, as well as the improvements that can be made. The final intention of the research is to offer, as a network and collegial body, proposals for teaching, learning and evaluation that will enable the empowerment of new generations of nurses, using RACT as a center of innovation and development.

Critical Thinking and the Nursing Process

In today’s health care arena, the nurse is faced with increasingly complex issues and situations resulting from advanced technology, greater acuity of patients in hospital and community settings, an aging population, and complex disease processes, as well as ethical and cultural factors.  Traditionally, nurses have used a problem-solving approach in planning and providing nursing care. Today the decision-making part of problem solving has become increasingly complex and requires critical thinking.

Definition of Critical thinking

Critical thinking is a multidimensional skill, a cognitive or mental process or set of procedures. It involves reasoning and purposeful, systematic, reflective, rational, outcome-directed thinking based on a body of knowledge, as well as examination and analysis of all available information and ideas. Critical thinking leads to the formulation of conclusions and the most appropriate, often creative, decisions, options, or alternatives. Critical thinking includes metacognition, the examination of one’s own reasoning or thought processes while thinking, to help strengthen and refine thinking skills. Independent judgments and decisions evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Nursing practice in today’s society mandates the use of high-level critical thinking skills within the nursing process. Critical thinking enhances clinical decision making, helping to identify patient needs and to determine the best nursing actions that will assist the patient in meeting those needs. Critical thinking and critical thinkers have distinctive characteristics. As indicated in the above definition, critical thinking is a conscious, outcome-oriented activity; it is purposeful and intentional. The critical thinker is an inquisitive, fair-minded truth seeker with an open-mindedness to the alternative solutions that might surface.

Critical thinking Process: Rationality and Insight

Critical thinking is systematic and organized. The skills involved in critical thinking are developed over time through effort, practice, and experience. Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Critical thinking requires background knowledge and knowledge of key concepts as well as standards of good thinking. The critical thinker uses reality-based deliberation to validate the accuracy of data and the reliability of sources, being mindful of and questioning inconsistencies. Interpretation is used to determine the significance of data that are gathered, and analysis is used to identify patient problems indicated by the data. The nurse uses inference to draw conclusions. Explanation is the justification of actions or interventions used to address patient problems and to help a patient move toward desired outcomes. Evaluation is the process of determining whether outcomes have been or are being met, and self-regulation is the process of examining the care provided and adjusting the interventions as needed. Critical thinking is also reflective, involving metacognition, active evaluation, and refinement of the thinking process. The critical thinker considers the possibility of personal bias when interpreting data and determining appropriate actions. The critical thinker must be insightful and have a sense of fairness and integrity, the courage to question personal ethics, and the perseverance to strive continuously to minimize the effects of egocentricity, ethnocentricity, and other biases on the decision making process.

Components of Critical thinking

Certain cognitive or mental activities can be identified as key components of critical thinking. When thinking critically, a person will do the following:

• Ask questions to determine the reason why certain developments have occurred and to see whether more information is needed to understand the situation accurately.
• Gather as much relevant information as possible to consider as many factors as possible.
• Validate the information presented to make sure that it is accurate (not just supposition or opinion), that it makes sense, and that it is based on fact and evidence.
• Analyze the information to determine what it means and to see whether it forms clusters or patterns that point to certain conclusions.
• Draw on past clinical experience and knowledge to explain what is happening and to anticipate what might happen next, acknowledging personal bias and cultural influences.
• Maintain a flexible attitude that allows the facts to guide thinking and takes into account all possibilities.
• Consider available options and examine each in terms of its advantages and disadvantages.
• Formulate decisions that reflect creativity and independent decision making.

Critical thinking requires going beyond basic problem solving into a realm of inquisitive exploration, looking for all relevant factors that affect the issue, and being an “out-of-the-box” thinker. It includes questioning all findings until a comprehensive picture emerges that explains the phenomenon, possible solutions, and creative methods for proceeding. Critical thinking in nursing practice results in a comprehensive patient plan of care with maximized potential for success.

Critical thinking In Nursing Practice

Using critical thinking to develop a plan of nursing care requires considering the human factors that might influence the plan. The nurse interacts with the patient, family, and other health care providers in the process of providing appropriate, individualized nursing care. The culture, attitude, and thought processes of the nurse, the patient, and others will affect the critical thinking process from the data-gathering stage through the decision-making stage; therefore, aspects of the nurse-patient interaction must be considered. Nurses must use critical thinking skills in all practice settings—acute care, ambulatory care, extended care, and in the home and community. Regardless of the setting, each patient situation is viewed as unique and dynamic. The unique factors that the patient and nurse bring to the health care situation are considered, studied, analyzed, and interpreted. Interpretation of the information presented then allows the nurse to focus on those factors that are most relevant and mostsignificant to the clinical situation. Decisions about what to do and how to do it are then developed into a plan of action.

Fonteyn (1998) identified 12 predominant thinking strategies used by nurses, regardless of their area of clinical practice:

Recognizing a pattern

• Setting priorities
• Searching for information
• Generating hypotheses
• Making predictions
• Forming relationships
• Stating a proposition (“if–then”)
• Asserting a practice rule
• Making choices (alternative actions)
• Judging the value
• Drawing conclusions
• Providing explanations

Fonteyn further identified other, less prominent thinking strategies the nurse might use:

• Posing a question
• Making assumptions (supposing)
• Making generalizations

These thought processes are consistent with the characteristics of critical thinking and cognitive activities discussed earlier. Fonteyn asserted that exploring how these thinking strategies are used in various clinical situations, and practicing using the strategies, might assist the nurse–learner in examining and refining his or her own thinking skills.

Throughout the critical thinking process, a continuous flow of questions evolves in the thinker’s mind. Although the questions will vary according to the particular clinical situation, certain general inquiries can serve as a basis for reaching conclusions and determining a course of action. When faced with a patient situation, it is often helpful to seek answers to some or all of the following questions in an attempt to determine those actions that are most appropriate:

• What relevant assessment information do I need, and how do I interpret this information? What does this information tell me?
• To what problems does this information point? Have I identified the most important ones? Does the information point to any other problems that I should consider?
• Have I gathered all the information I need (signs/symptoms, laboratory values, medication history, emotional factors, mental status)? Is anything missing?
• Is there anything that needs to be reported immediately? Do I need to seek additional assistance?
• Does this patient have any special risk factors? Which ones are most significant? What must I do to minimize these risks?
• What possible complications must I anticipate?
• What are the most important problems in this situation? Do the patient and the patient’s family recognize the same problems?
• What are the desired outcomes for this patient? Which have the highest priority? Does the patient see eye to eye with me on these points?
• What is going to be my first action in this situation? How can I construct a plan of care to achieve the goals?
• Are there any age-related factors involved, and will they require some special approach? Will I need to make some change in the plan of care to take these factors into account?
•  How do the family dynamics affect this situation, and will this have an affect on my actions or the plan of care?
• Are there cultural factors that I must address and consider?
• Am I dealing with an ethical problem here? If so, how am I going to resolve it?
• Has any nursing research been conducted on this subject?

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Critical thinking in clinical nurse education: application of Paul's model of critical thinking

Affiliation.

• 1 Thompson Rivers University, School of Nursing, Kamloops, BC, Canada. [email protected]
• PMID: 22525831
• DOI: 10.1016/j.nepr.2012.03.005

Nurse educators recognize that many nursing students have difficulty in making decisions in clinical practice. The ability to make effective, informed decisions in clinical practice requires that nursing students know and apply the processes of critical thinking. Critical thinking is a skill that develops over time and requires the conscious application of this process. There are a number of models in the nursing literature to assist students in the critical thinking process; however, these models tend to focus solely on decision making in hospital settings and are often complex to actualize. In this paper, Paul's Model of Critical Thinking is examined for its application to nursing education. I will demonstrate how the model can be used by clinical nurse educators to assist students to develop critical thinking skills in all health care settings in a way that makes critical thinking skills accessible to students.

Copyright © 2012 Elsevier Ltd. All rights reserved.

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Getting Ready for the Next-Generation NCLEX® (NGN): How to Shift from the Nursing Process to Clinical Judgment in Nursing

Authored by.

Donna D. Ignatavicius , MS, RN, CNE, CNEcl, ANEF, FAADN

Linda Silvestri , PhD, RN, FAAN

What is the Nursing Process?

The nursing process has been used for over 50 years as the systematic, stepwise method for problem solving to make safe, client-centered clinical decisions. Originally, there were four nursing process steps, published in the late 1960s. These were:

• Implementation

In the early 1970s, the North American Nursing Diagnosis Association (NANDA, currently called NANDA-I) was formed to develop a common language to identify standardized nursing diagnoses based on a nurse’s interpretation of assessment data. As a nurse educator, you likely include this additional step of Diagnosis as part of the nursing process, referred to as ADPIE:

Using a problem-solving approach as a basis for nursing practice requires the use of critical thinking and decision-making. Some experts have referred to that thinking more recently as clinical reasoning. The 2020 NCLEX-RN® Test Plan identifies the nursing process as one of five integrated processes which is defined as “a scientific, clinical reasoning approach to client care that includes assessment, analysis, planning, implementation, and evaluation” (NCSBN, 2019, p.5). Note that this definition does not include Diagnosis; rather the second step of the nursing process is labeled as Analysis.

The NCLEX-RN® and NCLEX-PN® do not measure the nursing graduate’s knowledge of nursing diagnoses (NDs) because NDs are not universally used as originally intended as a standardized language, even in the United States where the NANDA nursing diagnosis list began. Yet many faculty continue to teach the nursing process as a five-step ADPIE approach.

Comparing the Nursing Process and Clinical Judgment

While the nursing process has been taught in prelicensure programs for many years, nurses continue to make serious errors in practice, including failure-to-rescue clinical situations that sometimes result in sentinel events. Based on these errors and employer dissatisfaction with the clinical-decision ability of new graduates, the National Council of State Boards of Nursing (NCSBN) developed a model of clinical judgment that is built on and expands the nursing process. Officially entitled the NCSBN Clinical Judgment Measurement Model (NCJMM), this evidence-based model identifies six cognitive skills needed to make appropriate clinical judgments. These skills include:

• Recognize Cues
• Analyze Cues
• Prioritize Hypotheses
• Generate Solutions
• Take Action
• Evaluate Outcomes

The NCJMM will be the basis for the Next-Generation NCLEX-RN and NCLEX-PN (NGN) new test items that will be presented most often in an unfolding case format . These cases will present clinical situations in which the test candidate will need to use clinical judgment skills to answer questions about how to manage the presented client’s care.

If you are teaching in a state, province, or territory in which the nursing process is required as a regulation for prelicensure nursing education, follow these guidelines to help transition from the nursing process to clinical judgment:

• Use the term clinical judgment as part of your program’s definition of professional nursing and end-of-program student learning outcomes (also called program learning outcomes).
• Introduce the nursing process in your first basic nursing course as the foundation for clinical decision-making.
• Minimize emphasis on the NANDA nursing diagnosis list and ensure that students understand that the diagnostic labels and taxonomy are not universally used in health care today. Instead, assist students in learning the signs, symptoms, and behaviors that nurses and other interprofessional health care team members utilize and understand. For example, fever is a more commonly used term in nursing and health care than hyperthermia. A nurse can take a client’s body temperature and determine that he or she has a fever if the thermometer reads 103 o F (39.4 o C).     
• Introduce the NCSBN definition of clinical judgment and the six cognitive skills of the NCJMM early in your nursing program.
• Have students practice using the six cognitive skills in a variety of learning activities, including unfolding case studies in place of excessive lecture throughout your program.

Building on the Nursing Process to Transition to Clinical Judgment

As you and your students transition from the nursing process to clinical judgment, remember that clinical judgment is more closely aligned with how nurses in practice actually think to make the best possible decisions about client care. Also recall that clinical judgment in nursing is not a new concept. For example, Tanner, the National League for Nursing, and others have posited for almost 15 years that clinical judgment is a better problem-solving approach than the nursing process.

The NCJMM cognitive skills can be aligned with the nursing process steps and phases of Tanner’s clinical judgment model as illustrated below:

Comparison of the Nursing Process with Tanner’s Clinical Judgment Model and the NCSBN Clinical Judgment Measurement Model (NCJMM)

While these models may look very similar, the thinking processes differ. For example, in the Assessment step of the nursing process, the nurse collects subjective and objective client data using a systematic approach. By contrast, the Recognize Cues cognitive skill of clinical judgement requires the nurse to collect client data and then decide “What matters most?”—which client data (findings) are relevant in a specific contextual clinical situation and which data are not relevant? Two other examples comparing the nursing process steps and the cognitive skills of the NCJMM are described below:

As you begin or continue making the transition of building on the nursing process to emphasize clinical judgment in your program, remember that clinical judgment will be the focus of the new test item types for the NGN by no sooner than 2023. You still have time to begin the transition journey, but we suggest that you start it soon! More NGN resources are available on www.ncsbn.org and the Elsevier Evolve Faculty Resources webpage.

Reference :

National Council of State Boards of Nursing (NCSBN). (2018). NCLEX-RN® Examination: Test plan for the National Council Licensure Examination for Registered Nurses. Chicago, IL: Author.

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Southern university at new orleans launches bsn program with elsevier 360, webinar: building clinical judgment skills with reverse case studies, using screen-based virtual patient simulation to meet competencies.

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Article Review: Nurse Onboarding Can Improve Critical Thinking, Knowledge, and Satisfaction

By Felicia Sadler, MJ, BSN, RN, CPHQ, LSSBB , on February 3, 2022

Recently published in the Journal for Nurses in Professional Development , Onboarding New Graduate Nurses Using Assessment-Driven Personalized Learning to Improve Knowledge, Critical Thinking, and Nurse Satisfaction aimed to demonstrate how an evidence-based onboarding program can provide the most support possible to new graduate nurses as they transition from the classroom to practice.

The study compared two cohorts, one onboarded using an assessment-driven personalized learning plan, demonstrating:

• 8% improvement in communication
• 8% improvement in critical thinking
• Increased scores in all 5 medical-surgical assessment domains
• Improvement in 16 out of 24 nurse satisfaction scores (compared to only 7 out of 24 improved scores in traditional onboarding cohort)

Effective Nurse Onboarding

Healthcare leaders agree that effective onboarding is key to new nurse success, but often struggle to provide evidence-based support for specific onboarding programs.

However, healthcare organizations will benefit from measuring both the efficiency and effectiveness of an onboarding program. As leaders continue to focus on improving quality of care , improving the patient experience, and reducing readmissions, healthcare organizations find an even greater need for an effective onboarding process to ensure nurses are prepared to care for complex patient populations.

As noted in the study, traditional nursing onboarding programs have focused on technical skills and organization-specific policies and procedures. Although all of these are necessary for safe and effective care, they are not sufficient to meet the demands of today’s higher acuity, complex care environment. Higher acuity and more complex care require a higher level of critical thinking , knowledge, and clinical reasoning regarding disease process and evidence-based research and data to identify where opportunities for improvement exist or even the effectiveness of their process.

A Personalized Approach

It’s no surprise that new nurses will enter an organization with varied levels of knowledge and experiences. If nurse educators provide every nurse with the same information, some nurses may become bored and unengaged (if they’ve already mastered the information being taught), whereas other nurses who need more information may feel lost and left behind.

Nurse onboarding should be personalized to the new nurse in order to keep them engaged. As presented in the study, assessment driven, personalized learning is one important component to ensure knowledge gaps are identified and addressed. This lays the groundwork for a personalized learning approach that respects what the learner already knows.

Nurse Onboarding Study Overview

This study evaluated two cohorts, tracking their onboarding approaches. Compared to a traditional onboarding cohort, one cohort was onboarded using the Relias Onboarding assessment-driven personalized learning plan. The study compared critical thinking, knowledge, and nurse satisfaction between cohorts before and after personalized learning for onboarding.

As outlined in the article, this study showed that areas impacted by the personalized learning for onboarding, including relevant knowledge domains and critical thinking, were higher among nurses who participated in the personalized learning compared to nurses who were hired before the personalized learning was implemented.

For the measure of nurse satisfaction, the onboarding cohort showed improvement on 16 of 24 nurse experience questions between baseline and 12 months later, compared with the pre-onboarding cohort, which only showed improvement on 7 of the 24 nurse experience questions.

Research has demonstrated that effective onboarding programs show higher nurse satisfaction and higher competencies as well as lower turnover and lower stress levels. This suggests that this assessment-driven personalized learning is effective as it demonstrated higher nurse satisfaction and improvements in both knowledge and critical thinking compared to other cohorts.

Role of Relias

An efficient and effective onboarding program clearly demonstrates to new nurses that their healthcare organization is committed in their personal success and is willing to invest in them both personally and professionally.

Relias Onboarding was the assessment-driven personalized learning plan used to quantify the nurses’ clinical knowledge and judgment. This personalized learning component addresses ineffective orientation, by tailoring education to meet each individual nurse’s needs. An initial assessment identifies knowledge gaps for each nurse and then provides learning that addresses those gaps.

Additionally, preceptors can use the information from the assessment to identify which areas new nurses may need more or less support in order to help each nurse become safe, effective, and ready for independent practice.

Felicia Sadler, MJ, BSN, RN, CPHQ, LSSBB

Vice President, Quality, Relias

Share This Article

Onboarding New Graduate Nurses Using Assessment-Driven Personalized Learning to Improve Knowledge, Critical Thinking, and Nurse Satisfaction

As published in the Journal for Nurses in Professional Development, this study demonstrated how effective onboarding improved knowledge, critical thinking, and nurse satisfaction.

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