2. When was the patient’s last bowel movement?
3. Who is the patient’s emergency contact person?
4. Describe the patient’s current level of pain.
5. What information is in the patient’s medical record?
Critical thinking in nursing is the foundation that underpins safe, effective, and patient-centered care.
Critical thinking skills empower nurses to navigate the complexities of their profession while consistently providing high-quality care to diverse patient populations.
Potter, P.A., Perry, A.G., Stockert, P. and Hall, A. (2013) Fundamentals of Nursing
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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.
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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Nevşehir Hacı Bektaş Veli University, Semra ve Vefa Küçük, Faculty of Health Sciences, Nursing Department, 2000 Evler Mah. Damat İbrahim Paşa Yerleşkesi, Nevşehir, Turkey
Şefika Dilek Güven
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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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The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice. Nurses’ ability to recognize and respond to signs of patient deterioration in a timely manner plays a pivotal role in patient outcomes (Purling & King 2012). Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events (Tomlinson, 2015). The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement. Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010). At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction.
The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.
As lifelong learners, nurses are constantly accumulating more knowledge, expertise, and experience, and it’s a rare nurse indeed who chooses to not apply his or her mind towards the goal of constant learning and professional growth. Institute of Medicine (IOM) report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice. American Nurses Association (ANA), Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice (p.26)
Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier
The future of nursing: Leading change, advancing health, (2010). https://campaignforaction.org/resource/future-nursing-iom-report
Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today. 30(6), 515-520.
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Purling A. & King L. (2012). A literature review: graduate nurses’ preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23–24), 3451–3465
Thompson, C., Aitken, l., Doran, D., Dowing, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50 (12), 1720 - 1726 Tomlinson, J. (2015). Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Medical Education, 15(103)
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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.
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 .
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 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.
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.
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 .
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 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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By Hannah Meinke on 07/05/2021
The nursing profession tends to attract those who have natural nurturing abilities, a desire to help others, and a knack for science or anatomy. But there is another important skill that successful nurses share, and it's often overlooked: the ability to think critically.
Identifying a problem, determining the best solution and choosing the most effective method to solve the program are all parts of the critical thinking process. After executing the plan, critical thinkers reflect on the situation to figure out if it was effective and if it could have been done better. As you can see, critical thinking is a transferable skill that can be leveraged in several facets of your life.
But why is it so important for nurses to use? We spoke with several experts to learn why critical thinking skills in nursing are so crucial to the field, the patients and the success of a nurse. Keep reading to learn why and to see how you can improve this skill.
You learn all sorts of practical skills in nursing school, like flawlessly dressing a wound, taking vitals like a pro or starting an IV without flinching. But without the ability to think clearly and make rational decisions, those skills alone won’t get you very far—you need to think critically as well.
“Nurses are faced with decision-making situations in patient care, and each decision they make impacts patient outcomes. Nursing critical thinking skills drive the decision-making process and impact the quality of care provided,” says Georgia Vest, DNP, RN and senior dean of nursing at the Rasmussen University School of Nursing.
For example, nurses often have to make triage decisions in the emergency room. With an overflow of patients and limited staff, they must evaluate which patients should be treated first. While they rely on their training to measure vital signs and level of consciousness, they must use critical thinking to analyze the consequences of delaying treatment in each case.
No matter which department they work in, nurses use critical thinking in their everyday routines. When you’re faced with decisions that could ultimately mean life or death, the ability to analyze a situation and come to a solution separates the good nurses from the great ones.
Nursing school offers a multitude of material to master and upholds high expectations for your performance. But in order to learn in a way that will actually equip you to become an excellent nurse, you have to go beyond just memorizing terms. You need to apply an analytical mindset to understanding course material.
One way for students to begin implementing critical thinking is by applying the nursing process to their line of thought, according to Vest. The process includes five steps: assessment, diagnosis, outcomes/planning, implementation and evaluation.
“One of the fundamental principles for developing critical thinking is the nursing process,” Vest says. “It needs to be a lived experience in the learning environment.”
Nursing students often find that there are multiple correct solutions to a problem. The key to nursing is to select the “the most correct” solution—one that will be the most efficient and best fit for that particular situation. Using the nursing process, students can narrow down their options to select the best one.
When answering questions in class or on exams, challenge yourself to go beyond simply selecting an answer. Start to think about why that answer is correct and what the possible consequences might be. Simply memorizing the material won’t translate well into a real-life nursing setting.
As you know, learning doesn’t stop with graduation from nursing school. Good nurses continue to soak up knowledge and continually improve throughout their careers. Likewise, they can continue to build their critical thinking skills in the workplace with each shift.
“To improve your critical thinking, pick the brains of the experienced nurses around you to help you get the mindset,” suggests Eileen Sollars, RN ADN, AAS. Understanding how a seasoned nurse came to a conclusion will provide you with insights you may not have considered and help you develop your own approach.
The chain of command can also help nurses develop critical thinking skills in the workplace.
“Another aid in the development of critical thinking I cannot stress enough is the utilization of the chain of command,” Vest says. “In the chain of command, the nurse always reports up to the nurse manager and down to the patient care aide. Peers and fellow healthcare professionals are not in the chain of command. Clear understanding and proper utilization of the chain of command is essential in the workplace.”
“Nurses use critical thinking in every single shift,” Sollars says. “Critical thinking in nursing is a paramount skill necessary in the care of your patients. Nowadays there is more emphasis on machines and technical aspects of nursing, but critical thinking plays an important role. You need it to understand and anticipate changes in your patient's condition.”
As a nurse, you will inevitably encounter a situation in which there are multiple solutions or treatments, and you'll be tasked with determining the solution that will provide the best possible outcome for your patient. You must be able to quickly and confidently assess situations and make the best care decision in each unique scenario. It is in situations like these that your critical thinking skills will direct your decision-making.
While critical thinking skills are essential at every level of nursing, leadership and management positions require a new level of this ability.
When it comes to managing other nurses, working with hospital administration, and dealing with budgets, schedules or policies, critical thinking can make the difference between a smooth-running or struggling department. At the leadership level, nurses need to see the big picture and understand how each part works together.
A nurse manager , for example, might have to deal with being short-staffed. This could require coaching nurses on how to prioritize their workload, organize their tasks and rely on strategies to keep from burning out. A lead nurse with strong critical thinking skills knows how to fully understand the problem and all its implications.
Their solutions will take into account all their resources and possible roadblocks.
They’ll weigh the pros and cons of each solution and choose those with the greatest potential.
Finally, they will look back on the issue and evaluate what worked and what didn’t. With critical thinking skills like this, a lead nurse can affect their entire staff, patient population and department for the better.
You’re now well aware of the importance of critical thinking skills in nursing. Even if you already use critical thinking skills every day, you can still work toward strengthening that skill. The more you practice it, the better you will become and the more naturally it will come to you.
If you’re interested in critical thinking because you’d like to move up in your current nursing job, consider how a Bachelor of Science in Nursing (BSN) could help you develop the necessary leadership skills.
EDITOR’S NOTE: This article was originally published in July 2012. It has since been updated to include information relevant to 2021.
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Nursing July 22, 2024
When patients arrive in an ICU, they receive immediate life-saving care provided by medical professionals trained to treat their time-sensitive conditions. One of those professionals is a critical care nurse.
Critical care nurses, also known as ICU nurses, are registered nurses (RNs) who specialize in assessing and treating severely ill patients. To get started in this career, individuals need to earn a nursing degree and pass a national nursing exam. While optional training and additional experience, nurses who earn a critical care certification can advance in their nursing careers.
Critical care nurses care for patients who need ongoing monitoring and care due to a life-threatening medical condition, injury, or illness, such as a heart attack, an infection, serious burns, major surgery recovery, a severe heart disease, sepsis, or respiratory failure. Critical care nurses work in intensive care or critical care units, which are specialized departments dedicated to treating people with severe medical issues.
Critical care nurses often work as part of a critical care team that includes other healthcare professionals such as intensivists (critical care physicians), pharmacists, chaplains, respiratory therapists, dieticians, and social workers. These nurses regularly need to make quick and accurate decisions regarding the diagnosis and treatment of patients ranging from newborns to older adults.
Common duties of critical care nurses include:
Just as there are different types of nurses , there are several different types of specialized ICUs where critical care nurses can work, including:
Starting a career as a critical care nurse is similar to starting a career as any other kind of RN. It begins by gaining formal nursing education.
Aspiring critical care nurses first will be required to earn an Associate Degree in Nursing (ADN) or a Bachelor of Science in Nursing (BSN). Upon completion of the nursing program, graduates must pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN). After passing the exam, they can become licensed in their state to practice as an RN. To do this they need to satisfy the requirements of the State Board of Nursing in their state.
Due to the settings of ICUs, critical care nurses need to develop skills in certain areas that will enable them to work calmly in life-threatening and emergency situations. These areas include:
Prospective critical care nurses should have at least a minimum of two years of intensive care experience before applying for specific jobs. Typically, entry level nurses gain general patient care experience before moving on to emergency response units.
Pursuing a critical care certification is one way a nurse can demonstrate expertise in their specialty area. The American Association of Critical-Care Nurses (AACCN) offers several certification options for neonatal, pediatric, and adult specialties. While requirements for the certifications vary slightly, they generally include an active RN license and specific clinical practice hours.
Critical care nurses should continue their professional development throughout their careers by enrolling in courses, seminars, or workshops to keep abreast of new research and nursing practice changes. Aside from educational institutions, the AACCN offers an assortment of continuing education courses, many of which are available online.
Critical care nurses are RNs, and the U.S. Bureau of Labor Statistics (BLS) projects employment of RNs will grow 6% from 2022 to 2032. With factors like nurse retirements, the increasing population of older adults, and the need to care for more patients with chronic medical conditions, RNs are likely to remain in demand.
The BLS further reports that, as of 2022, there were 3.2 million RNs employed across the country. Hospitals were the largest employers of nurses, but job growth is projected to remain steady across several healthcare settings. Nurses are among the top five professionals who are the most in demand, according to a 2023 LinkedIn jobs report.
If you’re ready to start your career as a critical care nurse, completing a nursing program is the first step. One of the quickest ways to become an RN is to earn an Associate Degree in Nursing (ADN) . At Fortis, the ADN program provides fundamental nursing practice training, including practical and classroom learning.
Find out how Fortis can prepare you to become a skilled nurse and turn your love of emergency and critical care into a career.
Recommended Readings How Long Does It Take to Become a Nurse? LPN vs. RN: What’s the Difference? How to Become a Registered Nurse
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Tuan van nguyen.
1 Faculty of Nursing and Medical Technology, Can Tho University of Medicine and Pharmacy, Can Tho Vietnam
2 School of Nursing, College of Medicine, Chang Gung University, Taoyuan Taiwan
3 Department of Rheumatology, Chang Gung Memorial Hospital, Linkou Taiwan
4 Department of Nursing, College of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
The data that support the findings of this study are available from the corresponding author upon reasonable request.
To measure the level of critical thinking among Vietnamese professional nurses and to identify the related factors.
A cross‐sectional design was used.
The total sample included 420 professional nurses. Data were collected from July to September 2019 in three public hospitals located in Southwestern Vietnam. The level of critical thinking was measured using the Vietnamese version of the Nursing Critical Thinking in Clinical Practice Questionnaire. The data were analysed using the independent Student's t tests, ANOVA, Pearson's correlation and regression analysis.
Most of the participants had a low (48.3%) or moderate (45.5%) level of critical thinking. Age, gender, ethnicity, education level, health condition, duration of working as a nurse, duration of working in the current hospital, having heard the term “critical thinking” and work position had an impact on the critical thinking ability. Work position and gender explained 11% of the total variance in critical thinking ability.
Critical thinking is defined as the cognitive process of reasoning that involves trying to minimize errors and to maximize positive outcomes while attempting to make a decision during patient care (Zuriguel‐Pérez et al., 2015 ). The importance of critical thinking in nursing practice has been identified in the literature (Chang et al., 2011 ; Ludin, 2018 ; Mahmoud & Mohamed, 2017 ; Yurdanur, 2016 ; Zuriguel‐Pérez et al., 2015 ). The current nursing environment has become more complex and demanding, especially regarding the acuity and safety of patients and the rapid turnover rate of hospitalization. If professional nurses want to provide high‐quality care, critical thinking is required (Berkow et al., 2011 ; Brunt, 2005 ; Fero et al., 2009 ; Zuriguel‐Pérez et al., 2015 ). Nurses are often the first‐line professionals to observe and provide direct care for patients. Therefore, critical thinking is a necessary skill for them to be able to analyse clinical situations in order to make fast and correct decisions (Lee et al., 2017 ). More importantly, critical thinking can also improve patient outcomes by preventing habitual thinking that may lead to incorrect medication or procedures (Fesler‐Birch, 2005 ). The critical thinking ability of nurses can have an impact on the patient's safety, and it is a priority in educational programs for healthcare providers (Berkow et al., 2011 ; Buerhaus et al., 2006 ). We can identify those with poor critical thinking and provide in‐service education. Although critical thinking has been shown that is influenced by the experience and knowledge acquired during clinical practice (Zuriguel‐Pérez et al., 2015 ), other personal information needs to be considered to clarifying. Therefore, it is essential to measure the levels of critical thinking and to identify the work‐related and personal‐related factors that influence the critical thinking of nurses.
The literature has identified that there is a relationship between leadership and positive patient outcomes, such as fewer medication errors and nosocomial infections, lower patient mortality and higher patient satisfaction (Van Dyk et al., 2016 ; Wong, 2015 ). Alongside leadership, critical thinking is an important factor that supports the management. They can apply critical thinking skills in decision‐making and problem‐solving, and they can develop strategies that help staff nurses to improve their critical thinking ability (Van Dyk et al., 2016 ; Wong, 2015 ; Zuriguel‐Pérez et al., 2018 ). Thus, the ability to think critically is necessary for nurses because it will help them to effectively make decisions and to solve problems in practice.
Although the importance of critical thinking in nursing practice has been identified, a limited number of studies have been conducted in this population. Particularly, few hospitals have evaluated the critical thinking skills of nurses before employment or during the clinical competency evaluation (Lang et al., 2013 ). By reviewing 90 articles to assess the current state of the scientific knowledge regarding critical thinking in nursing, Zuriguel‐Pérez et al., ( 2015 ) found that only 16 studies used working nurses as participants. Furthermore, Zuriguel‐Pérez et al., ( 2018 ) reported that few studies have explored the critical thinking ability of nurse managers (NMs). Moreover, several studies have identified that working nurses have a low (Lang et al., 2013 ; Yurdanur, 2016 ) or moderate level of critical thinking (Chang et al., 2011 ; Lang et al., 2013 ; Zuriguel‐Pérez et al., 2018 ). To the researchers’ knowledge, no studies have investigated this issue in Vietnam.
In order to improve the quality and safety of patient care, various types of professional nurses have been established, such as Registered Nurses (RNs), NMs and administrative assistants (AAs). RNs provide direct care to the patients, NMs are responsible for forwarding management and delivering expert clinical care for patients, and AAs are an integral part of maintaining the quality of patient care. The AAs perform administrative tasks (e.g. filing, taking meeting minutes and distributing them and undertaking regular reports) that help NMs to spend more time assisting staff nurses and taking care of patients (Locke et al., 2011 ). Therefore, RNs, NMs and AAs need to cooperate to help patients to regain their health.
In Vietnam, professional nurses work in three different positions, which are NMs, general nurses (GNs) and AAs (Ministry of Health, 1997 ). Specifically, NMs are recognized as head nurses in Western countries, and their responsibilities are in charge of organizing and implementing comprehensive patient care and conduct a variety of administrative work (e.g. planning and assigning work to nurses, planning the acquisition of tools and consumables, checking care sheets, recording daily labour). GNs are similar to RNs in Western countries, and they provide direct and comprehensive care to patients. AAs perform administrative tasks (e.g. keeping records about the hospitalized and discharged patients, preserving medical records, managing daily medications). They also participate in patients care if necessary (Ministry of Health, 1997 , 2011 ). Although the roles of these three types of professional nurses are different, their final goal is the same to provide holistic care for patients. With the cooperation and effort of these three types of professional nurses, patients can recover. Therefore, more surveys are needed that examine these participants’ level of critical thinking and the associated work‐related factors.
Previous studies have also found that several personal‐related factors are associated with the nurses' critical thinking ability, which are age, gender, ethnicity, education qualification, working experience and shift work (Chang et al., 2011 ; Feng et al., 2010 ; Howenstein et al., 1996 ; Lang et al., 2013 ; Ludin, 2018 ; Mahmoud & Mohamed, 2017 ; Ryan & Tatum, 2012 ; Wangensteen et al., 2010 ; Yildirim et al., 2012 ; Yurdanur, 2016 ; Zuriguel‐Pérez et al., 2018 ). However, the relationships between the critical thinking ability and these variables are inconsistent. For example, age and critical thinking have been found to be positively correlated (Chang et al., 2011 ; Ludin, 2018 ; Zuriguel‐Pérez et al., 2018 ), negatively correlated (Howenstein et al., 1996 ) and not related (Lang et al., 2013 ; Mahmoud & Mohamed, 2017 ; Yurdanur, 2016 ). Gender and critical thinking have been reported with a statistically significant relationship (Liu et al., 2019 ; Ludin, 2018 ) and no relationship (Mahmoud & Mohamed, 2017 ; Wangensteen et al., 2010 ). Level of education and critical thinking have been found in a positive association (Chang et al., 2011 ; Ludin, 2018 ) and not association (Lang et al., 2013 ; Mahmoud & Mohamed, 2017 ). Year of experiences and critical thinking have been shown to be positively correlated (Chang et al., 2011 ; Ludin, 2018 ), negatively correlated (Howenstein et al., 1996 ) and not related (Lang et al., 2013 ; Mahmoud & Mohamed, 2017 ). Those inconsistent findings indicated the relationships between the personal‐characteristics and the critical thinking ability of professional nurses need further exploration. Therefore, this study aimed to examine the level of critical thinking of professional nurses and to explore the work‐related and personal‐related factors. This is the first study to investigate this issue in Vietnam. The results of the current study will make a significant contribution to the literature because it will provide thorough descriptions of the critical thinking of professional nurses and its associated factors. Furthermore, the findings may be used as a baseline for nurse managers and nurse educators to propose further strategies to improve this ability in professional nurses.
A cross‐sectional design was used. The Strengthening the Reporting of Observational Studies in Epidemiology guidelines were applied in this report (Von Elm et al., 2014 ).
Data collection was carried out from July to September 2019 in three representative and major public hospitals located in the Southwestern region of Vietnam. These hospitals have the same organizational structure, role of treating, operation of professional nursing and provide similar quality of health care to people around that area. The total numbers of professional in these three hospitals nurses were around 1,200. Besides, our study has two steps. The first step was to translate the English version of the Nursing Critical Thinking in Clinical Practice Questionnaire (N‐CT‐4 Practice) into the Vietnamese version. In that step, we used data as a pilot study to estimate the sample size in the second step, which was reported here. Sample size calculation was done by the formula: n = 1.96 2 × p × (1‐p)/0.05 2 , where p = .46 came from the poor level of critical thinking among nurses in the first step and 0.05 indicated the acceptable margin of error (5.0%); 382 participants were required by this formula. An additional 10% of participants were done to adjust for potential failures such as withdrawals or missing data (Suresh & Chandrashekara, 2012 ). Therefore, in total, 420 participants were required for this study. Convenience sampling was conducted to recruit the sample. The inclusion criteria were the nurses' employed full‐time employment in the study hospitals. Participants who participated in step 1 or being absent during the data collection such as sick leave or delivering a baby were excluded. Participants were grouped in each hospital and received an envelope with all questionnaires. Then, researchers explained the research's purpose, benefits and risks to the potential participants and the procedure for ensuring confidentiality, and the voluntary nature of the participation. The informed consent form was signed immediately after they agreed to participate in this study. Then, the participants were required to complete the questionnaires in 20 to 30 min and to return them to the data collector.
3.3.1. sample characteristics.
This instrument collected data about the personal information and occupational variables. The personal information included age, gender, marital status, ethnicity, religion, education level and self‐rated health conditions. The occupational variables were the duration of working as a nurse, the duration of working in the current hospital, the duration of working in the specific position, having heard the term “critical thinking” or not, previous exposure to critical thinking training or education or not, and type of work position.
The N‐CT‐4 Practice (V‐v) was used to measure the critical thinking ability of the professional nurses. The original instrument (N‐CT‐4 Practice) was established and classified based on the four dimensions of the 4‐circle critical thinking model of Alfaro‐LeFevre (Zuriguel‐Pérez et al., 2017 ). These four dimensions were personal; intellectual and cognitive; interpersonal and self‐management; and technical dimensions. The personal dimension has 39 items to assess the individual pattern of intellectual behaviours; the intellectual and cognitive dimension has 44 items to assesses the knowledge of activity comprehension connected to the nursing process and decision‐making. For the interpersonal and self‐management dimension, it has 20 items to analyse interpersonal abilities that allow for therapeutic communication with patients and health teams and to gain information that is associated with the patient in the clinical environment. The final one, the technical dimension, has 6 items to is concerned with knowledge and expertise in the procedures that are part of the discipline of nursing. This scale has 109 items that are rated using a four‐point Likert response format (1 = never or almost never, 2 = occasionally, 3 = often, and 4 = always or almost always), for example: “I recognize my own emotions.” (item 1); “I have the scientific knowledge required to carry out my professional practice.” (item 40); “I adapt information to the needs and capacities of the patient.” (item 84); “I possess skills in the use of information and communication technologies needed to produce optimal professional results.” (item 105). The total score is obtained from the sum of the 109 items. The scores range from 109–436, and they are categorized into a low level (score <329), moderate level (score between 329–395) and high level (score >395). The overall Cronbach's alpha was 0.96, and the intraclass correlation coefficient (ICC) was 0.77 (Zuriguel‐Pérez et al., 2017).
The N‐CT‐4 Practice (V‐v) was translated, and its psychometric properties were tested with 545 Vietnamese nurses. The results showed that the N‐CT‐4 Practice (V‐v) has acceptable reliability (Cronbach's alpha) and validity (content and construct validity). Particularly, the overall Cronbach's alpha was 0.98, with that of the four dimensions ranging from 0.86–0.97. The ICC was 0.81 over two weeks. The item content validity index was 1.0. Moreover, the goodness‐of‐fit indexes in a confirmatory factor analysis showed acceptable values, which were χ 2 / df = 2.87, root mean square error of approximation (RMSEA) = 0.059, standardized root mean square residual (SRMR) = 0.063, comparative fit index (CFI) = 0.73 and Tucker Lewis index (TLI) = 0.72 (T. V. Nguyen & Liu, 2021 ). Therefore, the N‐CT‐4 Practice (V‐v) can be used to measure the critical thinking ability of Vietnamese professional nurses.
This study conformed with the ethical principles of the Declaration of Helsinki (Helsinki Declaration, 2013 ), and it was granted research ethics committee approval by the ethical review board of the first author's institution.
The data were analysed using SPSS for Windows version 23.0 (IBM Corp.), and both descriptive and inferential statistics were calculated. The level of significance for all analyses was set at < 0.05. First, descriptive statistics were employed to summarize the collected data. The continuous variables were described using the mean and standard deviation ( SD ), and the frequency and percentage (%) were used for the categorical variables. Next, independent Student's t tests, analysis of variance (with Scheffe's post hoc comparison) and Pearson's correlation analysis were conducted to explore the association between the critical thinking ability and the personal and occupational factors. Then, a multiple regression analysis using the stepwise method was performed to identify the predictors of critical thinking ability (Pallant, 2010 ).
A total of 420 participants completed the questionnaires; the characteristics of overall participants and subjects in each group are listed in Table 1 . Three groups of subjects were included, which were NMs (24.8%), GNs (49.8%) and AAs (25.4%), respectively. Regarding the personal variables, almost all participants were Vietnamese (96.7%), no religion (73.1%) and had good health condition (60%). Meanwhile, the comparison among each group showed that age ( F = 9.89, p < .001), gender (χ 2 = 6.48, p < .05), marital status (χ 2 = 6.77, p < .05) and education level (χ 2 = 147.38, p < .001) had reached the statistical significance. Further analysis showed that the age of NMs was significantly older than subjects in both the GN and AA group, AA group had a higher ratio of that in the GN group, and the AA group had a higher ratio of married one than the GN group. For educational levels, subjects in the NM group had a higher ratio of bachelor and master degree, whereas the other two groups had a high ratio of diploma and associate degree.
Characteristics of the participants ( n = 420)
Variables | Totals | Comparisons among work position | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
NM ( = 104) | GN ( = 209) | AA ( = 107) | χ | (1) NM | (2) GN | (3) AA | ‐test | Scheffe's post hoc | |||
(%) | Mean ± | (%) | Mean ± | ||||||||
Personal variables | |||||||||||
Age (years) | 32.54 ± 7.32 | 35.22 ± 7.08 | 31.46 ± 7.0 | 32.05 ± 7.56 | 9.89 | (1) > (2), (3) | |||||
Gender | |||||||||||
Male | 105 (25) | 28 (26.9) | 60 (28.7) | 17 (15.9) | 6.48 | ||||||
Female | 315 (75) | 76 (73.1) | 149 (71.3) | 90 (84.1) | |||||||
Marital status | |||||||||||
Single/divorced/widowed | 169 (40.2) | 34 (32.7) | 97 (46.4) | 38 (35.5) | 6.77 | ||||||
Married | 251 (59.8) | 70 (67.3) | 112 (53.6) | 69 (64.5) | |||||||
Ethnicity | |||||||||||
Vietnamese | 406 (96.7) | 101 (97.1) | 205 (98.1) | 100 (93.5) | 4.79 | ||||||
Other | 14 (3.3) | 3 (2.9) | 4 (1.9) | 7 (6.5) | |||||||
Religion | |||||||||||
No | 307 (73.1) | 82 (78.8) | 149 (71.3) | 76 (71) | 2.33 | ||||||
Yes | 113 (26.9) | 22 (21.2) | 60 (28.7) | 31 (29) | |||||||
Education level | |||||||||||
Diploma | 126 (30.0) | 3 (2.9) | 90 (43.1) | 33 (30.8) | 147.38 | ||||||
Associate | 123 (29.3) | 8 (7.7) | 64 (30.6) | 51 (47.7) | |||||||
Bachelor's/graduate | 171 (40.7) | 93 (89.4) | 55 (26.3) | 23 (21.5) | |||||||
Self‐rated health condition | |||||||||||
Very good | 51 (12.1) | 9 (8.7) | 27 (12.9) | 15 (14) | 6.63 | ||||||
Good | 252 (60.0) | 71 (68.3) | 126 (60.3) | 55 (51.4) | |||||||
Fair/bad/very bad | 117 (27.9) | 24 (23.1) | 56 (26.8) | 37 (34.6) | |||||||
Work‐related factors | |||||||||||
Duration of working as a nurse (years) | 9.30 ± 7.05 | 12.30 ± 7.12 | 8.08 ± 6.42 | 8.75 ± 7.20 | 13.08 | (1) > (2), (3) | |||||
Duration of working in the current hospital (years) | 8.81 ± 6.85 | 11.66 ± 7.02 | 7.66 ± 6.33 | 8.29 ± 6.93 | 12.98 | (1) > (2), (3) | |||||
Duration of working in the specific position (years) | 6.10 ± 5.46 | 5.06 ± 4.94 | 7.41 ± 6.21 | 4.05 ± 3.27 | 14.79 | (2) > (1) > (3) | |||||
Heard the term "CT" | |||||||||||
No | 280 (66.7) | 56 (53.8) | 151 (72.2) | 73 (68.2) | 10.74 | ||||||
Yes | 140 (33.7) | 48 (46.2) | 58 (27.8) | 34 (31.8) | |||||||
Previous exposure to CT training/education | |||||||||||
No | 420 (100) | 104 (100) | 209 (100) | 107 (100) |
Abbreviations: AA, Administrator assistant; CT , Critical thinking; GN, General nurse; NM, Nurses manager ; SD , standard deviation.
Chi‐square and one‐way ANOVA test; significant at * p < .05; ** p < .01; *** p < .001.
Regarding work‐related factors, the characters of all participants and subjects in each group are also listed in Table 1 . The comparison of professional experience, such as duration of working as a nurse, duration of working in the current hospital, duration of working in this specific position and heard the terminology of "critical thinking" showed a significant statistical difference among the three groups ( p < .001). They showed that NMs had a longer duration of working as a nurse (mean = 12.30, SD = 7.12) and duration of working in the current hospital (mean = 11.6, SD = 7.02) than the other two groups; GNs had the longest duration of working in the specific position (mean = 7.41, SD = 6.21). More subjects in the NM group heard the terminology of "critical thinking" than subjects in the other two groups. However, none of the subjects had been exposed to critical thinking training or education. Furthermore, there was a positive correlation among age, the duration of working as a nurse, the duration of working in the current hospital and duration of working in a specific position ( r = .78–.975, p < .01).
The mean of the total scores of the N‐CT‐4 Practice (V‐v) for all participants was 333.86 ± 40.22 (with the average score/item = 3.06 ± 0.37), the median score was 331 (interquartile range [IQR] = 311–359), and it ranged from 204–436, which indicates that they generally had a moderate level of critical thinking. Meanwhile, most of the participants reported a low (48.3%) or moderate (45.5%) level of critical thinking. Only 6.2% of the participants had a high level of critical thinking. Regarding the four dimensions of the N‐CT‐4 Practice (V‐v), the average sum score was 119.52 ± 14.19 (with the average score/item = 3.06 ± 0.36) in the personal dimension, 136.38 ± 17.62 (with the average score/item = 3.10 ± 0.40) in the intellectual and cognitive dimension, 68.71 ± 12.65 (with the average score/item = 3.44 ± 0.63) in the interpersonal and self‐management dimension and 18.09 ± 3.01 (with the average score/item = 3.01 ± 0.50) in the technical dimension.
There were statistically significant associations between the critical thinking ability and some work‐related factors, such as work position ( F = 23.30, p < .001), duration of working as a nurse ( r = 0.15, p < .01), duration of working in the current hospital ( r = 0.13, p < .05) and having heard the term "critical thinking" ( t = −2.48, p < .05; Table 2 ). The findings indicated that NMs had higher scores than GNs and AAs. Moreover, nurses who had worked for a longer duration as a nurse or worked longer in the current hospital had a higher critical thinking ability. Meanwhile, those who had not heard the term "critical thinking" had lower scores than participants who had heard this term.
Association between the participants’ characteristics and the critical thinking ability ( n = 420)
Variables | Mean ± | a/b/ ‐value | ‐value | Scheffe's comparison |
---|---|---|---|---|
Personal factors | ||||
Age | 0.12 | . | ||
Gender | ||||
Male | 341.70 ± 37.29 | 2.32 | . | |
Female | 331.24 ± 40.88 | |||
Marital status | ||||
Single/divorced/widowed | 331.24 ± 40.49 | −1.09 | .275 | |
Married | 335.62 ± 40.03 | |||
Ethnicity | ||||
Vietnamese | 334.57 ± 39.57 | 1.97 | . | |
Other | 313.07 ± 53.73 | |||
Religion | ||||
No | 334.63 ± 39.39 | 0.65 | .516 | |
Yes | 331.75 ± 42.51 | |||
Education level | ||||
(1) Diploma | 327.84 ± 38.20 | 7.45 | . | 3 > 1, 2 |
(2) Associate | 327.50 ± 39.25 | |||
(3) Bachelor's/graduate | 342.86 ± 40.80 | |||
Self‐rated health condition | ||||
(1) Very good | 343.94 ± 37.25 | 3.41 | . | 1 > 3 |
(2) Good | 334.97 ± 39.47 | |||
(3) Fair/bad/very bad | 327.06 ± 42.19 | |||
Occupational factors | ||||
Duration of working as a nurse | 0.15 | . | ||
Duration of working in the current hospital | 0.13 | . | ||
Duration of working in the specific position | 0.07 | .184 | ||
Heard the term “critical thinking” | ||||
No | 330.44 ± 39.68 | −2.48 | . | |
Yes | 340.69 ± 40.56 | |||
Work position | ||||
(1) Nurse manager | 355.49 ± 38.53 | 23.30 | 1 > 2, 3 | |
(2) General nurse | 329.11 ± 32.79 | |||
(3) Administrative assistant | 322.11 ± 46.89 |
The bolded values indicate the level of statistical significance (with p < .05; p < .01; or p < .001) between the independent and dependent variables.
Abbreviations: SD , standard deviation.
There were statistically significant associations between the critical thinking ability and some personal‐related factors, such as age ( r = 0.12, p < .05), gender ( t = 2.32, p < .05), ethnicity ( t = 1.97, p < .05), education level ( F = 7.45, p < .01) and health condition ( F = 3.14, p < .05; Table 2 ). The findings indicated that the older nurses reported a higher critical thinking ability, and male nurses had a higher score than female ones. Vietnamese participants had higher scores than participants with other ethnicities. Participants with a bachelor's/graduate degree level of education had higher scores than participants with a diploma and associate degree level of education. Those with very good health had a higher score than participants who rated their health as fair/bad/very bad.
All of the statistically significant variables identified in the univariate analysis were selected as independent variables to determine the predictors of critical thinking ability. For the regression analysis, the categorical variables were first coded as dummy variables. The factors of having never heard of “critical thinking,” being an NM being male, being Vietnamese, having a diploma degree and being in very good health were selected as the standard factors. The results of the stepwise multiple regression method showed that there were only two predictors, namely the variables of work position and gender. Working as an AA or GN or being female can predict the critical thinking ability, and they accounted for 11% of the total variance ( F = 17.12, p < .001). This indicates that the AAs and GNs had a lower level of critical thinking than the NMs. Besides, when compared with male nurses, the female nurses exhibited a lower level of critical thinking (Table 3 ).
Predictors of the critical thinking ability ( n = 420)
Model | Beta | ‐value | square | ‐value | ‐value | |
---|---|---|---|---|---|---|
Constant | 362.11 | 0.11 | 17.12 | |||
Administrative assistant | −32.38 | −0.351 | ||||
General nurse | −26.55 | −0.330 | ||||
Female | −9.05 | −0.098 | . |
This study showed that the critical thinking ability of most professional nurses was at a low or moderate level. This finding is consistent with previous studies (Chang et al., 2011 ; Lang et al., 2013 ; Zuriguel‐Pérez et al., 2018 ). Using the same tool, Zuriguel‐Pérez et al. ( 2018 ) found that the median score of the N‐CT‐4 Practice was 363 (IQR = 340–386) for clinical nurses in Spain. Our study found a slightly lower median score (331; IQR = 311–359) but it was still in a moderate level (range of score: 329–395). Although critical thinking is a relatively new issue in Vietnamese professional nurses, it is not a brand new concept. Certain elements have been included in the nursing curriculum and clinical practice (e.g. the nursing process, problem‐based learning, evidence‐based practice). Therefore, up to 66.7% of participants had never heard the term "critical thinking," but 45.5% still reported a moderate level when measured using the N‐CT‐4 Practice (V‐v).
In Vietnam, clinical professional nurses are categorized into NMs, GNs and AAs with different job descriptions. Critical thinking ability has been identified as an important component for the high quality of care around the world, except in Vietnam. In order to identify this ability, we collected data from 3 hospitals in one region and grouped these data for analysis. Based on the comparison among NMs, GNs and AAs, it was found that NMs had a higher level of critical thinking than GNs and AAs. This can be explained by the fact that NMs have a higher age, work experience and high educational qualification than the other two groups. This result partially supports the finding that NMs report a slightly higher level of critical thinking than RNs (Zuriguel‐Pérez et al., 2018 ). Critical thinking is a necessary skill for effective and efficient management. Evidently, at present, NMs with a high level of critical thinking create positive practice environments that can help the staff nurses to deliver high quality and safe patient care (Zori et al., 2010 ). Therefore, all healthcare personnel needs to learn and apply critical thinking in order to conduct their work effectively and efficiently.
For clinical nurses, continuous in‐service education is very important to update their knowledge and skill of care. Literature found various factors associated with curriculum design and learning of critical thinking ability. Therefore, grouping subjects in the present study together in order to identify the related factors could help the development of further in‐service education of critical thinking ability effectively and efficiently. In this study, a statistically significant positive correlation was found between the critical thinking ability and age, the duration of working as a nurse and the duration of working in the current hospital. These findings are consistent with previous studies. For example, older nurses have a higher level of critical thinking than younger ones (Chang et al., 2011 ; Chen et al., 2019 ; Feng et al., 2010 ; Ludin, 2018 ; Wangensteen et al., 2010 ; Yurdanur, 2016 ; Zuriguel‐Pérez et al., 2018 ), and nurses with more experience report a better critical thinking ability than those with less experience (Chang et al., 2011 ; Chen et al., 2019 ; Feng et al., 2010 ; Ludin, 2018 ). Older and experienced nurses are more mature in their way of thinking (Chen et al., 2019 ; Ludin, 2018 ). Because there were statistically significant positive correlations among age, the duration of working as a nurse and the duration of working in the current hospital. This indicates that older nurses have a longer duration of working as a nurse or working in the current hospital so they have better critical thinking. However, the correlation between these factors and critical thinking in the current study is small; further explorations are suggested.
This study showed that there is a significant association between critical thinking ability and gender and ethnicity, which is also supported by the literature. Ludin ( 2018 ) found that female nurses reported a lower critical thinking ability than male nurses. Traditionally, females have generally had fewer opportunities to receive education and more difficulty asserting their rights during decision‐making than males in Vietnam (L. T. Nguyen et al., 2017 ). Even today, the phenomenon of gender inequality still exists in certain areas in Vietnam. This traditional burden and the limited opportunities to practice in a clinical care setting might lower the levels of the female participants’ critical thinking. Ethnicity has a similar impact, as found in the present study. For example, it has been reported that Caucasian and Hispanic/Latino participants have a significantly higher critical thinking ability than African American participants (Lang et al., 2013 ) and that Malaysian and Indian participants report different levels of critical thinking; nevertheless, only 0.9% of the participants were Indian (Ludin, 2018 ). However, in the present study, as almost all of the participants were Vietnamese (96.7%), the skewed distribution of the ethnicity might limit the generalizability of the results. In future studies, an equal distribution of ethnicity is strongly recommended.
This study also confirmed that those who had a bachelor's/graduate degree had a higher level of critical thinking than those who had a diploma or associate degree, even though the former had never heard the term "critical thinking." A vast amount of studies has found that education has a positive impact on the level of critical thinking (Chang et al., 2011 ; Gloudemans et al., 2013 ; Ludin, 2018 ; Yildirim et al., 2012 ; Zuriguel‐Pérez et al., 2018 ). Meanwhile, this study found that participants who had heard the term "critical thinking" displayed a higher level of critical thinking than those who had not heard this term. Education might be the major reason for this variation. In the present study, only 40.7% of participants had a bachelor's/graduate degree. In order to promote their levels of critical thinking, it is necessary to arrange for them, to encourage them, to attend advanced education or to provide further content in the in‐service education.
In this study, participants with very good health had a higher level of critical thinking than participants who self‐rated their health as fair/bad/very bad. Health status does have an impact on work productivity, job performance, quality of care and extra learning (Letvak et al., 2011 ). Thus, poor health limits their learning and critical thinking ability. This ability is an important predictor of real‐life outcomes (e.g. interpersonal, work, financial, health and education) (Butler et al., 2017 ). Therefore, the causal effects between health and critical thinking ability need further exploration.
In the current study, only the female gender and the type of work position as an AA or GN were identified as predictors, and they explained only 11% of the total variance of critical thinking ability in the regression model. The uneven distribution of gender and work position might be the reason for the low variance. Even though the male was significantly less than the female, NM was fewer than GN and AA. More factors need to be included in further studies.
The limitations of this study include that it used a convenience sample from only three public hospitals located in the Southwestern part of Vietnam. This sample does not represent all professional nurses in Vietnam. The N‐CT‐4 Practice is the instrument with good psychometric properties specific for clinical practice and translated into English (Zuriguel‐Pérez et al., 2017), Persian (FallahNezhad & Ziaeirad, 2018 ) and Turkish (Urhan & Seren, 2019 ). Different points of the Likert response format were selected by tools to measure critical thinking ability. For example, the N‐CT‐4 Practice selected a four‐point Likert response and it was rated in frequency, such as 1 = never or almost never and 4 = always or almost always. However, a seven‐point Likert scale for the Critical Thinking Disposition Assessment (CTDA) was selected and rated in levels of agreement, such as 1 for very strongly disagree and 7 for very strongly agree (Cui et al., 2021 ). Which response format can be more reprinting the characters of critical thinking ability? Further investigation is strongly suggested. Besides, the N‐CT‐4 Practice (V‐v) questionnaire has too many items that may lead to the boredom of the participants to answer and thus affect the accuracy of the results. Moreover, the collapsing of three distinctly separate groups of nurses into one group for most of the analyses lead to not showing differences in critical thinking and influencing factors among the three groups. These factors all limit the generalization of the present results. Based on these limitations, it is suggested that the use of nationwide systematic sampling and an international comparison are strongly suggested in further studies. Regarding the critical thinking questionnaire, it would be better to use the revised versions with fewer questions. Therefore, developmental and psychometric properties are suggested to shorten this questionnaire.
The results demonstrate that most of the professional nurses had a low or moderate critical thinking ability. Certain personal and occupational variables were significantly associated with the level of critical thinking. Being male or working as an NM were statistically significant predictors of critical thinking ability, and they explained only 11% of the total variance.
The findings of this study indicate that it is necessary to develop strategies to improve the critical thinking ability of professional nurses. The critical thinking ability has been confirmed to be an essential factor for high‐quality health care that focuses on the quality of patient care and patient safety. Besides, providing more opportunities to pursue advanced degrees or enhancing the provision of in‐service education in hospitals that involves classroom teaching or web‐based learning is strongly recommended for this specific group of nurses. Consequently, the quality of patient care could be improved.
The authors declare that they have no competing interests.
The authors would like to thank the expert panel, translators, research assistants, the hospitals and all of the clinical nurses who participated in this study. We are indebted to the study participants and would like to dedicate the research findings to improving the critical thinking ability of Vietnamese professional nurses in the future. No specific grant was received from funding agencies in the public, commercial, or not‐for‐profit sectors.
Van Nguyen T, Liu H‐E. Factors associated with the critical thinking ability of professional nurses: A cross‐sectional study . Nurs Open . 2021; 8 :1970–1980. 10.1002/nop2.875 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
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Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills. Images sourced from Getty Images. Critical thinking in nursing is essential to providing high-quality patient care.
The following are examples of attributes of excellent critical thinking skills in nursing. 1. The ability to interpret information: In nursing, the interpretation of patient data is an essential part of critical thinking. Nurses must determine the significance of vital signs, lab values, and data associated with physical assessment.
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.
Critical thinking is applied by nurses in the process of solving problems of patients and decision-making process with creativity to enhance the effect. It is an essential process for a safe, efficient and skillful nursing intervention. Critical thinking according to Scriven and Paul is the mental active process and subtle perception, analysis ...
Critical thinking is a complex, dynamic process formed by attitudes and strategic skills, with the aim of achieving a specific goal or objective. The attitudes, including the critical thinking attitudes, constitute an important part of the idea of good care, of the good professional. It could be said that they become a virtue of the nursing ...
Critical thinking is a necessary soft skill for nurses. It encompasses the ability to analyze information, evaluate data, and make reliable clinical judgments. Nurses use critical thinking to navigate the complexities of patient care, ensuring they can respond to diverse clinical situations with precision and confidence.
In summary, critical thinking is an integral skill for nurses, allowing them to provide high-quality, patient-centered care by analyzing information, making informed decisions, and adapting their approaches as needed. It's a dynamic process that enhances clinical reasoning, problem-solving, and overall patient outcomes.
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Nurses are critical thinkers. The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice.
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 ...
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Critical thinking allows nurses to double-check medication orders, consider potential drug interactions, and ensure the correct dosage is administered. This vigilance minimizes the risk of medication errors and enhances patient safety. 4. Developing and implementing care plans.
We believe these five strategies provide practical approaches for teaching critical thinking in the intensive care unit. ... Schwartzstein RM, Gusic M. Milestones of critical thinking: a developmental model for medicine and nursing. Acad Med. 2014; 89:715-720. [Google Scholar]
Nursing critical thinking skills drive the decision-making process and impact the quality of care provided," says Georgia Vest, DNP, RN and senior dean of nursing at the Rasmussen University School of Nursing. For example, nurses often have to make triage decisions in the emergency room. With an overflow of patients and limited staff, they ...
Tips to improve your critical thinking skills in nursing. Here are several tips to enhance your critical thinking skills as a nurse: 1. Ask patients open-ended questions. It's important to give all patients the same standard of care. Asking patients to elaborate on their medical history or point of view may help you communicate more effectively ...
Objective: The aim of this study was to understand how nurses use critical thinking to delegate nursing care. Background: Nurses must synthesize large amounts of information and think through complex and often emergent clinical situations when making critical decisions about patient care, including delegation. Method: A qualitative, descriptive ...
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The following inclusion criteria were examined: (a) clinical reasoning, clinical judgment, and critical thinking in nursing students as a primary study aim; (b) articles published for the last eleven years; (c) research conducted between January 2012 and September 2023; (d) articles published only in English and Spanish; and (e) Randomised ...
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1. INTRODUCTION. Critical thinking is defined as the cognitive process of reasoning that involves trying to minimize errors and to maximize positive outcomes while attempting to make a decision during patient care (Zuriguel‐Pérez et al., 2015).The importance of critical thinking in nursing practice has been identified in the literature (Chang et al., 2011; Ludin, 2018; Mahmoud & Mohamed ...
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