The purpose of this activity is to elucidate the concept of critical thinking, explore why it is a crucial skill in nurses and strategies to teach and foster this skill in student and novice nurses.
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At the conclusion of this activity, the learner will be prepared to:
- Define the concept of critical thinking as it pertains to nursing practice.
- Discuss why critical thinking is an important skill for successful nurses, including how nurses can use critical thinking as a tool.
- Review the ideal methods for teaching and improving critical thinking skills in student or novice nurses as demonstrated in the literature.
At the 8th Annual International Conference on Critical Thinking and Educational Reform in 1987, M. Scriven and R. 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 (Lakhanigam, 2017, para. 2).
A 2010 study in the Journal of Nursing Education defined critical thinking as “interpretation and analysis of the problem, reasoning to find a solution, applying, and evaluation of the outcomes” (para. 3). It builds upon a foundation of sound clinical knowledge, follows the nursing process, and combines natural curiosity, open-mindedness, and quick thinking (Lakhanigam, 2017). The National League for Nursing’s Commission for Nursing Education Accreditation (CNEA) defines critical thinking in nursing as the “deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating info that is factual and belief based, demonstrated by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research” (Carson-Newman University [CNU], 2018, para. 5). The core skills of critical thinking include the ability to interpret, analyze, evaluate, infer, explain, and self-regulate (CNU, 2018). Critical thinking involves features of problem solving and clinical decision making plus creativity. The 1990 Delphi Report by the American Philosophical Association (APA) determined the following to be crucial characteristics of strong critical thinkers:
- inquisitiveness with regard to a wide range of issues;
- concern to become and remain well-informed;
- alertness to opportunities to use critical thinking;
- self-confidence in one’s own abilities to reason;
- open-mindedness regarding divergent world views;
- flexibility in considering alternatives and opinions;
- understanding of the opinions of other people;
- fair-mindedness in appraising reasoning;
- honesty in facing one’s own biases, prejudices, stereotypes, or egocentric tendencies;
- prudence in suspending, making or altering judgments;
- willingness to reconsider and revise views where honest reflection suggests that change is warranted (Lippincott Solution, 2018, para. 7).
Critical thinkers should avoid illogical or circular reasoning, overgeneralizing, appealing to tradition, rigid and inflexible thinking, and bias in order to be successful. It may also require the active avoidance of personal prejudice, preferences, self-interest, or fear. Critical thinking often involves skepticism, flexibility, and “thinking outside of the box” to find alternative solutions missed by other more traditional/linear thinking (CNU, 2018; Nurse Journal, 2020). Critical thinking is more of a process or orientation of the mind and less of a method. 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).
Critical thinking is an important skill for nurses due to the high level of patient acuity/complexity and increased responsibility expected of nurses practicing in modern day medicine (CNU, 2018; Lippincott Solutions, 2018). The ever-increasing body of evidence and research compounds this need further (CNU, 2018). This need is amplified in critical care environments as the nurse’s decisions directly impact the patient on a greater scale than in less critical settings (Lakhanigam, 2017). Critical thinking helps nurses appropriately prioritize and safeguard patient care, make vital decisions quickly, and allows nurse leaders to make key policy decisions that are precise, clear, complete, fair, logical, and accurate (Nurse Journal, 2020). A lack of critical thinking may lead to patient harm, delays in diagnosis, incorrect treatment(s), or missing crucial clinical changes (Browne et al., 2019). Critical thinking skills allow the nurse to identify changes in patient status/condition and develop quick solutions, contributing to healthy and honest communication, leading to innovative improvements in care delivery, and improving the nurse’s decision making (Luna, n.d.). Critical thinking requires focus, commitment, discipline, and motivation from the nurse (CNU, 2018; Lakhanigam, 2017).
Nurses utilize critical thinking in numerous and varied ways. For nurses practicing in the majority of settings, prioritization is a necessity, as there is simply not enough time or resources in a given shift to provide extraneous care. Care that is most vital or of a time-sensitive nature should be performed first and by the most skilled or qualified provider. Effectively differentiating between which tasks must be done immediately and which ones 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 respond either through performing an intervention or communicating the information to a clinician. Critical thinking is what 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, which is backed by their intuition and reasoning. Finally, the critical thinker is able to assess their own practice to make adjustments and improvements on an ongoing basis. Being aware of scope of practice, adjusting their sense of urgency as appropriate, and utilizing the right action(s) for the right reason(s) are also components of critical thinking in nursing (CNU, 2018; Lippincott Solutions, 2018).
The field of nursing is rather fond of acronyms, abbreviations, mnemonics, and numbered lists, so it should surprise no one that nurse educators have developed The Five Rights of Clinical Reasoning to help nurses remember all of these various components of critical thinking.
- The right cues is a reminder to nurses that the quality of the information is more important than the quantity. Nurses receive an enormous amount of information regarding their patients, but critical thinking helps the nurse to focus on the most valuable and useful pieces of the data to streamline their information gathering. This is most likely to include their foundational nursing knowledge, the current clinical assessment data, as well as the handoff report from the prior shift, the patient history, and any previous documented patient
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The right patient recognizes that most nurses are simultaneously responsible for as many as six or more patients at one time, and to first assess and then prioritize those patients requires critical thinking.The right time refers to the need to assess and gather information in a timely manner, plan out the interventions based on prioritization knowledge as well as available resources, and then perform interventions at the most appropriate time and in the proper sequence.The right action refers to the most appropriate individual performing the most appropriate interventions and then documenting/notifying the required members of the care team in a timely manner.The right reason refers to the explanation/justification of interventions performed by the nurse, which may include policy, ethical, legal, and/or professional components (CNU, 2018).So now that it has been established what exactly critical thinking is, why it is important, 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 and patient simulation have been shown to assist in the development of critical thinking skills. These methods facilitate and encourage active learning, or the synthesis, analysis, and evaluation of content, as opposed to 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 utilized anytime or anywhere (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 judgement, delegation, and prioritization skills. Smith and Paul (2020) 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/objectives in order to teach clinical critical thinking skills and judgement. Students evaluated the activity after completion as very effective for retention of the intended content (Smith & Paul, 2020).
Group discussions or written essays on medical decision making in ethically complicated cases encourages engagement and active learning in those students or nurses struggling with critical thinking skills (Vignato & Guinon, 2019). Students should be asked open-ended questions, and instructors should allow sufficient time for reflection (Lippincott Solutions, 2018). Beyond group discussions, concept mapping may be even more effective when teaching/improving critical thinking skills in nurses. Concept mapping (see Figure 1 for example) is the visual representation of information in a chart, table, graph, flowchart, etc. which allows users to view the pieces of information as they relate to each other in a visual instead of auditory or text format. Odreman and Clyens (2020) found that the use of concept mapping during clinical debriefing sessions improves the ability to analyze and critically think about clinical concepts as well as the nurses’ own thoughts/feelings versus traditional team debriefing. Unfortunately, three randomized trials tested this theory and did not find a significant improvement in critical thinking skills in the students who were educated using concept maps versus other methods (Carbogim et al., 2017).
Nurse educators should strive to facilitate skill transfer, or the application and use of 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. This teaching method has been shown in multiple randomized trials to improve critical thinking skills in undergraduate students of nursing as compared to lecture-based lessons (Carbogim et al., 2017). As early as 2011, case studies were determined to be a functional and useful tool for facilitating the critical thinking practice required to hone this skill 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 associated with clinical exposure. They promote active learning to facilitate understanding of complicated or complex situations. However, case studies are often written or developed through a time-consuming process by authors, educators, or nurse leaders, who may have their own unconscious biases. Case studies can also be artificially narrow in their scope or focus. Despite this, the research indicates that they are effective and beneficial for students and teachers to improve critical thinking and problem-solving skills through active learning (Popil, 2011). Let’s review a patient scenario that may be encountered by a nurse to demonstrate the skill of critical thinking.
Larry is a 58-year-old male who presents to the emergency department with complaints of shortness of breath. He is a corporate professional with a history of obesity (BMI 32), asthma, and denies any illicit drug, alcohol, or tobacco use. Daily medications include an inhaled corticosteroid combined with Formoterol (Symbicort) for his asthma. The triage nurse assesses Larry and determines that he is tachycardic, hypertensive, and tachypneic.
- What issue is most likely causing Larry’s symptoms?
- What is the evidence for this idea?
- Are there other explanations for his symptoms or another way to explain the data?
- Of the alternatives, which are the most dangerous and need to 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.
Larry’s nurse assesses his pulse oximetry and determines that he is hypoxic (pulse oximetry reading is 85% of room air) and requests an order to apply supplemental oxygen. His lungs sound clear with no audible wheeze, and his vital signs are not improving with the application of oxygen, despite improvement in his oxygen saturation reading (now 97% on 2 liters). He is sweating profusely.
- What issue is most likely causing Larry’s symptoms?
- What is the evidence for this idea?
- Are there other explanations for his symptoms or another way to explain the data?
- Of the alternatives, which are the most dangerous and need to be ruled out first?
- What should the critically thinking nurse assess or do next?
As a respiratory therapist is administering an inhaled bronchodilator treatment to Larry, his nurse applies electrocardiogram (ECG) leads to assess his underlying cardiac rhythm. The ECG indicates that Larry has had an ST segment change from prior ECGs in his patient record, indicating this may be a new development.
- What issue is most likely causing Larry’s symptoms?
- What is the evidence for this idea?
- Are there other explanations for his symptoms or another way to explain the data?
- Of the alternatives, which are the most dangerous and need to be ruled out first?
- What should the critically thinking nurse assess or do next?
After discussing the changes seen on Larry’s ECG with the ED provider, orders are placed for aspirin (a one-time dose of 325 mg), morphine IV as needed for pain, and an immediate referral to the cardiac catheterization lab. He was diagnosed with an acute myocardial infarction, treated promptly, and recovered well.
Regarding the improvement of critical thinking skills in a practicing novice nurse, these skills can be effectively learned by observing, emulating, and interacting with more experienced nurses serving as mentors and/or preceptors who have spent their career developing these skills on a daily basis (Lakhanigam, 2017). Case studies and concept maps have also proven effective in training hospital-based graduate nurses regarding critical thinking skills (Carbogim et al., 2017). As mentioned earlier, nurses must commit to a constant and lifelong path of learning, questioning, and evaluating their own 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, but this dialogue is no less important to the development of critical thinking skills amongst these novice practitioners. Leadership should actively promote team member interaction to facilitate the development of improved critical thinking skills amongst team members. The participation in multidisciplinary task forces and committees will further expose the new graduate nurse to education, new experiences, novel challenges, and quiet introspection (CNU, 2018; Lippincott Solutions, 2018).
Nurse leaders and managers should be aware of the demonstrated success of team training sessions focused on recognizing and mitigating cognitive bias and conflict resolution. Browne and colleagues (2019) were able to show that training sessions consisting of didactic presentations, facilitated group discussions, and simulation technology amongst nearly 5,000 healthcare providers resulted in improved recognition and management of errors. The training process is feasible, well-received, and effective, based on an average rating of 4.68 out of 5 on post-activity evaluations of effectiveness. Their training utilizes the acronyms IDEA (four de-biasing strategies) and TLA (three methods for conflict resolution), both defined below:
I: identify assumptions
D: do not assume correctness
E: explore expectations
A: assess alternatives
T: tell your thoughts
L: listen actively
A: ask questions (Browne et al., 2019).
Additional strategies to improve nurses’ critical thinking skills is to ask open-ended questions and avoid the concept of only one correct answer. Similar to students, nurses should be allowed ample time for personal reflection and consideration following these discussions (Lippincott Solutions, 2018). A 2018 study found that critical reflection allowing for experiential and transformative learning improves critical thinking and communication skills amongst study participants. They facilitated the use of a reflective journal with associated sharing and feedback amongst 44 novice nurses over a period of six months which led to significant improvement in critical thinking skills based on the Clinical Critical Thinking Skills test (CCTS; Kim et al., 2018). In an effort to improve clinical competency, Afshar and colleagues (2020) identified three primary concerns; these include professional insufficiency (ineffective leadership, lack of professionalism, and/or insufficient education), basic shortages (in staff, facilities, and/or supplies), and external influences (physician-centered services, poor government/institutional policies, lack of education of patients). Their study design consisted of three primary changes to address their concerns, including increased education for staff (in the form of workshops and printed/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 not only job satisfaction and effectiveness scores, but also a significant improvement in patient satisfaction scores after their interventions (Afshar et al., 2020).
References
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Browne, A. M., Deutsch, E. S., Corwin, K., Davis, D. H., Teets, J. M., & Apkon, M. (2019). An IDEA: Safety training to improve critical thinking by individuals and teams. American Journal of Medical Quality, 34(6). https://doi.org/10.1177/1062860618820687
Carbogim, F., de Oliveira, L., Campos, G., Nunes, E., Rezende Alves, K., & Püschel, V. (2017). Effectiveness of teaching strategies to improve critical thinking in nurses in clinical practice: A systematic review protocol. JBI Database of Systematic Reviews and Implementation Reports, 15, 1602-1611. https://doi.org/10.11124/JBISRIR-2016-003035.
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Kim, Y.H., Min, J., Kim, S.H., & Shin, S. (2018). Effects of a work-based critical reflection program for novice nurses. BMC Medical Education, 18(30). https://doi.org/10.1186/s12909-018-1135-0
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Lippincott Nursing Education. (2016). Virtual simulations help students think like nurses so they can succeed as nurses. http://nursingeducation.lww.com/blog.entry.html/2016/10/19/virtual_simulations-mrgh.html
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Luna, A. (n.d.). 7 reasons critical thinking in nursing is important. https://www.onwardhealthcare.com/nursing-resources/seven-reasons-critical-thinking-in-nursing-is-important/
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