This activity aims to explain the concept of critical thinking, explore why it is a crucial skill in nursing, and identify strategies to teach and foster this skill in student and novice nurses.
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Critical Thinking
Disclosure Statement
This activity aims to explain the concept of critical thinking, explore why it is a crucial skill in nursing, and identify strategies to teach and foster this skill in student and novice nurses.
Upon completion of this activity, learners should be able to:
- define the concept of critical thinking as it pertains to nursing practice
- discuss why critical thinking is an essential skill for successful nurses, including how nurses can use critical thinking as a decision-making tool
- review the ideal methods for teaching and improving critical thinking skills in student or novice nurses as demonstrated in the literature
Nurses are responsible for offering high-quality, evidence-based care to optimize patient outcomes. As new treatments emerge, people are living longer, healthier lives. As the US population ages, more people live with chronic health conditions. These conditions have created a clinical environment that is more complex than ever before. The demands of the complex clinical environment require that nurses multitask and make sound clinical decisions using critical thinking when providing patient care. Critical thinking has been addressed and defined by multiple individuals and organizations. Critical thinking is often used interchangeably in nursing literature with problem-solving and clinical decision-making (Lippincott Solutions, 2018). At the 8th Annual International Conference on Critical Thinking and Educational Reform in 1987, Michael Scriven and Richard Paul defined critical thinking as:
- the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action. In its exemplary form, it is based on universal intellectual values that transcend subject matter divisions: clarity, accuracy, precision, consistency, relevance, sound evidence, good reasons, depth, breadth, and fairness (The Foundation for Critical Thinking, n.d., para. 3).
The National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA) defines critical thinking in nursing as the "deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is factually and belief based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research" (Benner et al., 2008, para. 4). The American Association of Colleges of Nurses (AACN) expanded on the NLN CNEA's definition in the Essentials of Baccalaureate Nursing which states that "critical thinking underlies independent and interdependent decision making. Critical thinking includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity" (Benner et al., 2008, para. 5). Critical thinking involves features of problem-solving and clinical decision-making plus creativity. The 1990 Delphi Report by Peter Facione on behalf of the American Philosophical Association (APA) was a landmark report on critical thinking (Facione, 1998). According to the report, the following are crucial characteristics of strong critical thinkers:
- curiosity concerning a wide range of issues
- interest in becoming and remaining well-informed
- awareness of situations to use critical thinking
- self-confidence in one's comprehension and judgment
- open-mindedness regarding conflicting worldviews
- flexibility in considering options and attitudes
- accepting the views of others
- fairness in appraising thinking
- honesty in facing one's own biases, prejudices, stereotypes, or egocentric tendencies
- cautiousness in suspending, making, or altering judgments
- willingness to reevaluate and modify views where reflection suggests modification is necessary (Facione, 1998)
Critical thinkers should avoid illogical or circular reasoning, overgeneralizing, appealing to tradition, rigid and inflexible thinking, and bias to succeed. It may also require avoiding personal prejudice, preferences, self-interest, or fear. Critical thinking often involves skepticism, flexibility, and thinking outside the box to find alternative solutions that are missed by other, more traditional linear thinking. Critical thinking incorporates habits of the mind (e.g., persistence, listening, empathy, flexibility, questioning) and learned skills. Research indicates that the primary skills required for successful critical thinking include analysis, implementation of standards, research, discernment, knowledge prediction, logical thinking, and transformation; prerequisites include contextual perspective, creativity, confidence, flexibility, inquisition, intuition, intellectual integrity, perseverance, reflection, and understanding (Carbogim et al., 2017; Morris, 2023; Westerdahl et al., 2022).
Critical thinking is essential for nurses due to high patient acuity, decreased staffing, and increased responsibility expected of nurses in the current healthcare climate. The ever-increasing body of evidence and research compounds this need further. This need is amplified in critical care environments as the nurse's decisions directly impact the patient more than in less acute settings. Critical thinking helps nurses appropriately prioritize and safeguard patient care, make vital decisions quickly, and allows nurse leaders to make policy decisions that are precise, clear, complete, fair, logical, and accurate. A lack of critical thinking may lead to patient harm, delays in diagnosis, incorrect treatment(s), or missing crucial clinical changes. It is estimated that 88% of novice nurses make a medication error, with 30% of these errors attributed to a lack of critical thinking skills. Critical thinking skills allow the nurse to identify changes in patient status or condition and develop quick solutions, contributing to prompt and thorough communication, leading to innovative improvements in care delivery, and improving the nurse's decision-making. Critical thinking requires the nurse's focus, commitment, discipline, and motivation (Gonzalez et al., 2020; Lippincott Solutions, 2018; Morris, 2023).
Nurses utilize critical thinking in numerous and varied ways. For nurses practicing in most settings, prioritization is necessary, as there is insufficient time or resources in a given shift to provide extraneous care. Care that is most vital or time-sensitive should be performed first and by the most skilled or qualified provider. Effectively differentiating between which tasks must be done immediately and which can wait requires astute critical thinking skills. When presented with data, whether a result from an imaging study or a laboratory test, the nurse must use critical thinking to analyze and interpret this data within the context of the patient to determine its significance. If a problem is identified, the nurse must intervene or communicate the information to a clinician. Critical thinking prepares nurses to apply their knowledge and experience to compile a list of appropriate interventions and alternatives, select the best option available by weighing the evidence, risks, and benefits, and incorporate intuition and pattern recognition. The nurse evaluates all of this information to identify the predicted outcomes from the plan of care and whether or not those outcomes are achieved. Critical thinking also prepares the nurse to fully explain and justify the actions taken, backed by intuition and reasoning. The critical thinker can assess their practice to make improvements on an ongoing basis through awareness of their scope of practice, adjusting their sense of urgency as appropriate, and utilizing th
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e right action(s) for the right reason(s) are essential components of critical thinking in nursing. Critical thinking also allows the nurse to escalate concerns to the appropriate healthcare provider promptly and effectively (Jillings, 2022; Lippincott Solutions, 2018).
When critical thinking is used with clinical judgment, the result is termed clinical reasoning. This considers the nurse's knowledge and experience (Domm et al., 2021). In 2010 nurse educators developed The Five Rights of Clinical Reasoning to help nurses remember the various components of critical thinking used in clinical reasoning (Domm et al., 2021; Levett-Jones et al., 2010):
- The right cue: this reminds nurses that the quality of the information is more important than the quantity. Nurses receive an enormous amount of information regarding their patients. However, critical thinking helps the nurse to focus on the most valuable and useful pieces of data to streamline their information gathering. This will most likely include their foundational nursing knowledge, the current clinical assessment data, the handoff report from the previous shift, the patient history, and any previously documented patient assessments.
- The right patient: this recognizes that most nurses are simultaneously responsible for as many as six or more patients at one time and that first assessing and then prioritizing the patients that need to be cared for first requires critical thinking.
- The right time: this refers to the need to assess and gather information promptly, plan out the interventions based on prioritization knowledge and available resources, and then perform interventions at the most appropriate time and in the proper sequence.
- The right action: this refers to the most appropriate individual performing the most appropriate interventions and then providing documenting and notifying the required members of the care team promptly.
- The right reason: this refers to the explanation or justification of why specific interventions were performed by the nurse, which may include established facility policies and procedures or ethical, legal, and professional components.
Importance and Use of Critical Thinking
So now that it has been established what critical thinking is, why it is essential, and how nurses utilize it in their daily responsibilities, we will review how critical thinking can be taught to student nurses and how these skills can be improved upon in new-graduate nurses.
Technology is a tool that can be used to our advantage, and the technology of telepresence robotics (using a remote-controlled wheeled device with a camera to allow students to be present on the nursing unit and in patient rooms remotely) and patient simulation has been shown to assist in developing critical thinking skills. These methods encourage active learning, or the synthesis, analysis, and evaluation of content, instead of rote memorization. Virtual simulators allow for more variation and customization than older, lifeless manikins. They can be programmed for different vitals, symptoms, procedures, and even patient demographics; they can be used anytime or anywhere. High-fidelity simulations increase nursing students' self-confidence, clinical skills, and critical thinking ability (Guerrero et al., 2022; Lippincott Nursing Education, 2016). Mudd and colleagues (2020) discuss how these technologies helped to prepare nurses to practice in complex and often high-paced acute care settings by assessing their competency, both at baseline and on an ongoing basis, and improving their clinical judgment, delegation, and prioritization skills. Smith and Paul (2021) were slightly more creative in their trial design. As an assigned clinical make-up lesson for ten student nurses, faculty members designed escape room scenarios to review diabetic ketoacidosis (DKA), aspiration pneumonia, and wound dehiscence. Students were asked to complete puzzles and tasks to reach specific goals and meet objectives to teach clinical critical thinking skills and judgment. Students evaluated the activity after completion and found the strategy very effective for retaining the intended content (Smith & Paul, 2021).
Group discussions or written essays on medical decision-making in ethically complicated cases encourage engagement and active learning among students or nurses struggling with critical thinking skills. Participants should be asked open-ended questions, and instructors should allow sufficient time for reflection (Lippincott Solutions, 2018; Vignato & Guinon, 2019). Beyond group discussions, concept mapping may be even more effective when teaching or improving critical thinking skills in nurses. Concept mapping is the visual representation of information. It allows users to view pieces of information, identify significant concepts, and determine how they relate to each other in a visual instead of an auditory or text format. Examples of the types of concept maps include a spider map (figure 1), flowchart, hierarchy map, or system map. Concept mapping during clinical debriefing sessions can improve the nurse's ability to analyze and critically think about clinical concepts and their thoughts and feelings versus traditional team debriefing. More meaningful learning is achieved since the individual creates the concept map based on the information gathered (Binoy & Raddi, 2022; Odreman & Clyens, 2020).
Figure 1
Concept Map Example
Nurse educators should strive to facilitate skill transfer, which is applying and using a new skill in additional environments and situations. Performance-based development systems (PBDS) may be utilized by nurse educators, nurse leaders, or hiring managers to assess an individual learner's needs (i.e., their ability to apply clinical knowledge in real-world situations) to help tailor their education and auxiliary training (Lippincott Solutions, 2018). Problem-based learning (PBL) challenges students to collaborate and apply cumulative knowledge to solve fictional unfolding clinical problems. The faculty member is a student resource and facilitator in this learning model. This teaching method has been shown in multiple randomized trials to improve teamwork, communication, and critical thinking skills in undergraduate nursing students compared to traditional lecture-based lessons (Carbogim et al., 2017; Kurt, 2020).
Case studies are another learning tool used in the classroom, simulation, and clinical settings to promote critical thinking in student and novice nurses. Case studies simulate clinical decision-making and offer the experience of clinical dilemmas. They elucidate human feelings, misinterpretations, and intentions while modeling experts' thinking and preparing them for the real world without the risk of clinical exposure. They promote active learning to facilitate understanding of complicated or complex situations. Unfortunately, the traditional case study is static, with all the information provided at the beginning of the case study. Recently there has been a switch to utilizing unfolding case studies. This type of case study is fluid and evolves as the learner makes choices and implements interventions. The learner is only provided with information as they move through the learning activity. This type of case study better promotes critical thinking since the student must implement interventions and adapt to changes in the patient. Unfolding case studies can prepare nursing students for the Next Generation NCLEX, which now incorporates case studies in the exam (Englund, 2020).
Let us review a patient scenario that a nurse may encounter to demonstrate the skill of critical thinking. A patient presents to the emergency department (ED) with shortness of breath. The patient is a corporate professional with a history of obesity (BMI 32) and asthma. They deny any illicit drug, alcohol, or tobacco use. Daily medications include inhaled budesonide/formoterol (Symbicort) for their asthma. The triage nurse assesses the patient and determines they are tachycardic, hypertensive, and tachypneic.
- What issue is most likely causing the patient's symptoms?
- What is the evidence for this idea?
- Are there other explanations for their symptoms or another way to explain the data?
- Which alternatives are the most critical and should be ruled out first?
- What should the critically thinking nurse assess next?
These questions would help to define and develop the next set of assessments. Based on those assessments, interventions can be planned.
The nurse assesses the patient's oxygen saturation and determines that they are hypoxic (pulse oximetry reading is 85% on room air) and requests an order to apply supplemental oxygen. The patient's lungs sound clear with no audible wheeze, and their vital signs are not improving with the application of oxygen, despite improvement in their oxygen saturation reading (now 97% on 2 liters of oxygen). The nurse also notes that the patient is diaphoretic. What issue is most likely causing the patient's symptoms?
- What is the evidence for this idea?
- Are there other explanations for their symptoms or another way to explain the data?
- Which alternatives are the most dangerous and must be ruled out first?
- What should the critically thinking nurse assess or do next?
As a respiratory therapist administers an inhaled bronchodilator treatment to the patient, the nurse applies electrocardiogram (ECG) leads to assess their underlying cardiac rhythm. The ECG indicates that the patient has had an ST segment change from prior ECGs found in the electronic health record, suggesting this may be an acute finding.
- What issue is most likely causing the patient's symptoms?
- What is the evidence for this idea?
- Are there other explanations for their symptoms or another way to explain the data?
- Which alternatives are the most dangerous and must be ruled out first?
- What should the critically thinking nurse assess or do next?
After discussing the changes on the patient's ECG with the ED provider, orders are received for a one-time oral dose of aspirin 325 mg, morphine 1 mg intravenously administered as needed for pain, and an immediate referral to the cardiac catheterization lab. The patient was diagnosed with an acute myocardial infarction, treated promptly, and recovered well.
New graduate nurses enter the workforce inexperienced and ill-prepared to think critically. It is estimated that the inability to think critically contributes to the 35%-60% attrition rate of new nurse graduates. The improvement of critical thinking skills in practicing novice nurses can be achieved effectively by observing, emulating, and interacting with more experienced nurses serving as mentors or preceptors who have been developing these skills daily throughout their careers. Case studies, simulations, and concept maps effectively improve hospital-based graduate nurses' critical thinking skills. As mentioned earlier, nurses must commit to a constant and lifelong path of learning, questioning, and evaluating their practice through continuing education (courses, conferences, and conventions) combined with honest self-reflection. Collegial dialogue amongst graduate nurses may be less formal than the clinical debriefing sessions that occur while a nursing student. However, this dialogue is no less important to developing critical thinking skills among these novice practitioners. Leadership should actively promote team-member interaction to facilitate the development of improved communication and critical thinking skills among team members. Participation in multidisciplinary task forces and committees will further expose the new graduate nurse to education, new experiences, novel challenges, and quiet introspection (Carbogim et al., 2017; Gonzalez et al., 2020; Lippincott Solutions, 2018).
Additional strategies to improve nurses' critical thinking skills are to ask open-ended questions and avoid the concept of a single correct answer. Like students, nurses should be allowed ample time for personal reflection and consideration following these discussions (Lippincott Solutions, 2018). Critical reflection can improve critical thinking and clinical reasoning by closing the gap between what is taught in the classroom and the real-world environment. Critical reflection allows the nurse to consider the clinical decisions made and ask themselves 'why' questions. The research on critical reflection in nursing is limited, and although it has been recognized as beneficial, there are limited ways to measure its benefit in nursing (Shin et al., 2022).
To improve clinical competency, Afshar and colleagues (2020) identified three primary concerns that must be addressed: professional insufficiency (ineffective leadership, lack of professionalism, and insufficient education), basic shortages (staff, facilities, and supplies), and external influences (provider-centered services, poor government/institutional policies, lack of patient education). Their study design consisted of changes to address their concerns, including increased staff education (in the form of workshops and printed or interactive educational materials), the involvement of student nurses in patient education as a resource to alleviate the resource shortage for the nurses, and increased motivation in the form of peer evaluations and performance recognition awards. They found an increase in job satisfaction and effectiveness scores and a significant improvement in patient satisfaction scores after their interventions (Afshar et al., 2020).
References
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