Turning new nurses into critical thinkers

As nurses know, seconds can often mean the difference between life and death.  With increasing responsibility and higher patient acuity, it’s imperative for nurses and bedside clinicians to be able to make quick, accurate decisions in response to unforeseen circumstances.

The term ‘critical thinking’ is often used interchangeably with problem-solving and clinical decision-making in nursing literature. Problem-solving focuses on identification and resolution, whereas critical thinking goes beyond this and incorporates asking questions and critiquing solutions. The concept of clinical decision-making focuses attention on the clinical nature of a problem, but falls short of facilitating understanding of the broader spectrum of the issue.

Creative thinking, a combination of imagination and knowledge, can also be helpful in understanding solutions that have failed and coming up with new ideas.

There are many skills necessary to be an effective critical thinker. Decision-making and critical thinking need to happen together in order to produce reasoning, clarification, and potential solutions. To advance nursing practice, it is necessary to develop and evaluate strategies to help new nurses develop these essential critical thinking skills.

Strategies for instituting critical thinking in new nurses

In assessing new graduate nurses’ critical-thinking capabilities, it’s helpful to consider the fundamental principles of critical thinking.  Ask the following 4 questions:

1. Can the nurse recognize that the patient has a problem?
2. Can the nurse manage the problem safely and effectively, recognizing his or her scope of practice?
3. Does the nurse have a relative sense of urgency?
4. Does the nurse take the right action for the right reason?

Just as there are similarities among the definitions of critical thinking across subject areas and levels, there are several generally recognized hallmarks of teaching for critical thinking. These include:

• Promote interaction among students as they learn. Learning in a group setting often helps each member achieve more.
• Ask open-ended questions that do not assume “one right answer.” Critical thinking is often exemplified best when the problems are inherently ill-defined and don't have a “right” answer. Open-ended questions also encourage students to think and respond creatively, without fear of giving the “wrong” answer.
• Allow sufficient time to reflect on the questions asked or problems posed. Critical thinking seldom involves snap judgments; therefore, posing questions and allowing adequate time before soliciting responses helps new nurses understand that they are expected to deliberate and to ponder, and that the immediate response is not always the best response.
• Teach for transfer. The skills for critical thinking should travel well. They generally will do so only if teachers provide opportunities for students to see how a newly acquired skill can apply to other situations and experiences.

Attributes of nurse critical thinkers

After evaluating where new nurses are at in terms of critical-thinking skills, look at the attributes of a critical thinker. Strong critical thinkers demonstrate the following characteristics: (Based on the APA Expert Consensus Delphi Report  description 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.

Impact of critical thinking on patient safety

Patient safety can be directly affected by the critical thinking ability of a nurse. Nurses must have the ability to recognize changes in patient condition, perform independent nursing interventions, anticipate orders, and prioritize. These actions require critical thinking ability, advanced problem-solving skills and the ability to communicate clearly.

Patient safety may be compromised if a nurse cannot provide clinically competent care. Assessments such as a performance-based development system (PBDS) can provide information about learning needs and facilitate individualized orientation targeted to increase performance level. PBDS evaluates a nurse’s ability to think critically in clinical situations, assessing ability to use clinical knowledge in real-world situations.

Research has shown that these instruments predict strength in critical thinking in problem situations and success on professional licensure examinations.

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