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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

Images sourced from Getty Images

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

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

What Is Critical Thinking In Nursing?

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

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

The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

What is Critical Thinking in Nursing? (Explained W/ Examples)

Last updated on August 23rd, 2023

Critical thinking is a foundational skill applicable across various domains, including education, problem-solving, decision-making, and professional fields such as science, business, healthcare, and more.

It plays a crucial role in promoting logical and rational thinking, fostering informed decision-making, and enabling individuals to navigate complex and rapidly changing environments.

In this article, we will look at what is critical thinking in nursing practice, its importance, and how it enables nurses to excel in their roles while also positively impacting patient outcomes.

What is Critical Thinking?

Critical thinking is a cognitive process that involves analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

It’s a mental activity that goes beyond simple memorization or acceptance of information at face value.

Critical thinking involves careful, reflective, and logical thinking to understand complex problems, consider various perspectives, and arrive at well-reasoned conclusions or solutions.

Key aspects of critical thinking include:

• Analysis: Critical thinking begins with the thorough examination of information, ideas, or situations. It involves breaking down complex concepts into smaller parts to better understand their components and relationships.
• Evaluation: Critical thinkers assess the quality and reliability of information or arguments. They weigh evidence, identify strengths and weaknesses, and determine the credibility of sources.
• Synthesis: Critical thinking involves combining different pieces of information or ideas to create a new understanding or perspective. This involves connecting the dots between various sources and integrating them into a coherent whole.
• Inference: Critical thinkers draw logical and well-supported conclusions based on the information and evidence available. They use reasoning to make educated guesses about situations where complete information might be lacking.
• Problem-Solving: Critical thinking is essential in solving complex problems. It allows individuals to identify and define problems, generate potential solutions, evaluate the pros and cons of each solution, and choose the most appropriate course of action.
• Creativity: Critical thinking involves thinking outside the box and considering alternative viewpoints or approaches. It encourages the exploration of new ideas and solutions beyond conventional thinking.
• Reflection: Critical thinkers engage in self-assessment and reflection on their thought processes. They consider their own biases, assumptions, and potential errors in reasoning, aiming to improve their thinking skills over time.
• Open-Mindedness: Critical thinkers approach ideas and information with an open mind, willing to consider different viewpoints and perspectives even if they challenge their own beliefs.
• Effective Communication: Critical thinkers can articulate their thoughts and reasoning clearly and persuasively to others. They can express complex ideas in a coherent and understandable manner.
• Continuous Learning: Critical thinking encourages a commitment to ongoing learning and intellectual growth. It involves seeking out new knowledge, refining thinking skills, and staying receptive to new information.

Definition of Critical Thinking

Critical thinking is an intellectual process of analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

What is Critical Thinking in Nursing?

Critical thinking in nursing is a vital cognitive skill that involves analyzing, evaluating, and making reasoned decisions about patient care.

It’s an essential aspect of a nurse’s professional practice as it enables them to provide safe and effective care to patients.

Critical thinking involves a careful and deliberate thought process to gather and assess information, consider alternative solutions, and make informed decisions based on evidence and sound judgment.

This skill helps nurses to:

• Assess Information: Critical thinking allows nurses to thoroughly assess patient information, including medical history, symptoms, and test results. By analyzing this data, nurses can identify patterns, discrepancies, and potential issues that may require further investigation.
• Diagnose: Nurses use critical thinking to analyze patient data and collaboratively work with other healthcare professionals to formulate accurate nursing diagnoses. This is crucial for developing appropriate care plans that address the unique needs of each patient.
• Plan and Implement Care: Once a nursing diagnosis is established, critical thinking helps nurses develop effective care plans. They consider various interventions and treatment options, considering the patient’s preferences, medical history, and evidence-based practices.
• Evaluate Outcomes: After implementing interventions, critical thinking enables nurses to evaluate the outcomes of their actions. If the desired outcomes are not achieved, nurses can adapt their approach and make necessary changes to the care plan.
• Prioritize Care: In busy healthcare environments, nurses often face situations where they must prioritize patient care. Critical thinking helps them determine which patients require immediate attention and which interventions are most essential.
• Communicate Effectively: Critical thinking skills allow nurses to communicate clearly and confidently with patients, their families, and other members of the healthcare team. They can explain complex medical information and treatment plans in a way that is easily understood by all parties involved.
• Identify Problems: Nurses use critical thinking to identify potential complications or problems in a patient’s condition. This early recognition can lead to timely interventions and prevent further deterioration.
• Collaborate: Healthcare is a collaborative effort involving various professionals. Critical thinking enables nurses to actively participate in interdisciplinary discussions, share their insights, and contribute to holistic patient care.
• Ethical Decision-Making: Critical thinking helps nurses navigate ethical dilemmas that can arise in patient care. They can analyze different perspectives, consider ethical principles, and make morally sound decisions.
• Continual Learning: Critical thinking encourages nurses to seek out new knowledge, stay up-to-date with the latest research and medical advancements, and incorporate evidence-based practices into their care.

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.

What are the Levels of Critical Thinking in Nursing?

The development of critical thinking in nursing practice involves progressing through three levels: basic, complex, and commitment.

The Kataoka-Yahiro and Saylor model outlines this progression.

1. Basic Critical Thinking:

At this level, learners trust experts for solutions. Thinking is based on rules and principles. For instance, nursing students may strictly follow a procedure manual without personalization, as they lack experience. Answers are seen as right or wrong, and the opinions of experts are accepted.

2. Complex Critical Thinking:

Learners start to analyze choices independently and think creatively. They recognize conflicting solutions and weigh benefits and risks. Thinking becomes innovative, with a willingness to consider various approaches in complex situations.

3. Commitment:

At this level, individuals anticipate decision points without external help and take responsibility for their choices. They choose actions or beliefs based on available alternatives, considering consequences and accountability.

As nurses gain knowledge and experience, their critical thinking evolves from relying on experts to independent analysis and decision-making, ultimately leading to committed and accountable choices in patient care.

Why Critical Thinking is Important in Nursing?

Critical thinking is important in nursing for several crucial reasons:

Patient Safety:

Nursing decisions directly impact patient well-being. Critical thinking helps nurses identify potential risks, make informed choices, and prevent errors.

Clinical Judgment:

Nursing decisions often involve evaluating information from various sources, such as patient history, lab results, and medical literature.

Critical thinking assists nurses in critically appraising this information, distinguishing credible sources, and making rational judgments that align with evidence-based practices.

Enhances Decision-Making:

In nursing, critical thinking allows nurses to gather relevant patient information, assess it objectively, and weigh different options based on evidence and analysis.

This process empowers them to make informed decisions about patient care, treatment plans, and interventions, ultimately leading to better outcomes.

Promotes Problem-Solving:

Nurses encounter complex patient issues that require effective problem-solving.

Critical thinking equips them to break down problems into manageable parts, analyze root causes, and explore creative solutions that consider the unique needs of each patient.

Drives Creativity:

Nursing care is not always straightforward. Critical thinking encourages nurses to think creatively and explore innovative approaches to challenges, especially when standard protocols might not suffice for unique patient situations.

Fosters Effective Communication:

Communication is central to nursing. Critical thinking enables nurses to clearly express their thoughts, provide logical explanations for their decisions, and engage in meaningful dialogues with patients, families, and other healthcare professionals.

Aids Learning:

Nursing is a field of continuous learning. Critical thinking encourages nurses to engage in ongoing self-directed education, seeking out new knowledge, embracing new techniques, and staying current with the latest research and developments.

Improves Relationships:

Open-mindedness and empathy are essential in nursing relationships.

Critical thinking encourages nurses to consider diverse viewpoints, understand patients’ perspectives, and communicate compassionately, leading to stronger therapeutic relationships.

Empowers Independence:

Nursing often requires autonomous decision-making. Critical thinking empowers nurses to analyze situations independently, make judgments without undue influence, and take responsibility for their actions.

Facilitates Adaptability:

Healthcare environments are ever-changing. Critical thinking equips nurses with the ability to quickly assess new information, adjust care plans, and navigate unexpected situations while maintaining patient safety and well-being.

Strengthens Critical Analysis:

In the era of vast information, nurses must discern reliable data from misinformation.

Critical thinking helps them scrutinize sources, question assumptions, and make well-founded choices based on credible information.

How to Apply Critical Thinking in Nursing? (With Examples)

Here are some examples of how nurses can apply critical thinking.

Assess Patient Data:

Critical Thinking Action: Carefully review patient history, symptoms, and test results.

Example: A nurse notices a change in a diabetic patient’s blood sugar levels. Instead of just administering insulin, the nurse considers recent dietary changes, activity levels, and possible medication interactions before adjusting the treatment plan.

Diagnose Patient Needs:

Critical Thinking Action: Analyze patient data to identify potential nursing diagnoses.

Example: After reviewing a patient’s lab results, vital signs, and observations, a nurse identifies “ Risk for Impaired Skin Integrity ” due to the patient’s limited mobility.

Plan and Implement Care:

Critical Thinking Action: Develop a care plan based on patient needs and evidence-based practices.

Example: For a patient at risk of falls, the nurse plans interventions such as hourly rounding, non-slip footwear, and bed alarms to ensure patient safety.

Evaluate Interventions:

Critical Thinking Action: Assess the effectiveness of interventions and modify the care plan as needed.

Example: After administering pain medication, the nurse evaluates its impact on the patient’s comfort level and considers adjusting the dosage or trying an alternative pain management approach.

Prioritize Care:

Critical Thinking Action: Determine the order of interventions based on patient acuity and needs.

Example: In a busy emergency department, the nurse triages patients by considering the severity of their conditions, ensuring that critical cases receive immediate attention.

Collaborate with the Healthcare Team:

Critical Thinking Action: Participate in interdisciplinary discussions and share insights.

Example: During rounds, a nurse provides input on a patient’s response to treatment, which prompts the team to adjust the care plan for better outcomes.

Ethical Decision-Making:

Critical Thinking Action: Analyze ethical dilemmas and make morally sound choices.

Example: When a terminally ill patient expresses a desire to stop treatment, the nurse engages in ethical discussions, respecting the patient’s autonomy and ensuring proper end-of-life care.

Patient Education:

Critical Thinking Action: Tailor patient education to individual needs and comprehension levels.

Example: A nurse uses visual aids and simplified language to explain medication administration to a patient with limited literacy skills.

Adapt to Changes:

Critical Thinking Action: Quickly adjust care plans when patient conditions change.

Example: During post-operative recovery, a nurse notices signs of infection and promptly informs the healthcare team to initiate appropriate treatment adjustments.

Critical Analysis of Information:

Critical Thinking Action: Evaluate information sources for reliability and relevance.

Example: When presented with conflicting research studies, a nurse critically examines the methodologies and sample sizes to determine which study is more credible.

Making Sense of Critical Thinking Skills

What is the purpose of critical thinking in nursing.

The purpose of critical thinking in nursing is to enable nurses to effectively analyze, interpret, and evaluate patient information, make informed clinical judgments, develop appropriate care plans, prioritize interventions, and adapt their approaches as needed, thereby ensuring safe, evidence-based, and patient-centered care.

Why critical thinking is important in nursing?

Critical thinking is important in nursing because it promotes safe decision-making, accurate clinical judgment, problem-solving, evidence-based practice, holistic patient care, ethical reasoning, collaboration, and adapting to dynamic healthcare environments.

Critical thinking skill also enhances patient safety, improves outcomes, and supports nurses’ professional growth.

How is critical thinking used in the nursing process?

Critical thinking is integral to the nursing process as it guides nurses through the systematic approach of assessing, diagnosing, planning, implementing, and evaluating patient care. It involves:

• Assessment: Critical thinking enables nurses to gather and interpret patient data accurately, recognizing relevant patterns and cues.
• Diagnosis: Nurses use critical thinking to analyze patient data, identify nursing diagnoses, and differentiate actual issues from potential complications.
• Planning: Critical thinking helps nurses develop tailored care plans, selecting appropriate interventions based on patient needs and evidence.
• Implementation: Nurses make informed decisions during interventions, considering patient responses and adjusting plans as needed.
• Evaluation: Critical thinking supports the assessment of patient outcomes, determining the effectiveness of intervention, and adapting care accordingly.

Throughout the nursing process , critical thinking ensures comprehensive, patient-centered care and fosters continuous improvement in clinical judgment and decision-making.

What is an example of the critical thinking attitude of independent thinking in nursing practice?

An example of the critical thinking attitude of independent thinking in nursing practice could be:

A nurse is caring for a patient with a complex medical history who is experiencing a new set of symptoms. The nurse carefully reviews the patient’s history, recent test results, and medication list.

While discussing the case with the healthcare team, the nurse realizes that the current treatment plan might not be addressing all aspects of the patient’s condition.

Instead of simply following the established protocol, the nurse independently considers alternative approaches based on their assessment.

The nurse proposes a modification to the treatment plan, citing the rationale and evidence supporting the change.

This demonstrates independent thinking by critically evaluating the situation, challenging assumptions, and advocating for a more personalized and effective patient care approach.

How to use Costa’s level of questioning for critical thinking in nursing?

Costa’s levels of questioning can be applied in nursing to facilitate critical thinking and stimulate a deeper understanding of patient situations. The levels of questioning are as follows:

• 15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)
• Nursing Concept Map (FREE Template)
• Clinical Reasoning In Nursing (Explained W/ Example)
• 8 Stages Of The Clinical Reasoning Cycle
• How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples
• What is the “5 Whys” Technique?
• What Are Socratic Questions?

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.

Reading Recommendation

Potter, P.A., Perry, A.G., Stockert, P. and Hall, A. (2013) Fundamentals of Nursing

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Effective clinical learning for nursing students

Approaches that meet student and nurse needs..

• Direct care nurses serve as significant teachers and role models for nursing students in the clinical setting.
• Building critical thinking skills is one of the most important outcomes in the clinical setting for nursing students.
• Collaboration with nursing faculty during the clinical rotation can ease the burden on direct care nurses and facilitate a positive learning experience for the student.

The nursing profession continues to experience several challenges—some longstanding and exacerbated by the COVID-19 pandemic. The shortage of nurses at the bedside and reports of nurses planning to leave the profession soon place stress on the workforce and the healthcare system. The situation has put even more pressure on nursing schools to recruit and retain students who enter the workforce well-prepared for practice and capable of filling these vacancies. However, concerns exist surrounding students’ critical thinking skills and their readiness for a demanding career.

The challenge

A longstanding shortage of nursing school faculty and a reliance on new graduate nurses to serve as preceptors create challenges to properly preparing nursing students for a demanding role that requires excellent critical thinking skills.

What-Why-How? Improving Clinical Judgement

New nurses and clinical judgment

Nurse faculty shortage

Lack of interest and incentives lead to difficulty recruiting nurses from the bedside or practice to education. Many 4-year schools require a terminal degree to teach full-time in their undergraduate programs, but only 1% of nurses hold a PhD. In addition, according to the National Advisory Council on Nurse Education and Practice (NACNEP), the average doctorally prepared nurse faculty member is in their 50s, which means they may soon retire. The surge in doctor of nursing practice programs has helped to bridge this gap, but attracting advanced practice nurses to academia from their more lucrative practice roles continues to prove difficult.

Concerns about the practice readiness of new graduate nurses have existed for several years. Missed clinical experiences and virtual learning during the COVID-19 pandemic heightened those concerns. The National Council of State Boards of Nursing (NCSBN) addressed the calls from nurse employers to make progress in this area by revamping the NCLEX-RN and NCLEX-PN exams to create Next Generation NCLEX (NGN), which includes more clinical judgment and critical thinking items. Nurse educators are working hard to prepare students for both practice and the new exam items by incorporating more active learning into classroom, clinical, and lab activities and emphasizing the importance of clinical judgment skills.

In most areas of the country, clinical student experiences have returned to pre-pandemic arrangements. State boards of nursing mandate maximum faculty-to-student ratios for clinical experiences. Schools can choose to have faculty supervise fewer students than the maximum, but faculty and clinical site shortages may eliminate that option. In many cases, preceptor-style experiences (such as capstone or practicum courses) have higher faculty-to-student ratios, and preceptors may have to meet specific criteria, such as a certain amount of experience.

Nursing faculty who facilitate on-site learning and supervise and teach students during their clinical experiences face several challenges. Some faculty supervise students across multiple units because unit size can’t accommodate 8 to 10 students at one time. Faculty may or may not have access to the organization’s electronic health records or other healthcare information technology, such as medication dispensing cabinets or glucometers.

In such instances, direct care nurses play an important role in the student’s experience at the clinical site. Their familiarity with the unit, the patient population, and the organization’s technology facilitates learning.

Direct care nurses

Allowing nursing students into the hospital can improve the patient care experience and potentially recruit students to work at the organization in the future. However, precepting a student or new employee creates an extra burden on an already overextended bedside nurse. NACNEP identifies several challenges for obtaining qualified preceptors, including lack of incentives and limited preparation in clinical teaching and learning strategies. Many hospitals have nursing students on the same unit several days a week to accommodate multiple area schools. This means that staff nurses are expected to teach students on most of their workdays during a typical school semester.

Unit nurse experience creates another barrier to effective precepting of nursing students. A study by Thayer and colleagues reported that the median length of experience for inpatient nurses working a 12-hour shift was less than 3 years at an organization. Without a better alternative, new graduate nurses frequently teach nursing students, although they may still be in what Benner describes as the advanced beginner stage of their career (still learning how to organize care, prioritize, and make clinical judgments). It’s difficult for someone who’s still learning and experiencing situations for the first time to teach complex concepts.

A guide to effective clinical site teaching

The following strategies promote critical thinking in students and collaboration with nurse faculty to ease direct care nurses’ teaching workload. Not every strategy is appropriate for all student clinical experiences. Consider them as multiple potential approaches to help facilitate meaningful learning opportunities.

Set the tone

Nursing students frequently feel anxious about clinical experiences, especially if they’ve been told or perceive that they’re a burden or unwanted on the unit. When meeting the student for the first time, welcome them and communicate willingness to have them on the unit.

If you feel that you can’t take on a student for the day, speak to the nurse faculty member and charge nurse to explore other arrangements. Nurse faculty recognize that work or personal concerns may require you to decline precepting a student. Faculty members want to find the best situation for everyone. If the charge nurse or supervisor determines that the student still needs to work with you, talk to the nurse faculty about how they can help ease the burden and facilitate the student’s learning experience for the day.

Begin your time with the student by asking about their experience level and any objectives for the day. Understanding what the student can or can’t do will help you make the most out of the clinical experience. You’ll want to know the content they’re learning in class and connect them with a patient who brings those concepts to life. A student may have assignments to complete, but their focus should be on patient care. Help the student identify the busiest parts of the day and the best time to review the electronic health record and complete assignments.

If a situation requires your full attention and limits training opportunities, briefly explain to the student what will happen. If you have time, provide the student with tasks or specific objectives to note during the observation. Involve the nursing faculty member to help facilitate the learning experience and make it meaningful.

Be a professional role model

Students like to hear about the benefits and rewards of being a nurse, and about each nurse’s unique path. Students also enjoy learning about the “real world” from nurses, but keep in mind that they’re impressionable. Speaking negatively about the unit, patients, organization, or profession may discourage the student. If you must deviate from standard care, such as performing a skill differently than it’s traditionally taught in school, provide the rationale or hospital policy behind the decision.

Feel free to discuss the student’s nursing school experience but don’t diminish the value of their education or assigned work. Keep in mind that school assignments, such as nursing care plans or concept maps, aren’t taught for job training but to deliberately and systematically promote critical thinking. These assignments allow a student to reflect on how a patient’s pathophysiology and nursing assessment and interventions relate to one another.

Reinforce how concepts students learn in school provide valuable knowledge in various settings. For example, if the student is on a medical-surgical unit but says that they want to work in obstetrics, engage the student by pointing out links between the two areas, such as managing diabetes and coagulation disorders. Provide encouragement and excitement about the student’s interest in joining the profession at a time of great need.

Build assessment skills

Explain to students your approach to performing assessments and organizing patient care. Most students learn comprehensive head-to-toe assessments but, in the clinical setting, need to focus on the most relevant assessments. To promote critical thinking, ask the student what data they should focus on gathering based on the patient’s condition. Many students focus on the psychomotor aspect of assessment (performing the assessment correctly); ask them about the subjective data they should gather.

Allow the student to perform an assessment and then compare findings. For example, a student may know that a patient’s lung sounds are abnormal but not remember what the sound is called or what it means. Provide them with the correct terminology to help connect the dots. Discuss with the student when reassessments are warranted. If appropriate, allow a student to reassess the patient (vital signs, output, pain, other physical findings) and then confirm their findings and discuss what any changes mean for the clinical situation. If you don’t have time for these types of discussions following a student’s patient assessment, ask nursing faculty to observe and discuss findings with the student.

Discuss care management

Take advantage of opportunities to discuss concepts such as prioritization, advocacy, delegation, collaboration, discharge planning, and other ways in which the nurse acts as a care manager. Pointing out what’s appropriate to delegate to unlicensed assistive personnel or a licensed practical nurse will prove valuable and help reinforce concepts frequently covered on the NGN exam.

Promote critical thinking

The NCBSN has introduced the Clinical Judgment Measurement Model (CJMM) as a framework for evaluating the NGN exam, which incorporates unfolding case studies that systematically address six steps: recognize cues, analyze cues, generate hypotheses, generate solutions, take action, and evaluate outcomes. Each candidate encounters three case studies, with six questions, one for each step of the CJMM. Nursing faculty incorporate this framework and language into the nursing curriculum to help students think systematically and critically and prepare them for the exam.

Nurses with practice experience use this type of framework to gather information, make judgments, and take action. As a nurse approaches Benner’s competent stage of nursing practice, this type of thinking becomes intuitive, and nurses may not even be aware of the conclusions they draw and decisions they make based on their clinical judgment skills. To help students understand why something is happening, they should continue to work through a process like this deliberately. For example, many students view medication administration as a simple task and may say in post-conference discussion, “All I did was give meds.” You perform many assessments and make various judgments while administering medications, but you may not think to discuss them with students. Asking questions of students while they’re performing what may seem like repetitive tasks can help prompt critical thinking. (See Critical questions .)

Critical questions

Enhance self-efficacy

Many nurses believe that the student must follow them to every patient. This can be overwhelming for the direct care nurse and a barrier to agreeing to work with students. Other approaches can better facilitate learning. Most students will complete an assignment focused on one or two patients. Encourage the student to spend time alone with those patients to perform a more comprehensive history and assessment, help patients with basic care, and provide education. Select a patient who might enjoy the extra attention to ensure a mutually beneficial experience.

Also, consider asking the student to find information using available resources. Such inquiry can benefit you and the student. For example, prompt a student to answer one or more critical thinking questions using their textbooks or resources available on the hospital’s intranet. If time prevents you from explaining complex topics or helping the student problem-solve, ask the student to take the information they find to their faculty member to review. Nurse faculty won’t be familiar with the specific details of all patients on the unit, so identify the most appropriate questions for the student to consider to help the nurse faculty facilitate learning.

Allowing the student time to find answers themselves builds self-efficacy and confidence and also relieves some of the stress and anxiety associated with being asked questions on the spot. This strategy also models the professional approach of using evidence-based resources to find information as needed in the clinical setting.

To ensure a positive learning experience and reduce anxiety, provide the student with ample time to prepare for performance-based skills. For example, identify an approximate time that medications will be administered to one patient and ask the student to independently look up the medication information by that time. This is more beneficial for the student than observing every patient’s medication administration or participating only in psychomotor tasks, such as scanning and giving injections. This also can free up your time by setting the expectation that the student will have the chance to prepare for and be directly involved in one medication pass.

Similarly, if an opportunity exists for practicing a psychomotor skill, such as inserting a urinary catheter or suctioning a tracheostomy, ask the student to review the procedure with their instructor using hospital policy and resources. If time doesn’t allow for a review, have the student observe to ensure provision of the best care and efficient use of time and resources.

Opportunities in education

Nurses who enjoy working with students or new staff members may want to consider academic roles. Many advanced nursing degrees, available in various formats, focus on education. For those who want to try teaching or have an interest in teaching only in the clinical setting, opportunities exist to work as adjunct faculty or to participate in hospital-based professional development activities. Adjunct faculty (part-time instructors) teach a variety of assignments and workloads, including in clinical, lab, or classroom settings. Many clinical adjunct faculty are nurses who also work in the organization with patients and may teach one group of students one day a week. Clinical and lab assignments vary from 4- or 6-hour experiences to 12-hour shifts.

According to NACNEP, most nursing programs require that adjunct faculty and clinical preceptors have the same or higher level of educational preparation as the program; for example, a nurse with a bachelor of science in nursing (BSN) may be able to teach clinicals for associate degree in nursing or BSN programs, depending on the state’s requirements and the school’s needs. Educational requirements to work in nursing programs vary by school. In some cases, adjunct faculty who don’t have a master’s degree may be supervised by full-time faculty with advanced degrees.

Benefits for adjunct faculty can include extra income, professional development, personal reward, tuition discounts or remissions, and giving back to the profession. Locate opportunities on nursing school websites or by talking to the nursing instructors or administrators in the local area.

Everyone benefits

Applying teaching approaches that benefit students and nurses can help ensure a positive clinical learning experience for everyone. When you graciously accept and teach students you help create positive encounters that enhance student critical thinking skill development, aid program retention, and support organizational recruitment.

Jennifer Miller is an assistant professor of nursing at the University of Louisville School of Nursing in Louisville, Kentucky .

American Nurse Journal. 2024; 19(4). Doi: 10.51256/ANJ042432

American Association of Colleges of Nursing. Nursing faculty shortage fact sheet. October 2022. aacnnursing.org/news-information/fact-sheets/nursing-faculty-shortage

Benner P. From Novice to Expert: Excellence and Power in Clin­i­cal Nursing Practice . Menlo Park, CA: Addison-Wesley; 1984.

National Advisory Council on Nurse Education and Practice. Preparing nurse faculty, and addressing the shortage of nurse faculty and clinical preceptors. January 2021. hrsa.gov/sites/default/files/hrsa/advisory-committees/nursing/reports/nacnep-17report-2021.pdf

National Council of State Boards of Nursing. Clinical Judgment Measurement Model. 2023. nclex.com/clinical-judgment-measurement-model.page

Thayer J, Zillmer J, Sandberg N, Miller AR, Nagel P, MacGibbon A. ‘The new nurse’ is the new normal. June 2, 2022. Epic Research. epicresearch.org/articles/the-new-nurse-is-the-new-normal

Key words: nursing students, nursing education, critical thinking, precepting

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All nursing programs need to put in more clinical time. Students do not get the time in clinicals so they do not have the opportunities to develop their clinical judgement and thinking skills. Clinical time is what glues concept and theory together if they don’t get the clinical time they are less likely to develop these skills which contributes to errors, burnout and nurses leaving the field.

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Miller J. Effective clinical learning for nursing students. American Nurse Journal. 2024;19(4):32-37. doi:10.51256/anj042432 https://www.myamericannurse.com/effective-clinical-learning-for-nursing-students/

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How to Apply Critical Thinking in Nursing

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Harnessing the power of critical thinking can be the key to becoming a successful and competent nurse. 

Developing and refining your critical thinking skills is crucial as you embark on your nursing journey. By doing so, you’ll enhance your ability to provide high-quality care, advance your professional growth, and contribute to the ever-evolving nursing field.

What is critical thinking in nursing?

Critical thinking is an essential cognitive process that enables nurses to analyze, evaluate, and synthesize information to make informed decisions. In the context of nursing, it involves observing, interpreting, and responding to patient needs effectively. 

Critical thinking allows nurses to go beyond memorized facts and apply logical reasoning to address patient problems holistically.

As a nurse, you’ll encounter multifaceted healthcare scenarios, each presenting its unique challenges. Critical thinking enables you to approach these situations systematically, evaluate the available data, identify relevant factors, and understand the patient’s condition comprehensively.

By employing critical thinking skills, you can differentiate between urgent and non-urgent issues, prioritize care, anticipate potential complications, and adapt your interventions accordingly. This analytical approach helps minimize errors, promote patient safety, and achieve positive patient outcomes.

Why is critical thinking important in nursing?

Critical thinking serves as the backbone of nursing practice. You’ll encounter various uncertainties, changing conditions, and ethical dilemmas as a nurse. Developing critical thinking abilities empowers you to navigate these challenges confidently and provide optimal patient care.

In nursing, critical thinking is crucial for the following reasons:

• Enhanced Clinical Judgment: Critical thinking enables assessing complex situations, analyzing available information, and drawing logical conclusions. It enhances your clinical judgment, allowing you to make informed decisions based on the best available evidence and expert consensus.
• Effective Problem Solving: Nursing involves encountering problems and finding effective solutions. Critical thinking equips you with the tools to identify underlying issues, explore alternative options, and implement interventions that address the root cause of the problem.
• Patient Advocacy: Critical thinking empowers you to advocate for your patients’ needs. By actively engaging in critical inquiry, you can challenge assumptions, question policies, and promote patient-centered care.
• Adapting to Changing Environments: Healthcare is constantly evolving, with new research findings, technologies, and treatments emerging regularly. Developing critical thinking skills helps you adapt to these changes, ensuring you stay updated and deliver evidence-based care.

Examples of Critical Thinking in Nursing

Let’s dive into some real-life examples that highlight how critical thinking plays a crucial role in nursing practice:

• Prioritization: Imagine working in an emergency department where multiple patients arrive simultaneously with varying degrees of severity. Utilizing critical thinking, you can assess each patient’s condition, prioritize care based on the urgency of their needs, and allocate resources effectively.
• Medication Administration: When administering medication, critical thinking prompts you to cross-check the prescribed dose, assess potential drug interactions or allergies, and evaluate the patient’s response to the medication. This proactive approach ensures patient safety and minimizes medication errors.
• Ethical Dilemmas: Critical thinking helps you navigate complex ethical dilemmas by analyzing the values at stake, considering legal and ethical principles, and collaborating with the healthcare team to make decisions that align with the patient’s best interests.

Supplement Your Nursing Studies and Boost Your Grades

At SimpleNursing , we understand the significance of critical thinking in nursing education. Our comprehensive digital study tools are designed to enhance your critical thinking abilities, providing you with interactive case studies, practice questions, and simulated patient scenarios. 

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The importance of critical thinking in nursing.

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While not every decision is an immediate life-and-death situation, there are hundreds of decisions nurses must make every day that impact patient care in ways small and large.

“Being able to assess situations and make decisions can lead to life-or-death situations,” said nurse anesthetist Aisha Allen . “Critical thinking is a crucial and essential skill for nurses.”

The National League for Nursing Accreditation Commission (NLNAC) defines critical thinking in nursing this way: “the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief-based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research.”

Why Critical Thinking in Nursing Is Important

An eight-year study by Johns Hopkins reports that 10% of deaths in the U.S. are due to medical error — the third-highest cause of death in the country.

“Diagnostic errors, medical mistakes, and the absence of safety nets could result in someone’s death,” wrote Dr. Martin Makary , professor of surgery at Johns Hopkins University School of Medicine.

Everyone makes mistakes — even doctors. Nurses applying critical thinking skills can help reduce errors.

“Question everything,” said pediatric nurse practitioner Ersilia Pompilio RN, MSN, PNP . “Especially doctor’s orders.” Nurses often spend more time with patients than doctors and may notice slight changes in conditions that may not be obvious. Resolving these observations with treatment plans can help lead to better care.

Key Nursing Critical Thinking Skills

Some of the most important critical thinking skills nurses use daily include interpretation, analysis, evaluation, inference, explanation, and self-regulation.

• Interpretation: Understanding the meaning of information or events.
• Analysis: Investigating a course of action based on objective and subjective data.
• Evaluation: Assessing the value of information and its credibility.
• Inference: Making logical deductions about the impact of care decisions.
• Explanation: Translating complicated and often complex medical information to patients and families in a way they can understand to make decisions about patient care.
• Self-Regulation: Avoiding the impact of unconscious bias with cognitive awareness.

These skills are used in conjunction with clinical reasoning. Based on training and experience, nurses use these skills and then have to make decisions affecting care.

It’s the ultimate test of a nurse’s ability to gather reliable data and solve complex problems. However, critical thinking goes beyond just solving problems. Critical thinking incorporates questioning and critiquing solutions to find the most effective one. For example, treating immediate symptoms may temporarily solve a problem, but determining the underlying cause of the symptoms is the key to effective long-term health.

8 Examples of Critical Thinking in Nursing

Here are some real-life examples of how nurses apply critical thinking on the job every day, as told by nurses themselves.

Example #1: Patient Assessments

“Doing a thorough assessment on your patient can help you detect that something is wrong, even if you're not quite sure what it is,” said Shantay Carter , registered nurse and co-founder of Women of Integrity . “When you notice the change, you have to use your critical thinking skills to decide what's the next step. Critical thinking allows you to provide the best and safest care possible.”

Example #2: First Line of Defense

Often, nurses are the first line of defense for patients.

“One example would be a patient that had an accelerated heart rate,” said nurse educator and adult critical care nurse Dr. Jenna Liphart Rhoads . “As a nurse, it was my job to investigate the cause of the heart rate and implement nursing actions to help decrease the heart rate prior to calling the primary care provider.”

Nurses with poor critical thinking skills may fail to detect a patient in stress or deteriorating condition. This can result in what’s called a “ failure to rescue ,” or FTR, which can lead to adverse conditions following a complication that leads to mortality.

Example #3: Patient Interactions

Nurses are the ones taking initial reports or discussing care with patients.

“We maintain relationships with patients between office visits,” said registered nurse, care coordinator, and ambulatory case manager Amelia Roberts . “So, when there is a concern, we are the first name that comes to mind (and get the call).”

“Several times, a parent called after the child had a high temperature, and the call came in after hours,” Roberts said. “Doing a nursing assessment over the phone is a special skill, yet based on the information gathered related to the child's behavior (and) fluid intake, there were several recommendations I could make.”

Deciding whether it was OK to wait until the morning, page the primary care doctor, or go to the emergency room to be evaluated takes critical thinking.

Example #4: Using Detective Skills

Nurses have to use acute listening skills to discern what patients are really telling them (or not telling them) and whether they are getting the whole story.

“I once had a 5-year-old patient who came in for asthma exacerbation on repeated occasions into my clinic,” said Pompilio. “The mother swore she was giving her child all her medications, but the asthma just kept getting worse.”

Pompilio asked the parent to keep a medication diary.

“It turned out that after a day or so of medication and alleviation in some symptoms, the mother thought the child was getting better and stopped all medications,” she said.

Example #5: Prioritizing

“Critical thinking is present in almost all aspects of nursing, even those that are not in direct action with the patient,” said Rhoads. “During report, nurses decide which patient to see first based on the information gathered, and from there they must prioritize their actions when in a patient’s room. Nurses must be able to scrutinize which medications can be taken together, and which modality would be best to help a patient move from the bed to the chair.”

A critical thinking skill in prioritization is cognitive stacking. Cognitive stacking helps create smooth workflow management to set priorities and help nurses manage their time. It helps establish routines for care while leaving room within schedules for the unplanned events that will inevitably occur. Even experienced nurses can struggle with juggling today’s significant workload, prioritizing responsibilities, and delegating appropriately.

Example #6: Medication & Care Coordination

Another aspect that often falls to nurses is care coordination. A nurse may be the first to notice that a patient is having an issue with medications.

“Based on a report of illness in a patient who has autoimmune challenges, we might recommend that a dose of medicine that interferes with immune response be held until we communicate with their specialty provider,” said Roberts.

Nurses applying critical skills can also help ease treatment concerns for patients.

“We might recommend a patient who gets infusions come in earlier in the day to get routine labs drawn before the infusion to minimize needle sticks and trauma,” Robert said.

Example #7: Critical Decisions

During the middle of an operation, the anesthesia breathing machine Allen was using malfunctioned.

“I had to critically think about whether or not I could fix this machine or abandon that mode of delivering nursing anesthesia care safely,” she said. “I chose to disconnect my patient from the malfunctioning machine and retrieve tools and medications to resume medication administration so that the surgery could go on.”

Nurses are also called on to do rapid assessments of patient conditions and make split-second decisions in the operating room.

“When blood pressure drops, it is my responsibility to decide which medication and how much medication will fix the issue,” Allen said. “I must work alongside the surgeons and the operating room team to determine the best plan of care for that patient's surgery.”

“On some days, it seems like you are in the movie ‘The Matrix,’” said Pompilio. “There's lots of chaos happening around you. Your patient might be decompensating. You have to literally stop time and take yourself out of the situation and make a decision.”

Example #8: Fast & Flexible Decisions

Allen said she thinks electronics are great, but she can remember a time when technology failed her.

“The hospital monitor that gives us vitals stopped correlating with real-time values,” she said. “So I had to rely on basic nursing skills to make sure my patient was safe. (Pulse check, visual assessments, etc.)”

In such cases, there may not be enough time to think through every possible outcome. Critical thinking combined with experience gives nurses the ability to think quickly and make the right decisions.

Improving the Quality of Patient Care

Nurses who think critically are in a position to significantly increase the quality of patient care and avoid adverse outcomes.

“Critical thinking allows you to ensure patient safety,” said Carter. “It’s essential to being a good nurse.”

Nurses must be able to recognize a change in a patient’s condition, conduct independent interventions, anticipate patients and provider needs, and prioritize. Such actions require critical thinking ability and advanced problem-solving skills.

“Nurses are the eyes and ears for patients, and critical thinking allows us to be their advocates,” said Allen.

Image courtesy of iStock.com/ davidf

Last updated on Jan 05, 2024 .

Originally published on Aug 25, 2021 .

The views expressed in this article are those of the author and do not necessarily reflect those of Berxi™ or Berkshire Hathaway Specialty Insurance Company. This article (subject to change without notice) is for informational purposes only, and does not constitute professional advice. Click here to read our full disclaimer

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Creative Ways to Enhance and Assess Critical Thinking in Nursing Students

Parker, Kimberly C.

About the Author Kimberly C. Parker, DNP, RN, is a clinical instructor, University of Alabama Capstone College of Nursing, Tuscaloosa, Alabama. For more information, contact her at [email protected] .

The author has declared no conflict of interest.

Nursing students should be challenged to implement critical thinking decisions regarding conclusions they implement for patient care. This article reinforces common techniques and introduces new practices to teach critical thinking. Many ways are currently recognized utilizing an assortment of techniques. The concepts from an escape room are a great way to deliver opportunities for students to practice this skill and can be provided economically and easily. Being creative in managing these concepts will offer an exciting chance to introduce critical thinking for your students.

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Thinking Like a Nurse: The Critical Thinking Skills in the Nursing Practice

Thinking how to nurse is thinking like a nurse. Florence Nightingale (1860) wrote on her notes that women who have charge of the other’s health—to which the application of her integrated experiences must teach herself to think how to nurse, a self-learning acquired from “hints”.

Perhaps, Nightingale referred “hints” as the use of critical thinking skills in patient’s care. The ability to think critically was the foundation of nursing practice started from historic times and is becoming one of the key performance indicators for both students and nursing professionals nowadays.

Educational system continues to evolve and progresses heeding to the needs of the society, and parallel to the changing educational structure and methodology. However, Haber (2020) reported that only 75% of employers claim that the students they hire who underwent 12 or more years of formal education lack of critical thinking and problem-solving abilities despite the progress in the educational system.

What is Critical Thinking?

Critical thinking skills, a fundamental skill that plays a pivotal role in our daily survival. In general terms, the skill will not stop in memorization, the process goes beyond connecting the dots from one to concept to another, problem-solving techniques, think creatively, and apply the learned knowledge in new ways (Walden University, 2020). Kaminske (2019), defines critical thinking skills as a domain-specific skill on the ability to solve problems and make effective decisions that require expertise to be applied in a range of situations and scenarios.

In the nursing practice, Critical thinking skill works in assimilation with critical reasoning as a practice-based discipline of decision-making to the health care professionals. Critical thinking is the process of the intentional higher level of thinking to identify patient’s health care needs and appraise evidence-based practice to make choices in the delivery of care.

On the other hand, clinical reasoning as integrated to clinical thinking in application to clinical situation works as a cognitive process to utilized thinking strategies to gather and critically analyze the data concerning the health care needs of the patient, organized the information according to its prioritization, and formulate efficient nursing care plans to improve patient’s outcomes (Berman, et al., 2016).

“Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action”, a precise definition presented by Michael Scriven and Richard Paul at the Eighth Annual International Conference on Critical Thinking and Education Reform during the summer of 1987 (Lakhanigam, 2017).

Lakhanigam added the definition published by the Journal of Nursing Education in 2010 that describes critical thinking as the process involving interpretation and analysis of the problem, reasoning to find a solution, applying, and finally evaluation of the outcomes”. Regis College (2020), emphasized the use of deductive reasoning in observation, analyzing information, formulate conclusions, and performing appropriate actions in a self-directed process.

Theories on the Physiology of Thinking

From the ancient theory of “tabula rasa”, as describes in Wikipedia (2020) that humans are born without built-in mental content, and all knowledge is collected by the brain from experiences and perceptions. In this computer age, a neurologist discovered neurological pathways on how to re-program or reformat our brains like computers by analyzing how the brain appears to process, recognize, remember and transfer information at the level of neural circuits, synapses and neurotransmitters. Willis (2012) discussed the brain’s neuroplastic response to stimulation called neuroplasticity. The information is processed in the reflective and cognitive functions of prefrontal cortex wherein learning incorporated into networks of longterm conceptual memory.

Neuroplasticity is greatly affected by stress, boredom and frustration as seen in the neuroimaging scans of students showed that active metabolic states block the processing in the prefrontal cortex. In response to stress, the amygdala as the switching station became hyperactive resulting to switches of input and output away from the prefrontal cortex down to the control of the lower reactive brain, this response is called fight/flight/freeze (act out/zone out). In this situation, the lower brain’s reactive behaviours are in control. This will result in the loss of information access to the prefrontal cortex and new learning is not retained.

Elseways, Knowles (1984) four principles of andragogy of adult learning included (a.) experiences from mistakes that provide the basis for the learning activities; and (b.) the importance of problems and crisis, as adult learning is problem-centred rather than content-oriented; as well as (c.) involvement in the planning and evaluation of learning; and lastly, (d.) that adults are most interested in a subject that is relevant to their job and personal life.

Learning and thinking as applied in a higher-level context, Ausubel’s assimilation theory may recount the theories on critical thinking. In this theory, Ausubel claimed that learning occurs as a result of the interaction between the acquired learning and the cognitive structure in application to practice (Seel, 2012). Moreover, critical analysis and differentiation of interrelationships between concepts called concept mapping refines the knowledge into a more organized, precise, specific, and integrated learning.

In different circumstances, nursing as a professional working in a toxic environment of the sick, pained, hopeless, weak, and dying patients; bullying, queen bee syndrome, and seniority egoism of colleagues; and backbreaking workloads—have reported cases of work-related boredom and stress. The application of the three theories may improve mentoring-learning strategies in meaningful nursing education and training.

Theories on learning acquisition from the collection of information, physiologic processing on cognitive-reflective functions of the brain, concept mapping, and internal/external utilization of knowledge in application to critical thinking are the frameworks of a skilled critical thinker.

Characteristics of a Skilled Critical-Thinker

Health care system can go a long way, achieving a considerable success having employees that possess the ability to think critically thus decreasing errors in clinical judgments. For this purpose, every nurse is required to obtain the characteristics of an excellent skilled critical thinker.

The study of Scheffer and Rubenfeld revealed the common qualities among internationally diverse expert nurses from nine different countries supporting the idea of critical thinking in nursing that encompasses logic and reasoning (Berman, et. Al., 2016), and that includes:

11 Affective Components of a Skilled Critical-Thinker Nurse:

• Perseverance
• Open-mindedness
• Flexibility
• Inquisitiveness
• Intellectual integrity
• Perspective

7 Cognitive Skills of a Skilled Critical-Thinker Nurse:

• Information seeking
• Discriminating
• Transforming knowledge
• Applying standards
• Logical reasoning

Critical Thinking Beyond Exigency and Expediency

Undeniably, nurses with critical thinking ability diversified with effective problem-solving and efficient decision-making skills are the most in-demand and highly valued in the field of the health care industry and academe.

As a nurse striding in the most complicated, stressful and multi-tasking job, you are responsible for making life-changing decisions under the pressure of time and emotions. These reasons as to why critical thinking skills in nursing practice plays a vital role in the care of the patient. Luna (2020), cited seven importance of critical thinking skills in the practice of nursing, such as:

• Nurses’ Critical Thinking Heavily Impacts Patient Care
• It’s Vital to Recognizing Shifts in Patient Status
• It’s Integral to an Honest and Open Exchange of Ideas
• It Allows You to Ensure Patient Safety
• It Helps Nurses Find Quick Fixes and Troubleshooting
• Critical Thinking can Lead to Innovative Improvements
• It Plays a Role in Rational Decision Making

Critical thinking skill is needed in problems identification and implementation of interventions resulting in improved patients outcomes, as well as development in nursing practice by providing new insights on the learned knowledge. Feedback and reflections provide interconnections between nursing research , critical thinking and the nursing practice (Berman, et. Al., 2016).

Critical Thinking Skills: The Mastery, Update and Upgrade

Critical thinking skill is an ability beyond thinking rationally and clearly. It is a process of thinking independently and working at your own feet in formulating own opinions or new theory by utilizing critical analysis on the interrelationship of two or more ideas and delineating conclusions without external control (Wabisabi Learning, 2020).

Modified Wabisabi Learning’s 12 Solid Strategies for Teaching Critical Thinking Skills, and its Application to Nursing Education, Training and Practice:

1. Practice on Eloquence in Question and Answer (Solution Fluency)

Mastery requires ample amount of practice to become highly skilled in critical thinking. Accustom to deliberate open discussions encouraging brainstorming on issues affecting the practice and daily living by using explicit open-ended questions and comprehensive instructions for problem-solving may provide opportunities to apply knowledge into practice as well as encouraging the transfer of ideas between domains (Haber, 2020). Brainstorming is an excellent learning tool to exercise critical thinking (Walden University, 2020) particularly if applied in a situational crisis or a hospital scenario.

2. Create a Foundation

From the theory of back to basic, mastery of low-level skills is a requirement in preparatory to the application of critical thinking skills (Kaminske, 2019).

Learning experiences from theoretical and experiential knowledge are good foundations to start critical thinking. Moreover, practicing thinking skills obtained from theoretical and experiential undertakings improve intellectual ability (Berman, et. al., 2016). Practical understanding and specialization on a particular focus may excel you more in thinking critically. The competence and skills acquired from clinical experience are the most essential learning in developing clinical judgment.

3. Consult the Classics

Nursing theorists and their work are the best examples of consulting the classics. In critical thinking, nurses identify claims based on facts, conclusions, judgment/opinions and evidence-based practice. Exploring nursing theorists and their works are like exploring great minds, acquiring lessons on character motivation, refuting theories or formulating a new theory from existing theory. Case studies and in-depth objective critiques of nursing theories may not only promote critical thinking but act as a leverage to bridge the gap between theory and practice.

4. Create an Environment for Open Communication

During clinical rounds, nurses and/or students with a clinical instructor are engaged into thinking process by providing the opportunity to communicate assessment data, collaborate ideas, formulate nursing care plan, and discuss the various context of the situation from different perspectives (Di Vito-Thomas, 2005).

5. Use Information Fluency

Information fluency is mastering the proper use of information and to the ability to intuitively analyze and interpret it in unearthing knowledge and appropriate facts useful in solving a problem (Wabisabi Learning, 2020).

Knowledge of medical conditions, procedures and its connections to patient’s care are important in building critical thinking. Learning from available resources like medical journals, surfing the internet, and meaningful dialogue with colleagues can increase your medical know-how (Jillings, 2020).

6. Utilize Peer Groups

Peer groups, particularly well experienced and highly skilled colleagues are an excellent source of information, questions, and problem-solving techniques as it expands thinking and viewpoints. It also develops interpersonal skills like teamwork and resolving conflicts (Berman, et. Al., 2016).

7. Try One Sentence of Reflections at a time

Reflections will teach the learner to apply their knowledge, logic and reasoning by explaining themselves in a low-pressure setting. It provides an opportunity to explore situations with a different approach and better solutions for future use (Jillings, 2020).

The mastery of metacognition helps the learner to use reflection in defining clinical experiences and explore ways on how to improve it. Recollecting facts and events in patient’s care may integrate the learner into different concepts by connecting different ideas from one another (Di Vito-Thomas, 2005).

8. Problem-solving with Reasoning

Understanding rationale, the sets of reasons or logical basis for a course of action assist the learners to gain a broad knowledge of the topic and promotes a higher level of understanding. Problem-solving guided by rationale is a technique to the use of deductive and inductive reasoning in the thinking process (Di Vito-Thomas, 2005).

9. Roleplaying and Return Demonstration

Role-playing is a self-directed activity that encourages analytic and creative thinking. It helps the learner to internalize empathy while compromising in portraying a role or another persona creating a wider chance for memory retention.

Practice and repetition of observed procedures during return demonstration creates an avenue for re-thinking ways on how to do a task properly with ease in your own phase as you implement it by yourself.

10. Thinking and Speaking With Sketch (Concept Mapping)

Incorporating a concept with multiple perspectives and connecting complex ideas in a structured way to search for potential solutions. These processes create an abstract concept that encourages logical arguments used in critical thinking (Kaminske, 2019).

Interactive activities such as case study with a panel discussion, observing clinical dynamics during in-depth arguments, making a multidisciplinary joint care plan for patient promotes an environment for critical thinking thus facilitating the development of clinical judgment (Di Vito-Thomas, 2005).

11. Do Some Prioritizing and Decision-making

Make critical thinking as a culture and not just an activity by encouraging decision-making. Prioritizing through analyzing information, applying knowledge, and evaluating a prospected solution are the cornerstones of decision-making. This will allows the learner to apply learned theories to a different scenario by weighing the advantages and disadvantages of different solutions and option in deciding best practices.

12. Correct Misconceptions and Personal Bias

Personal beliefs greatly influence one’s ability to think critically as people always seek out ideas that conform to their own beliefs (Kaminske (2019). Several factors that act as the pitfalls in critical thinking are misconceptions, personal bias, and assumptions—which can bring a learner into a wrong direction. A discussion with colleagues who have mastery in evidence-based practice and conducting more in-depth investigations can give ideas and extends point of view (Jillings, 2020).

Conclusion and Suggestions:

Analytical skills through keen observation, understanding important data, and identifying a pattern of recognition; problem-solving capacity by connecting relationship of phenomena, data interpretation guided by significance and rationale; and use of reflection and evaluation abilities in formulating conclusion are the important factors in clinical judgment and decision-making.

Critical thinking is a learned skill resulted from a rolled-up innate curiosity in the application of strong theoretical and experiential foundations in solving clinical problems that direct to the best care decision, which produce positive patient outcomes and improve patient care services.

In this era of technological advancement where machine replaces almost of everything, critical thinking still plays an important role in the nursing practice. Nurses who can manipulate complex clinical situations with efficient skills on critical/analytical thinking, problem-solving and decision-making are often in the front line to compete for the position with greater autonomy and higher chances for opportunities.

• Nightingale, F. (1860). Notes on Nursing: What it Is, and what it is Not. London: Harrisons & Sons.
• Haber, J. (2020). It’s Time to Get Serious About Teaching Critical Thinking. Inside Higher Ed. Retrieved on 24 October 2020 from https://www.insidehighered.com/views/2020/03/02/teaching-students-think-critically-opinion
• Walden University. (2020). 7 Ways to Teach Critical Thinking in Elementary Education. Retrieved on 24 October 2020 from https://www.waldenu.edu/online-bachelors-programs/bs-in-elementary-education/resource/seven-ways-to-teach-critical-thinking-in-elementary-education
• Kaminske, A.N. (2019). Can We Teach Critical Thinking?. The Learning Scientists. Retrieved on 24 October 2020 from https://www.learningscientists.org/blog/2019/2/28/can-we-teach-critical-thinking#:~:text=beliefs%20(3).-,Can%20we%20teach%20critical%20thinking%3F,happens%20to%20enjoy%20science%20fiction
• Berman, A., Snyder, S.J. & Frandsen, G. (2016). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, 10 th New Jersey: Pearson Education, Inc.
• Lakhanigam, S. (2017). Critical Thinking: A Vital Trait for Nurses. Minority Nurse. Retrieved on 24 October 2020 from https://minoritynurse.com/critical-thinking-vital-trait-nurses/
• Regis College (2020). How to Leverage Critical Thinking in Nursing Practice. Retrieved on 24 October 2020 from https://online.regiscollege.edu/blog/how-to-leverage-critical-thinking-in-nursing-practice/
• (2020). Tabula Rasa. Retrieved on 24 October 2020 from https://en.wikipedia.org/wiki/Tabula_rasa
• Willis, J. (2012). A Neurologist Makes the Case for Teaching Teachers About the Brain. George Lucas Educational Foundation. Retrieved on 24 October 2020 from https://www.edutopia.org/blog/neuroscience-higher-ed-judy-willis
• Knowles, M. (1984). The Adult Learner: A Neglected Species, 3 rd Houston, TX: Gulf Publishing.
• Seel, N.M. (2012). Assimilation Theory of Learning. In: Seel N.M. (eds) Encyclopedia of the Sciences of Learning. Springer, Boston, MA. https://doi.org/10.1007/978-1-4419-1428-6_358
• Luna, A. (2020). 7 Reasons Critical Thinking In Nursing Is Important. AMN Healthcare Company. Retrieved on 24 October 2002 from https://www.onwardhealthcare.com/nursing-resources/seven-reasons-critical-thinking-in-nursing-is-important/
• Wabisabi Learning. (2020). 12 Solid Strategies for Teaching Critical Thinking Skills. Retrieved on 24 October 2020 from https://wabisabilearning.com/blogs/critical-thinking/teaching-critical-thinking-skills
• Di Vito-Thomas, P. (2005). Nursing Student Stories on Learning How to Think Like a Nurse. Nurse Educator, 30(3), pp. 133-136.
• Jillings, B. (2020). Critical Thinking in Nursing: Why It’s Important and How to Improve. AMN Healthcare Company. Retrieved on 24 October 2020 from https://www.americanmobile.com/mobile/NZArticle/?articleId=3346

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Career Advice > Professional Development > Upskilling and Promotions > 5 Ways to Improve Critical Thinking in Nursing

5 Ways to Improve Critical Thinking in Nursing

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Want to get better at critical thinking? In nursing, this mental skill is essential for analyzing clinical situations, solving problems, and making informed decisions. Being a critical thinker helps you give safe, efficient, and skillful nursing care. But sharpening your critical thinking skills isn’t just a personal quest for improvement; it’s a professional necessity.

Critical thinking is an essential skill for every member of the healthcare team. As a nurse and life-long learner, you have the power to strengthen your skills and build your confidence as a clinician. Whether you’re a new or experienced nurse, you can keep building this skill in any area of nursing .

What Is Critical Thinking in Nursing?

The definition of critical thinking is the practice of applying reason and questioning assumptions to solve problems. But it’s different from problem-solving and clinical reasoning — it’s a separate strategy that focuses on asking questions and critiquing solutions. While you’ll use critical thinking to understand what’s going on with a patient, this technique can also be used to improve your logical reasoning and communication skills outside of work.

Critical thinking is also different from didactic learning, where you take in information at face value. Instead, it is an active process that involves perception, analysis, synthesizing information, and evaluating what you’ve learned.

You probably remember your instructors talking about critical thinking in nursing school , and you built a foundation for this skill through simulations, peer learning, and clinical test questions. But remember that you can keep improving this skill throughout your career, for the rest of your life.

Why Is Critical Thinking Important in Nursing?

Medical problems and their solutions are complex. Without critical thinking, clinicians might miss essential data, and patient’s lives and outcomes may hang in the balance. Using critical thinking in nursing practice helps clinicians see problems from every angle, with an understanding that there might not be a perfect solution.

For example, a nurse who is thinking critically will hold a patient’s routine hypertension medicine if their blood pressure is high and ask the provider for clarification. A nurse who isn’t thinking critically might take the medication order at face value, not considering that a patient’s status may change. No matter what specialty you work in, whether you’re in post-acute or acute care , growing your critical thinking skills will make you a better nurse.

5 Strategies to Boost Your Critical Thinking Skills

Looking for ways to improve your nursing skill set? Here’s how to improve critical thinking in nursing practice.

1. Ask Questions (Even If You’re Experienced)

Asking questions amongst coworkers can feel nerve-racking because you might worry that your questions sound stupid. You might wonder if you should already know the answer. But chances are, someone else has had the same question as you, and everyone on the medical team is learning all the time.

Next time you’re not sure why a patient is receiving a medication or you wonder if a different intervention would be appropriate, speak up. Ask an experienced mentor or coworker, or even the medical team if it’s appropriate. You might learn something new and build your critical thinking skills in the process.

Working in medicine means that you’re always learning, and asking questions helps you take advantage of opportunities to build your clinical thinking. Even seasoned nurses don’t know everything, and new research and innovations mean that medicine is changing constantly. Plus, asking questions can help you understand how different clinicians understand patient problems, yielding new insights and perspectives.

2. Reflect on Each Shift

Another way you can learn more from each shift is to spend some time intentionally thinking about your patients, your clinical decisions, and their outcomes. Debriefing after your shift gives you the space to reflect on what happened, so you can integrate new information to carry on to your next shift. In addition, debriefing after simulation has been shown to improve critical thinking in student nurses.

This doesn’t have to take much time. At the end of your next shift, you might take five minutes to think about these questions, or even write down your answers:

• What went well on this shift?
• What felt difficult on this shift?
• What could I have done differently?
• What was I unsure about on this shift?

If questions come up that you couldn’t get answered during your shift, seek answers online, or write down these questions to ask when you’re back at work. Taking a moment to intentionally debrief helps you gain lessons from every nursing shift, strengthening your critical thinking muscle.

3. Understand Your Biases and Assumptions

Practicing medicine means that you’re often guided by educated assumptions. For example, when you see a first-time pregnant patient come in for birth, you might assume based on your clinical experience that they’ll give birth relatively quickly. Making logical conclusions based on your clinical experiences can help you anticipate patient needs. But when you rely too heavily on assumptions over data, you can miss key information.

Implicit bias is another way that clinicians may miss what’s right in front of them because of assumptions. Nurses might form these biases based on societal trends and personal experiences, and they might be negative or positive. Everyone carries these unconscious biases, but in the clinical setting, they can impede care and put patients at risk.

To understand your biases, you could take an implicit bias test . Knowing where you hold positive and negative biases can help you think critically about them when you care for those types of patients.

4. Learn From Nursing Experts

Another way to boost your critical thinking in nursing is to learn from experts when you’re off the job. There are dozens of free resources for clinicians, where you can learn about real-world clinical scenarios and build your critical thinking skills. Whether you work in obstetrics, med-surg , pediatrics , or operating room nursing , you’ll likely find a podcast, video series, or book that you can learn from.

The next time you’re washing dishes, taking a walk, or driving somewhere, check out a nursing podcast in your specialty. Or, flip through a nursing book in your down time. Over time, you’ll probably find yourself referring back to insights during your nursing shifts.

5. Use the Nursing Process

If you’re needing a framework for how to approach critical thinking, the nursing process is a tried-and-true method. You probably became familiar with this process during nursing school. Here are the steps:

• Assessment: Collect and analyze patient data to recognize issues and patterns, enhancing your observational and analytical skills.
• Diagnosis: Interpret data to identify clinical problems, prioritize needs, and formulate nursing diagnoses , refining critical thinking abilities.
• Planning: Develop tailored care plans based on patient needs and evidence-based practices, requiring analytical and decision-making skills.
• Implementation: Execute care plans, adapting interventions based on assessments and patient responses, promoting problem-solving skills.
• Evaluation: Assess intervention effectiveness, analyze outcomes, and modify plans as needed, honing reflective and analytical thinking.

Thinking Critically About Your Next Career Change?

Ready to improve your critical thinking? In nursing, every shift is a chance to learn. If you’re looking for a new opportunity, sign up for IntelyCare’s job notifications to receive tailored nursing opportunities.

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Critical Thinking

Critical Thinking in Nursing

Maggie Convey and Sarah Malo

All nursing regulatory bodies and associations cite the importance of active, critical thinking in all clinical contexts. Nursing is not a profession of complacency. In your undergraduate experience, you will have direction and opportunities to practice you critical thinking, clinical reasoning, and clinical judgement skills in all nursing courses. There is a clear connection between knowledge and knowing, critical thinking and the application of such knowledge into the role of the nurse, as seen below (Raymond-Seniuk & Profetto McGrath, 2017).

Nursing care and practice comes from thinking about and identifying knowledge from a nursing encounter, considering the nursing role, and considering the broader context to promote action.

Critical Thinking Indicators

From Rosalinda Alfaro-Lefevre (2019), personal critical thinking indicators offer an opportunity to reflect on your current thinking patterns.

Engaging and questioning your current practice is a form of  self-reflection. Honest and ongoing evaluation of your own progress is a necessity in nursing. Self-reflection can be fostered by asking yourself the following questions: What am I doing well? How am I doing well? What might I benefit from improving or changing? How might I go about doing so?

Reflecting on your own values, assumptions, biases, and thinking are effective ways to improve the quality of your thinking.

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Foundations for Success in Nursing: Manual Copyright © 2021 by Maggie Convey and Sarah Malo. All Rights Reserved.

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Curriculum framework to facilitate critical thinking skills of undergraduate nursing students: A cooperative inquiry approach

Christian makafui boso.

1 Department of Nursing and Midwifery, Faculty of Medicine & Health Sciences, Stellenbosch University, Cape Town South Africa

2 School of Nursing and Midwifery, College of Health and Allied Sciences, University of Cape Coast, Cape Coast Ghana

Anita S. van der Merwe

Janet gross.

3 Peace Corps Liberia, Mother Patern College of Health Sciences, Stella Maris Polytechnic, Monrovia Liberia

Associated Data

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Critical thinking (CT) is vital in assisting nurses to function efficiently in the ever‐changing health care environment. A CT‐based curriculum framework provides the impetus necessary to drive the acquisition of CT skills of students. Yet, there is no known CT‐based framework contextualized to developing countries where seniority tradition is a norm. Therefore, the aim of this study was to develop a CT‐based curriculum framework to facilitate the development of CT skills of nursing students in developing countries.

Cooperative inquiry.

Using purposive sampling, 11 participants comprising students, educators and preceptors developed a CT‐based curriculum framework.

Findings were organized into a framework illustrating interconnected concepts required to foster CT skills of nursing students. These concepts include authentic student–facilitator partnership, a facilitator that makes a difference; a learner that is free to question and encouraged to reflect; a conducive and participatory learning environment; curriculum renewal processes and contextual realities.

1. INTRODUCTION

Nurses in today's volatile and complex health care environment need to be able to critically appraise information when giving care (Dozier et al.,  2021 ; Whiteman et al.,  2021 ). Nursing regulatory bodies worldwide such as the Nursing and Midwifery Council of Ghana ( 2015 ) and the South African Nursing Council ( 2014 ) recognize critical thinking (CT) as crucial for nurses. These bodies require that nursing curricula promote CT skills of students (Dozier et al.,  2021 ; Gholami et al.,  2016 ). The rationale is that individuals with CT skills are potentially able to make good clinical judgements (Dozier et al.,  2021 ; Gholami et al.,  2016 ) which may lead to good patient outcomes (Ward‐Smith,  2020 ).

Critical thinking‐based curricula adopt learning outcomes, instructional methods and assessment approaches that are grounded on the principles of CT. Such CT‐based curricula create a participatory and democratic learning environment for students. Students will be empowered if they are allowed to take risks, encouraged to make inputs, permitted to share their opinions and if their mistakes are rectified with dignity (Raymond et al.,  2017 ). Thus, as consistent with Billings & Halstead ( 2005 ) view, a curriculum should aim at enhancing active learning and the student–faculty interaction (as cited in Billings & Halstead,  2005 ). Learning environments where divergent views are suppressed (Raymond et al.,  2017 ), and the educator is seen as the authority of information (Boso & Gross,  2015 ) do not promote CT in students.

A considerable number of reforms in higher education have stressed the need to facilitate CT skills of students (Butler,  2012 ). CT courses have been introduced in different academic disciplines such as nursing, law, sociology, psychology and philosophy. Despite the attention CT has received, there remains doubt whether graduates are being prepared to think critically (Butler,  2012 ). At the heart of this challenge is the fact that the concept of CT has not been incorporated into the teaching methods of many educators (Billings & Halstead,  2005 ). For example, educators construct questions that are mostly at the lower level of thinking (Amoako‐Sakyi & Amonoo‐Kuofi,  2015 ). This suggests that educational institutions may be failing in their quest to develop CT skills of students (Dunne,  2015 ).

In many developing countries, nursing schools encounter challenges that may further compound the challenge of assisting students to engage in CT skills. For example, in Ghana, challenges such as limited resources in nursing schools (Talley,  2006 ) have been reported. Specifically, a lack of qualified educators (Bell et al.,  2013 ), infrastructural and logistical constraints (Talley,  2006 ), inappropriate instructional methods and large class sizes (Wilmot et al.,  2013 ) are some of the challenges affecting nursing education. Also, as indicated in the authors' previous articles (Boso et al.,  2020 , 2021c ), sociocultural norms uphold the seniority tradition. Traditionally, seniority is valued in most global societies. The aged are viewed as the source of knowledge, power and authority, thus seniority is a dominant cultural norm (Chen & Chung,  2002 ). For example, an individual is not expected to disagree or question an authority figure in public even if the authority figure appears to be wrong (Donkor & Andrews,  2011 ). The seniority tradition has been noted as a challenge to facilitating the CT skills of students (Chan,  2013 ; Raymond et al.,  2017 ). Meanwhile, the complexity of fostering CT skills of students has often been underestimated leading to diverse conceptualizations of CT (Dwyer et al.,  2014 ). Diverse conceptualizations could impede the development of CT skills of students.

Notwithstanding these challenges, a CT‐based curriculum framework could provide the needed impetus to foster the development of CT skills of students. A curriculum framework could provide ‘a means of conceptualizing and organizing the knowledge, skills, values, and beliefs critical to the delivery of a coherent curriculum that facilitates the achievement of the desired curriculum outcomes’ (Billings & Halstead,  2005 , p. 167). More importantly, a CT‐based framework provides a participatory and effective learning environment for both the learner and the educator (Dozier et al.,  2021 ; Duron et al.,  2006 ) even in societies where the seniority tradition is strongly adhered to. Yet, these authors could not identify a known curriculum framework to drive the facilitation of CT skills in the context of developing countries where the seniority tradition is a norm.

2. AIM OF THE STUDY

The aim of this study was to develop a CT‐based curriculum framework to facilitate the development of CT skills of nursing students in developing countries.

3. BACKGROUND

This study was underpinned by an eclectic model derived from Dwyer et al.'s ( 2014 ) and Duron et al.'s ( 2006 ) frameworks of CT development (see Figure  1 ). This eclectic model addressed four interconnected concepts relating to the exploration of experiences of students and educators towards CT skills facilitation namely CT, memory, comprehension (Dwyer et al.,  2014 ) and instructional activities (Duron et al.,  2006 ). These concepts are further explicated.

Eclectic model of critical thinking development adopted from Duron et al.'s ( 2006 ) and Dwyer et al.'s ( 2014 ) models of CT. Permission to adapt was obtained.

3.1. Critical thinking

There is no agreement about the definition of CT (Raymond et al.,  2018 ) and its relationship with memory and comprehension (Dwyer et al.,  2014 ). According to Davies and Barnett ( 2015 ), there are three main approaches to CT, namely, ‘skills‐and‐judgement’, ‘skills‐plus‐propensity’ and ‘skills‐plus‐disposition‐actions’ perspectives. The skills‐and‐judgement perspective of CT views CT as the possession of a set of characteristic skills. The skills‐plus‐propensity perspective highlights both skills and dispositions aspects of CT. While the ‘skills‐plus‐disposition‐actions’ view, also known as criticality, sees CT beyond skills and disposition to include actions/activism. The skills‐plus‐propensity view on which this study is based recognizes that activism is an outcome of CT and not necessarily an aspect of CT. Thus, Facione's ( 1990 ) definition accepted for the purposes of this study illustrates skills‐plus‐propensity perspective of CT: ‘…purposeful, self‐regulatory judgment which results in interpretation, analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment is based…’ (Facione,  1990 , p. 5).

Though Facione's definition has been criticized for being long‐winded and difficult to implement (Davies & Barnett,  2015 ), its use for CT assessment in nursing education is evident (Raymond et al.,  2017 ). Dwyer et al.'s ( 2014 ) model incorporate both reflective judgement (skills) and self‐regulatory functions of metacognition (disposition) as requirements for CT consistent with Facione's ( 1990 ) definition. Self‐regulation refers to the individual's ability, willingness and perceived need to think critically when solving problems.

3.2. Memory

Critical thinking skills are dependent on what information one can remember (Dwyer et al.,  2014 ). Information is either stored in short‐ or long‐term memory. Dwyer et al. ( 2014 ) assert that through deliberate attention or perception processes, information is stored as short‐term memory (working memory). This short‐term memory includes two sub‐systems—phonological loop and visuospatial sketchpad; a central executive (attention focussing process that relates to long‐term memory) and episodic buffer (storage centre that integrates new information from working memory with existing memory from long‐term memory) (Baddeley,  2010 ). Through manipulation, information in short‐term memory may be encoded as long‐term memory. Long‐term memory is stored as schemas (categorization of knowledge based on how it will be used).

3.3. Comprehension

Meaningfully organizing information into schemas for future retrieval requires understanding or comprehension (Dwyer et al.,  2014 ). Comprehension encompasses the ability to translate or interpret information based on previous learning (Huitt,  2011 ). Long‐term memory and comprehension are fundamental processes for CT application (Dwyer et al.,  2014 ).

3.4. Instructional activities

Duron et al. ( 2006 ) designed a 5‐step model to provide a practical impetus in the acquisition of CT skills. This model focuses on steps that educators should take to foster the CT skills of students. The 5‐step framework requires that educators first determine learning objectives. The educator should identify the behaviours that the students should exhibit by the time they exit a course. The objectives should correspond to the higher order of Bloom's taxonomy. Secondly, the importance of teaching through questioning is underlined. The educator should design appropriate questions and questioning techniques to encourage discussion. The questions should vary and be concise to generate student participation. Particularly, divergent questions encourage CT. Thirdly, practice before assessing is considered important – inclusive of learning experiences that encourage active and experiential learning. Fourthly, the educator should continuously review, refine and improve instructional activities for CT skills. These include strategies such as evaluating students' participation through teaching, diary and journaling. Lastly, educators need to provide feedback and assessment of learning. Thoughtful, purposeful and timely feedback should be provided to students on their performance.

It is the contention of these authors that a CT‐based curriculum framework should address factors that either impede or enhance the students' abilities to memorize information (attention/perception processing), comprehend, reflectively make judgement (ability to analyse, evaluate and create) and engage in self‐regulation functions (disposition towards CT). Pursuant to this view, these authors observed classroom instructional practices (Boso et al.,  2020 ), explored the experiences of students and educators (Boso et al.,  2021c ) and assessed the CT disposition of students (Boso et al.,  2021b ). These studies revealed a number of issues that informed the development of a CT‐based curriculum framework. For example, challenges such as seniority tradition, large class size; negative attitude, lack of commitment and inappropriate assessment styles/methods of educators; background and culture, learning practices, lack of comprehension of the participant, distractive behaviour of students (Boso et al.,  2020 , 2021c ) were identified. Though students had a confident disposition towards reasoning, they did not have a mindset of truth‐seeking (Boso et al.,  2021b ). Lack of involvement of students in curriculum reviews and continuous professional development programs on CT for faculty were also identified as challenges in developing CT skills of students (Boso et al.,  2021c ). Also, educators' examination questions about a higher order of thinking constituted <6% (Boso et al.,  2021a ).

4.1. Research design

This article is the concluding part of a larger project (see Boso et al.,  2020 , 2021a , 2021b , 2021c ) that sought to develop a CT‐based curriculum framework. The study used participatory action research (PAR), specifically, cooperative inquiry (CI) as an overarching research design to develop a CT‐based curriculum framework. CI is one of the approaches embedded in PAR (Mash,  2014 ; Mash & Meulenberg‐Buskens,  2001 ) and is used interchangeable with PAR in this article. PAR inter alia assists in problem solving (Hart & Bond, 1995 ; Mash,  2014 ), promotes organizational improvement (Hart & Bond, 1995), bridges the theory–practice gap (Mash,  2014 ; Rolfe, 1996 ) and allows users to be involved (Beresford, 2006 ).

4.2. Study setting, population and sampling

The study was conducted in the nursing school of an accredited publicly funded university in Ghana. There were approximately 527 nursing students and 16 full‐time faculty members. Like many educational institutions in developing countries, the school had challenges such as a lack of sufficient qualified faculty, and infrastructural and logistical constraints that may militate against assisting students to acquire CT skills. For example, class sizes could range from 50 to 150 students.

The study participants included students who had been enrolled in the degree nursing program for at least a year, nurse educators with current full‐time appointments with at least a year of teaching experience, preceptors and coordinators of CT‐based medical programs. It is believed that these participants had been associated with the nursing educational system long enough to provide rich data on their experiences and expertise. Furthermore, using diverse stakeholders in the study aided in providing balanced perspectives.

Twelve participants comprised 3 educators (with 1 being a coordinator of a CT‐based medical program), 2 preceptors, 6 students and the researcher himself were part of the cooperative inquiry group (CIG). Pertinent to the tenets of cooperative inquiry, these CIG were to collaboratively engage to develop a CT‐based curriculum framework. To select students for the CIG, presentations on the purpose and nature of the study were made in their respective classrooms. A list of those who agreed to participate in the study was compiled based on the different educational levels. Individuals were randomly selected and contacted through email or telephone. Similarly, a list of preceptors was obtained. In the Ghanaian context, preceptors are clinical nurses who instruct students during clinical placement. They were contacted and those who were willing to participate were ranked based on their educational level and experience. Two preceptors with Master's degrees in nursing were selected to participate in the study as their clinical experience and educational background provided the necessary expertise towards developing the CT‐based curriculum framework. Two educators were randomly selected while the coordinator of the CT‐based medical program (also an educator) was purposively invited through email and/or telephone. The CIG was engaged throughout the entire research process to identify ideas, observe, and reflect on results to develop a framework to foster CT skills of students. Seven steps of the research process evolved till the aim of the study was met. Different data sets—qualitative and quantitative—were gathered and analysed, culminating in the development of the framework.

4.3. Summary of research process

In this study, O'Leary's cycle of action research as described by Koshy et al. ( 2011 ) was adopted. The process alternates from observation, reflection and planning to action. Seven steps from observation to action were followed during the entire research project (see Figure  2 ). The cooperative inquiry group members were engaged throughout the seven steps of the research process. In total, three workshop meetings were held.

Summary of research process.

4.3.1. Step 1

Data were collected on the instructional practices/activities of the selected school from September 2017 to March 2018. These data sets were to aid the CIG in understanding current practices and to provide the baseline data for the development of the framework. Factors that either inhibited or enhanced perception/attention processing and comprehension of information and reflective judgement (analysing, evaluating and creating) according to Dwyer et al.'s ( 2014 ) were identified. Prior to data collection, the participants were exposed to the research methodology and methods at a training workshop held in September 2017. Nine participants—the first author (initiating researcher), two preceptors, one educator and five students—were able to attend this session. The first author introduced the CIG members to the Nominal Group Technique (NGT). The NGT is considered one of the most frequently used formal consensus building techniques (Harvey & Holmes, 2012 ). The NGT includes five stages, namely: (1) introduction and explanation, (2) silent generation of ideas, (3) sharing ideas—round robin, (4) group discussion/clarifying and (5) voting and ranking. Measures to ensure the rigour of inquiry were discussed and agreed upon. Two educators who were unable to attend the session were met individually and the purpose and methods of the study were discussed with them.

4.3.2. Step 2

The analysed data from step 1 were presented to the CIG members at a second meeting held in March 2018. Nine participants—three educators, two preceptors, three students and the first author—were present at this meeting. The CIG deliberated on the results obtained through group discussions facilitated by the first author. Upon reflection, CIG agreed that the data provided enough basis for a draft framework to be considered. Vital issues about instructional practices had been elicited.

4.3.3. Step 3

Following the reflection on the data, the CIG through the Nominal Group Technique (NGT) facilitated by the first author designed a draft framework. Three questions were formulated for the NGT session, namely, (a) What concept(s) should be included in the framework that will facilitate CT skills of nursing students? (b) How should these elements/components/concepts/variables be related? and (c) What should the structure of the framework be?

At the first stage of introduction and explanation of the NGT, purpose of the study, NGT procedure and the three questions for the NGT procedure were reiterated to provide all members with the same point of reference. At the second stage of the NGT, members were allocated 5 minutes to generate ideas for the framework. Seventy‐six concepts were generated. These concepts were collated at the third stage of the NGT process. The fourth stage saw the concepts discussed, their meanings sought and consolidated. Through consensus, some concepts or synonyms were removed, leaving a total of 45 concepts. For example, the concept learner replaced and/or represented similar concepts such as student and nursing students. Likewise, facilitators replaced educators and/or lecturers. The 45 concepts were further consolidated (categorized) into nine. These included learner (and associated characteristics), educator/facilitator (and associated characteristics), teaching methods/style, learning environment, institutional support, assessment, technology, review system and curriculum. At the final stage, the CIG members voted to rank the concepts in order of importance. Learner, facilitator, teaching methods, learning environment and assessment were the five most ranked concepts. The first author was tasked to develop the draft framework with the concepts and relationships for the CIG members to review individually and for subsequent evaluation by students and educators for its applicability. Accordingly, the draft framework was designed by the first author together with one of the CIG members and subsequently distributed to all CIG members for input.

The draft framework suggested that the teaching‐learning process needed to be a caring professional relationship between the learner and the facilitator. This relationship should be the heart of the curriculum. The draft framework included six concepts/components which included: (a) caring professional relationship; (b) facilitator; (c) learner; (d) learning environment; (e) outcome setting, system review and advocacy and (f) contextual dynamics.

4.3.4. Step 4

The draft framework was made available to six educators and eight students in the selected school to review/comment on its applicability. The following questions accompanied the draft framework: How applicable is this framework in facilitating CT skills of students? What do you believe are the strength(s)/weakness(es) of this framework? What concept(s) do you believe should be removed and/or added to the framework to make it more applicable? Three educators and six students evaluated the draft framework. Given that these groups of participants are part of the nursing school, their views about the applicability of the framework were important to consider when implementing the framework in a real‐life situation.

4.3.5. Step 5

The students' and educators' comments and critiques about the draft framework were carefully analysed thematically by the first author. The draft framework was evaluated as applicable by all participants (3 applicable, 6 very applicable). The reasons for their choices included that the framework was simple, realistic, comprehensive (essential factors included), improved relationships for easier communication, made the facilitator a role model, made the learner an active participant and the learner's view was encouraged. Considering the strengths of the framework, the evaluators thought the framework was well structured, bridged gaps in the learner–facilitator relationship, comprehensively covered most factors of education, and covered current trends, and legal/regulatory issues.

The following were seen as the weaknesses of the draft framework by the evaluators: (a) difficulty to elicit commitment from all; (b) challenges associated with the hard environment; (c) possibility of being misused by students; (d) possible failure of the authentic student–facilitator partnership; (e) perceived difficulty to explain complex concepts/processes such as outcome setting, advocacy, system review and (f) possible lack of CT skills of learners and facilitators. They also thought concepts like culture, time, students' involvement, external motivation and career counselling should be included in the framework.

4.3.6. Step 6

The results of the evaluation of the draft framework were presented to the CIG at a workshop facilitated by the first author in May 2018. The comments and critiques of the framework were reflected on by the CIG for possible revision. Eight participants—two preceptors, five students and the first author were present at this 5‐h workshop. The CIG members considered the weaknesses identified during the evaluation as rather systemic challenges in the selected school and not of the framework. In their view, a framework should represent the ideal. Also, the CIG members thought culture, time and students' involvement were already captured.

4.3.7. Step 7

A revised framework was designed to reflect the views of the evaluators of the draft framework. Some concepts/processes were fine‐tuned, and others were further explicated by the members (see Results section for more details). For example, the caring professional relationship was altered to authentic student–facilitator partnership. Likewise, more extended phrases were used to provide further explication to the facilitator, learner and learning environment. Through NGT, ownership was suggested and added to the definition of authentic student–facilitator partnership. The CIG held the assertion that ownership will enhance responsible learner and educator behaviour. The final framework is presented in the Results section.

The results from the cooperative inquiry were organized into a framework illustrating interconnected concepts required to foster CT skills of nursing students in developing countries. The framework proposes six key interconnected thematic priorities (see Figure  3 ) to drive the development of CT of students. The concepts/themes included in the final framework were (a) authentic student–facilitator partnership, (b) a facilitator that makes a difference, (c) a learner that is free to question and encouraged to reflect, (d) a conducive and participatory learning environment, (e) curriculum renewal processes and (f) contextual realities. These six concepts are important components that should drive a curriculum based on CT principles. The concepts which emanated from the CIG discussions are described below.

Critical thinking‐based curriculum for undergraduate nursing program.

5.1. Authentic student–facilitator partnership

The authors of this study suggest that the central focus of the teaching–learning process should be authentic partnership between the learner and the facilitator (Raymond et al.,  2018 ). This view is motivated by the evidence of dysfunctional learner–facilitator relationships coupled with heightened students' perceptions of mistrust, lack of support, lack of emotional connectedness and lack of democratic practices informed by cultural realities identified (Boso et al.,  2020 , 2021c ). These authors define authentic student–facilitator partnership as a supportive, empathetic, learner‐directed, mutually respectful, accountable and democratic learning relationship which focuses on assisting a learner to engage in meaningful learning experiences toward the development of CT skills.

It is suggested that the educator takes responsibility for the optimum functioning of this partnership (Billings & Halstead,  2005 ; Mangena & Chabeli,  2005 ; Raymond et al.,  2017 ). However, both the student and the facilitator (Raymond et al.,  2018 ) should feel a sense of ownership of the teaching and learning process. The findings of this study suggest that factors relating to both students and facilitators could either facilitate or inhibit the fostering of CT skills acquisition. Consequently, both the student and the facilitator should be committed to setting up appropriate boundaries to govern this partnership. These boundaries should include adherence to educational justice—creating equal opportunities, fair evaluation, fair criticism and non‐discrimination on the basis of gender, race or religious status (Boozaripour et al.,  2018 ). Adherence to boundaries is likely to enhance the perception of trust and ownership.

5.2. A facilitator that makes a difference

We see the facilitator as the leader, role model, mentor and guardian of the student for a purposeful learning experience towards CT skills acquisition. It was evident in this study that the facilitator's approach to classroom management and general attitude towards students and cultural realities influenced how students engaged in the teaching and learning process (Boso et al.,  2020 , 2021c ). Cultural competence in healthcare is a global standard; thus, the facilitator should be aware of the influence of cultural tendencies (Chan,  2013 ; Donkor & Andrews,  2011 ) on the student–facilitator partnership. The facilitator should become a role model in terms of how he/she collaborates and communicates (Raymond et al.,  2018 ) as well as his/her punctuality to class. These general effective teaching tenets are required to set the tone for the reflective engagement of students towards the acquisition of CT skills. For example, a lack of punctuality will limit the amount of instructional time required for students to think critically. Also, the facilitator should demonstrate CT tenets in his/her teaching.

Furthermore, the facilitator needs to demonstrate scholarly attributes and experience in teaching, clinical skills, and theoretical nursing knowledge; be student‐centred, empathetic, supportive; and enthusiastic about the nursing profession and teaching (Billings & Halstead,  2005 ; Mangena & Chabeli,  2005 ; Raymond et al.,  2018 ). The facilitator needs to connect with the learner on an emotional level (Raymond et al.,  2018 ). It is proposed that the facilitator should use tools such as CT‐oriented learning outcomes/objectives, appropriate assessment for CT and active learning teaching approaches/methods. In addition, teaching and assessment methods should vary and should be driven by appropriate questioning techniques (Duron et al.,  2006 ; Raymond et al.,  2018 ). These questioning techniques should predominantly target higher‐order of thinking to help students to engage in appropriate thinking moments (Duron et al.,  2006 ).

5.3. A learner that is free to question and encouraged to reflect

The learner is the inquirer/discoverer of knowledge guided by the facilitator in an educational program. It was noted in this study that students were influenced by the Ghanaian cultural realities (Boso et al.,  2020 , 2021c ) that did not allow them to question authority (Donkor & Andrews,  2011 ) and the type of assessment/teaching methods to which they are exposed. These authors posit that to assist in fostering CT skills of learners, the students should not see themselves as a receptacle in which content/information is dumped, but rather as rational individuals who can decide for themselves regarding truth. Therefore, students should adopt CT‐oriented learning practices that ensure a reflective view of content/information for self‐determination and lifelong learning. This encourages facilitators to share their CT with students (Raymond et al.,  2018 ). In addition, they should be encouraged to be self‐motivated and self‐directed.

Strategies needed to promote CT skills in students should include the use of CT‐oriented learning outcomes/objectives, appropriate assessment for CT and active learning teaching methods. Additionally, teaching and assessment methods should vary and should be driven by appropriate questioning techniques (Duron et al.,  2006 ; Raymond et al.,  2018 ) which should target higher order of thinking to help students to engage in appropriate thinking moments (Duron et al.,  2006 ).

5.4. Conducive and participatory learning environment

The authentic student–facilitator partnership between the learner and the facilitator occurs in a conducive learning environment that promotes CT (Mangena & Chabeli,  2005 ; Raymond et al.,  2018 ). This environment has two components: hard and soft. The hard environment involves a library, learning space and technology. Appropriate use of technology should be employed in the teaching–learning process. This study showed that students were engaged in distractive use of social media and technology in the classroom (Boso et al.,  2020 ). Guidelines for the use of technology/social media should be available to help learners and facilitators derive maximum benefits from these tools. Also, institutional support is required for the provision of appropriate technology, learning space, appropriate class size and library resources for a meaningful learning experience (Raymond et al.,  2017 , 2018 ).

The soft environment involves the intangible safe, empathetic and democratic atmosphere created to encourage the learner to share his/her views freely. This conducive atmosphere should permeate the entire school environment. This helps to establish emotional connectedness between the students and other role players in the educational environment (Raymond & Profetto‐McGrath, 2005 ; Raymond et al.,  2017 , 2018 ). It was noted in this study that students did not feel adequately supported, and were not regularly engaged in curriculum reviews and other matters that directly affect their learning (Boso et al.,  2021c ). Consequently, we propose the establishment of a system of support (including financial aid) for students and practical avenues for students' engagements based on a consultative process involving students and other role players. Additionally, school managers should provide support to facilitators through staff development programs on CT. Assisting faculty development in the area of CT instructional methods will help educators to infuse CT tenets in their own courses (Mangena & Chabeli,  2005 ; Raymond et al.,  2017 , 2018 ). Measures such as assigning facilitators with teaching assistants should be adopted to give facilitators more time to engage in CT instructional practices (Shell,  2001 ). Facilitators in this study expressed the concern of inadequate time to engage students, partially due to the absence of teaching assistants.

5.5. Curriculum renewal processes

We propose that renewal processes should be adopted for a CT‐oriented curriculum as a whole and of parts as deemed necessary and considering local, national and international trends. The aim of these processes should be to encourage continuous feedback and review that will lead to curriculum improvement (Duron et al.,  2006 ). Students and other role players should be engaged in the curriculum renewal processes. In reviewing the curriculum, contemporary CT assessment theory and practices should be used. Furthermore, the renewal process should adhere to the standards of curriculum review processes. Also, the relevance of courses should be continuously examined to ensure that they attract students' engagement towards CT skills. Consistent with CT activism tenets (Davies & Barnett,  2015 ), advocacy should be encouraged to effect changes that may be occasioned by observations from the curriculum review. Particularly, educators should be encouraged to engage in advocacy to effect changes that may be necessary to assist students to acquire CT skills.

5.6. Contextual realities

A curriculum does not exist in a vacuum. It should be designed and operated in a specific context (Billings & Halstead,  2005 ). The learning process and the extent to which one can address CT skills are influenced by contextual realities. These contextual realities include the program of study, the global/national trends and policies and legal/regulatory framework. For example, as an undergraduate nursing program, CT is highly recommended as a competency (World Health Organization,  2009 ). It is therefore suggested that CT should be taught as a course and teaching methods that support CT be infused into all courses of the program. Global and national trends and policies need to be considered. For example, international development goals, disease patterns and burdens, employer expectations and needs, international best practices and standards, and availability of health facilities and clinical staff for clinicaleducation should guide the curriculum. Additionally, legal/regulatory bodies' requirements need to be adhered to. In the Ghanaian under graduate nursing context, the requirements of the Ghana Tertiary Education Commission (formerly of the National Accreditation Board), the Nursing and Midwifery Council of Ghana and the university in which the program is undertaken would be essential to consider.

6. ETHICAL CONSIDERATIONS

Research Ethics Committee approveal was obtained from the Health Research Ethics Committee of Stellenbosch University (Ref. No. FS17/05/106) and the university in which the study was conducted (name withheld to ensure the anonymity of participants). Written permission was sought from the dean of the selected school. All participants including students, nurse educators and preceptors provided informed consent. Given that this was a PAR, the owner of the authorship and the findings were made explicitly clear to the participants as suggested by Mash ( 2014 ). The names and the contributions of participants were kept confidential and the group was supported by the researcher throughout the study.

7. LIMITATION OF THE STUDY

The quality of a PAR is dependent on how the initiating researcher can unmask and diffuse power differentials. The power relational challenges inherent in many studies may be perpetuated (Scotland, 2012). Given that a hierarchical situation and power inequalities could arise because of the involvement of students, the students' representation was increased to form half of the cooperative inquiry group. Also, training of the cooperative inquiry group was carried out to address coercion, collaboration and partnership. The Nominal Group Technique was adopted for decision‐making to ensure that no one's view was disproportionately rated above others. In addition, the absence of one or two members at different times may have influenced the flow and consistency of ideas generated.

8. CONCLUSION

Conducting a study with the purpose of developing a framework of CT development is appropriate for different reasons. Consistent with the context of this study where the seniority tradition exists which may negatively influence the student–faculty relationship, this curriculum framework emphasized the importance of authentic interaction between students and the faculty in facilitating the CT skills of students. The recommended framework derived may suggest a wider implication for nursing schools and universities to provide CT‐based continuous professional development programs for their nurse faculty. Additionally, the study findings may have implications for monitoring and evaluation activities with the view of improving standard setting and teaching–learning experiences of students.

Based on this study, it is envisaged that nurse educators, who play a pivotal role in nursing education, will find reasons to refine their instructional practices. Also, further research focussing on different contexts of CT in Ghana may be useful. Most importantly, this framework may provide direction for how a curriculum can be predicated on CT, thereby removing arbitrariness.

AUTHOR CONTRIBUTIONS

All the authors made substantial contributions to the manuscript. CMB, ASVDM and JG conceived and designed the study. CMB collected data, analysed and drafted the manuscript. ASVDM and JG supervised the study and made critical revisions to the paper.

FUNDING INFORMATION

No external funding.

CONFLICT OF INTEREST STATEMENT

We do not have any conflict of interest to report.

ACKNOWLEDGEMENTS

We wish to acknowledge Victor Angbah for assisting in data collection. We also express our gratitude to the study participants. Furthermore, we express our profound gratitude to the authority and staff of the educational institution used for this study.

Boso, C. M. , van der Merwe, A. S. , & Gross, J. (2023). Curriculum framework to facilitate critical thinking skills of undergraduate nursing students: A cooperative inquiry approach . Nursing Open , 10 , 5129–5138. 10.1002/nop2.1748 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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• Critical Thinking

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

(Write 2-3 paragraphs)

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

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

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

The Paul-Elder framework has three components:

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

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

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

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

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

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

In nursing, critical thinkers need to be:

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

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

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

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

• Decide/identify

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

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

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

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

• New information – patient assessment

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

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

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

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

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

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

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

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

(Write 3-5 paragraphs)

Important skills for critical thinking

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

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

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

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

These decisions have to be based upon sound reasoning:

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

Critical thinking pitfalls

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

Illogical Processes

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

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

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

Closed Minded

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

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

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

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

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

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

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

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

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

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

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

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

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

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Why Critical Thinking Skills in Nursing Matter (And What You Can Do to Develop Them)

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.

Why are critical thinking skills in nursing important?

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.

How are critical thinking skills acquired in nursing school?

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.

How can you develop your critical thinking skills as a nurse?

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.”

How are critical thinking skills applied in nursing?

“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.

Do critical thinking skills matter more for nursing leadership and management positions?

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.

• How will patient care be affected by having fewer staff?
• What kind of strain will be on the nurses?

Their solutions will take into account all their resources and possible roadblocks.

• What work can be delegated to nursing aids?
• Are there any nurses willing to come in on their day off?
• Are nurses from other departments available to provide coverage?

They’ll weigh the pros and cons of each solution and choose those with the greatest potential.

• Will calling in an off-duty nurse contribute to burnout?
• Was this situation a one-off occurrence or something that could require an additional hire in the long term?

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.

Beyond thinking

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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Using the Nursing Process and Critical Thinking to Mitigate Future Pandemics

Norman Wright

RNformation (Nevada) July 2024

This article appears on page 10 of

Norman Wright, MS, BSN, RN

It has been four years since the COVID-19 pandemic began, and now there is enough history and data to start exploring what happened, why it happened, and how nurses can be essential to mitigate the impact of future pandemics. The Sars-Cov-2 virus has existed since 2019, and since then, like it or not, we all have been participating in what can be called “The Greatest Medical Experiment Ever Done.” COVID-19 infections and disease continue, but thankfully, the impact is minimal at this time.

Medical experiments are meticulously conducted by separating populations into groups or cohorts. A cohort can be divided in multiple ways, but most medical experiments only include two variables. Thus, studies on vaccine efficacy divides the sample population into two cohort groups, those who were vaccinated and the unvaccinated. Both the vaccinated group and control group must be randomly selected and representative of the whole population. For example, if the average age of the vaccinated population is under 40, but the average age of the control group is over 60, false results could occur. Additionally, the control group must be represented equally to the experimental group on many variables including sex-at-birth status, and racially balanced to have generalizability back to the population and universal validity. 

For this reason, studying the impact of Sars-Cov-2 on the entire Earth’s population is impossible because there are infinite numbers of variables and potential confounding effects involved. These potential variables include: 

• When the population was initially exposed. 
• When lockdowns were initiated. 
• How long the lockdowns lasted. 
• Was the population vaccinated. 
• What news and information sources was the population exposed to. 
• The quality of available health care. 
• Political dynamics. 
• Depending on which side of the equator you live on, was it summer or winter when the infections and deaths occurred? 

Our World in Data compared the excess mortality in various nations worldwide since the COVID-19 pandemic began. “Excess mortality is a term used in epidemiology and public health that refers to the number of deaths from all causes during a crisis above and beyond what we would have expected to see under ‘normal’ conditions”. ourworldindata.org/excess-mortality-covid

To reduce the variables, we will only review excess deaths data per 100,000 population from three nations: 

• Australia, 127 
• Canada, 181 
• The United States, 404

Question, why does the USA have well over 200 excess deaths per capita? Mortality Risk of COVID-19 – Our World in Data

Another way to define the success or failure of the interventions calculates deaths per million population (DPM). According to Worldometer , as of April 14, 2024 (the last day Worldometer posted COVID-19 statistics), Australia had 937 COVID-19 related DPM, Canada 1,538, and the USA had 3,642 DPM. Again, the question is “Why does the United States have over 2,100 more DPM than Australia and Canada?” 

The impact of the COVID-19 pandemic can be divided into two distinct eras – before, and after the vaccines became widely accessible. Prior to vaccine availability in the spring of 2021, the main approaches to prevent the spreading of infection were masking, quarantines, and lockdowns.

All three sample nations declared a COVID-19 health emergency between March 15 and March 17, 2020, and initiated quarantines/lockdowns within a few days of each other. Later, Australia implemented a Zero-COVID initiative which lasted until the fall of 2021. During the time that Zero-COVID was implemented the number of infections and deaths in Australia were minimal. Just a few months after Australia’s restrictions were relaxed, the Omicron variant, which sent infection rates soaring worldwide, dramatically increased Australia’s infection and death rates. The majority of infections and deaths that occurred in Australia happened after January 2022. (See coronavirus.jhu.edu/region/australia )

A Zero-COVID response initially saves lives but there are also consequences, including social and economic ramifications. Additionally, a population that was never exposed to the pathogen has no natural immunity and when the ZeroCOVID policies ended, infections and deaths in China increased exponentially. China began COVID-19 travel restrictions in Wuhan in January 2020 and the restrictions progressed to a draconian Zero-Covid policy of lockdowns and quarantines which were maintained until December 2022.

China’s travel and quarantine restrictions were finally relaxed in early December 2022 after many large protests were occurring. Immediately after China’s ZeroCOVID strategies abruptly ended, the number of infections skyrocketed. On December 25, 2022, China ceased reporting infections and deaths. China’s National Health Commission to stop publishing daily COVID-19 figures – CNA

According to estimates by researchers Du et al. (2023) “China announced a slight easing of its zero-COVID rules on November 11, 2022, and then a major relaxation on December 7, 2022. We estimate that the ensuing wave of SARS-CoV-2 infections caused 1.41 million deaths in China during December 2022–February 2023, substantially higher than that reported through official channels.” ( Estimate of COVID-19 Deaths, China, December 2022–February 2023 ). 

Reporting dangerous pathogens in a timely, accurate, forthright and honest way is essential to prevent future pandemics. China began to understand the virulence of the virus by late 2019, but delayed notifying the world, and this delay is a factor that contributed to causing to the worldwide pandemic ( Allam, 2022 ). China must be criticized for its lack of transparency, which is ongoing to this day. Also, according to current data, both from Australia and China, strict extended lockdowns may initially save lives but this intervention also has social and economic costs.  

Canada considered, but never initiated a Zero-COVID policy. The quarantine/ lockdown response did not remain in place as long as Australia’s, but Canada’s restrictions were relaxed at a slower pace than in the USA, which rapidly opened up after April 16, 2020, when the Trump Administration released its plan outlining how states should reopen. Within 2 weeks, some states began reopening. CDC Museum COVID-19 Timeline

Although the pandemic was politicized in Australia and Canada, the politicization of the Sars-Cov-2 virus and disinformation surrounding it was most prevalent in the USA. COVID became a part of the 2020 Presidential election campaigns. False cures, including ivermectin and hydroxychloroquine, were touted by various media outlets. Protests against using masks began, and nurses who were once hailed as heroes were attacked by individuals who believed the COVID-19 pandemic was a hoax, which some news sources and social media outlets promoted incessantly.

After the vaccines became widely available in early 2021, many people flocked to get vaccinated and for the next few months demand for the vaccines far exceeded supply. But soon the anti-vax campaign began promoting lies and disinformation about the vaccines saying the vaccines were (a) developed too fast, (b) not tested enough, (c) microchips were injected, (d) the vaccinations made us magnetic, or (e) our DNA was changed. The vaccines purportedly also impacted female fertility and made male gonads grow abnormally. These are only a few of the outright lies that were constantly spread. Reports about the COVID vaccines causing sudden deaths were hyped to the point where an August 2022 poll by the Kaiser Family Foundation (KFF) found over 20% of those polled believe that more people have died from the COVID-19 vaccines than have died from the COVID-19 virus. KFF Health Misinformation Tracking Poll Pilot

Disinformation about the safety and efficacy of the COVID vaccines, especially the mRNA vaccines, has led to serious harm and death in some communities where a large percent of the community remains unvaccinated. These lies about the mRNA vaccines even convinced some Idaho legislators to propose a 2023 law making it a misdemeanor to give an mRNA vaccine. Thus, if passed, giving a Moderna or Pfizer COVID vaccine, or any vaccine that uses updated mRNA technology could land a nurse in jail for up to a year. Fortunately, this bill did not become law. HOUSE BILL NO.154 (2023) – Vaccines, misdemeanor

The Nurses’ Responsibility to Address Disinformation Nursing 101 taught us the nursing process. According to the American Nurses Association the nursing process is “a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well.” 5 Core Areas of the Nursing Process Explained | ANA

We were taught to use the nursing process to promote the health of the individual patient that we are caring for, but now we expand the concept and use it to address the health of our community as a whole. Thus, our patient becomes everyone living in the community we serve.

The USA is a diverse nation, and although there were 3,642 deaths per million in our nation as a whole, when we compare the DPM in the individual states, we find that COVID ravaged some states more than others. Arizona’s 4,726 DPM is the highest of all the states, while Hawaii at 1,531, Utah at 1,784, and Vermont at 1,825 are the lowest. https://www.worldometers.info/coronavirus/country/us/

According to the Lancet, “If Arizona were a country, our crude COVID-19 mortality rate would rank among the worst in the world, similar to Russia, Romania, and Belarus and just behind Peru.” arizona-had-the-highestper-capita-standardized-covid-19-death-rate-in-the-u-s/

Now the question becomes what caused this dramatic disparity? Why is Vermont’s DPM number of 1,825 close to Canada’s 1,538? We could erroneously assume that because Vermont and Canada are both located in the North their similar climates are the reason until we learn that Utah, a state that borders Arizona has 1,784 DPM, so other variables are involved, and this is where critical thinking becomes essential.

Since the beginning of 2020 each state individually decided how to address COVID-19. Unfortunately, we still do not have a nationwide plan developed to mitigate Sars-Cov-3 or any other future pathological pandemic.  

False data skews statistics and is misleading. Therefore, it is essential to collect and use accurate data to mitigate the impact of a pandemic. When the community is constantly bombarded with faulty inaccurate data, when a disease is politicized, when news sources constantly hype dishonest sources and question those that are reliable the health of the community is at risk and proper response to combat the disease becomes impossible. 

It is our responsibility to separate the truth from fake news, misinformation and disinformation, and this involves critical thinking. We have learned to use the nursing process on an individual patient and to appropriately treat your patient you must constantly reassess your patient without having preconceived beliefs, biases, or prejudices. Expand the nursing process to address how a disease impacts the society as a whole.

For the past four years we have all lived with COVID-19. The media and on-line sources of information that we listen to has a direct correlation to our perception of reality. Perhaps you once believed all of the disinformation about the pandemic. Indeed, some reading this article may still believe the anti-vax rhetoric, and if so, please reassess and update the validity of the information you received. Recall what your understanding and beliefs were in 2021 regarding ivermectin, vaccines, and COVID-19 in general. Are they the same today? 

According to the nursing process, “Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well.” 

Even though we all live in Nevada, we all perceive reality differently because we have diverse backgrounds. Our reality depends on our past and present life experiences, the friends we associate with, the information we consume and how we perceive that information through the lens we view our environment. 

Although it is proven that the COVID-19 vaccines are effective in preventing hospitalizations and death the anti-vax machine continually uses faulty, slanted and distorted data to “prove” the vaccines don’t work. A recent example of this is a November 2023 lawsuit that Texas Attorney Ken Paxton filed against Pfizer that purports that the vaccines were not as effective as claimed. 

aimed. In a December 4, 2023, rebuttal article titled “Texas sues Pfizer with COVID an anti-vax argument” Beth Mole writes that the lawsuit conflates relative vs. absolute risk to evaluate the efficacy of the vaccine. Do your own research into the merits of the lawsuit and ask yourself, is this lawsuit just another attempt to cause confusion for political gain? Texas-sues-pfizerwith-covid-anti-vax-argument

Researchers Wallace et al. (2023) researched the question, “Was political party affiliation a risk factor associated with excess mortality during the COVID-19 pandemic in Florida and Ohio?” The cohort study evaluated 538,159 deaths in individuals aged 25 years and older in Florida and Ohio between March 2020 and December 2021. The finding was that “excess mortality was significantly higher for Republican voters than Democratic voters after COVID-19 vaccines were available to all adults, but not before. These differences were concentrated in counties with lower vaccination rates, and primarily noted in voters residing in Ohio.” Their conclusion was, “differences in excess mortality by political party affiliation after COVID-19 vaccines were available to all adults suggest that differences in vaccination attitudes and reported uptake between Republican and Democratic voters may have been a factor in the severity and trajectory of the pandemic in the US.” https://doi.org/10.1001/jamainternmed.2023.1154

No matter what your political bias may be, tuning into different channels and exposing yourself to ideas that you may not agree with can be difficult, but it is essential to identify what disinformation is. Use your critical thinking skills to sort out the information and data in an open, nonprejudicial way.

It is June 1, 2024, and we are in the middle of an election cycle like none I have ever witnessed. Fake news, lies, disinformation and spin constantly flood our broadcast, print and social media. As we approach November this year, use the nursing process and your critical thinking skills to cast your vote in a responsible way. Whether you consider yourself Republican, Democrat, Libertarian, Independent or other, do the research, seek out the truth and use accurate information to make your decision. 

References Allam Z. (2020). The First 50 days of COVID-19: A Detailed Chronological Timeline and Extensive Review of Literature Documenting the Pandemic. Surveying the Covid-19 Pandemic and its Implications, 1–7. https://doi.org/10.1016/B978-0-12-824313-8.00001-2

American Nurses Association. “The Nursing Process.” Nursingworld.org, 2019, www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursingprocess/

“Australia – COVID-19 Overview – Johns Hopkins.” Johns Hopkins Coronavirus Resource Center, coronavirus.jhu.edu/region/australia

CDC. “COVID-19 Timeline.” Centers for Disease Control and Prevention, CDC, 15 Mar. 2023, www.cdc.gov/museum/timeline/covid19.html

“China’s Top Health Body Stops Publishing Daily Covid Case Figures as Infections Soar.” CNN, 25 Dec. 2022, www.cnn.com/2022/12/25/asia/china-covid-casespublishing-nhc-intl/index.html . Accessed 17 Jan. 2023.

Du, Z., Wang, Y., Bai, Y., Wang, L., Cowling, B., & Meyers, L. (2023). Estimate of COVID-19 Deaths, China, December 2022–February 2023. Emerging Infectious Diseases, 29(10), 2121-2124. https://doi.org/10.3201/eid2910.230585 .

“Excess Mortality during the Coronavirus Pandemic (COVID-19).” Our World in Data, ourworldindata.org/excess-mortality-covid .

Harper, K. B. (2023). Texas Attorney General Sues Pfizer, Claiming Vaccines Didn’t End Pandemic Quickly Enough. The Texas Tribune, 30 Nov. 2023, https://www.texastribune.org/2023/11/30/texas-attorneygeneral-pfizer-lawsuit/ .

LEGISLATURE of the STATE of IDAHO Sixty-Seventh Legislature First Regular Session -2023 in the HOUSE of REPRESENTATIVES HOUSE BILL NO. 154 by HEALTH and WELFARE COMMITTEE an ACT

Lopes, Lunna, et al. “KFF Health Misinformation Tracking Poll Pilot.” KFF, 22 Aug. 2023, www.kff.org/coronavirus-covid-19/poll-finding/kff-healthmisinformation-tracking-poll-pilot .

Our World in Data. “Mortality Risk of COVID-19 – Statistics and Research.” Our World in Data, 2020, ourworldindata.org/mortality-risk-covid .

The Lancet: Arizona Had the Highest Per-Capita Standardized COVID-19 Death Rate in the U.S between January 2020 & July 2022 – AZ Public Health Association. 28 Mar. 2023, https://azpha.org/2023/03/28/the-lancet-arizona-had-the-highestper-capita-standardized-covid-19-death-rate-in-the-us-between-january-2020-july-2022/ .

Wallace, J., Goldsmith-Pinkham, P., & Schwartz J.L. (2023). Excess death rates for republican and democratic registered voters in Florida and Ohio during the COVID-19 pandemic.” JAMA Internal Medicine, 183, 9; 916–923, https://doi.org/10.1001/jamainternmed.2023.1154 .

Worldometer. “Coronavirus Toll Update: Cases & Deaths by Country.” Worldometer, 13 Apr. 2024, www.worldometers.info/coronavirus/ .

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Indonesian university boosts Asia’s public health programmes through research training

Growing up in Bangladesh where several infectious diseases transmitted by helminths (worms) take a large health toll, Tilak Chandra Nath has always been fascinated with the challenges of addressing diseases of poverty.

After graduating as a biologist, Ezra Valido’s interest in infectious diseases took him to work in a rural, poor community in the eastern Philippines, where he headed public health programmes on tuberculosis, measles, dengue and chikungunya.

Valido’s community was devastated in 2013 by Typhoon Haiyan, one of the most powerful tropical cyclones ever recorded. From that, he gained experience working in the aftermath of a disaster, including how to prevent waterborne diseases and sanitation-related illnesses.

As a TDR-supported fellow, also at UGM in 2017, Valido’s research project focused on how willing people were to take doses of the dengue vaccine in poor communities in the Philippines’ Quezon City. His initial plan was to focus on how the vaccines were rolled out. But this had to be shelved after community and media outrage based on misinformation about the vaccine led the government to cancel its vaccination plans.

TDR’s postgraduate training programme on implementation research

Both Nath and Valido were part of a special postgraduate training programme focused on implementation research, based at UGM’s Faculty of Medicine, Public Health and Nursing, located in Yogyakarta. 

The programme, involving students from both WHO’s South-East Asia and Western Pacific Regions, is supported by TDR, a global programme for research on diseases of poverty ,   hosted by the World Health Organization (WHO) in Geneva, and co-sponsored by the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), WHO and the World Bank.

UGM is part of TDR’s global postgraduate training scheme network , developed over the past eight years to boost the skills of future research leaders.  

The initiative focuses on building students’ skills in implementation research, a fast-growing field that supports the identification of system bottlenecks to delivering health services and approaches to addressing them. It is particularly useful in low- and middle–income countries where many health interventions do not reach those who need them the most.

One of the two partner institutions in Asia Pacific is UGM, where the initiative is co-ordinated by Professor Yodi Mahendradhata, Dean of Research and Development at the Faculty of Medicine, Public Health and Nursing. 

Involved from the start

Mahendradhata is proud of the fact that UGM was involved from the start - back in 2015 – in  TDR’s fellowship scheme as well as in the parallel development of course content for implementation research. So he feels considerable ownership over how it has evolved.

“It wasn’t just about receiving the tools and the toolkits, but being involved very early on in the development of the implementation research course, and that is what we particularly appreciate from TDR,” said Mahendradhata. “We learned a lot from participating in the development process, and that gives us a sense of ownership.”

His university has also developed and piloted lessons on implementation research as a part of a TDR-supported Massive Open Online Course (MOOC) , enabling researchers in places like Nepal and Myanmar to participate in virtual training, with UGM as the hub.

Critical and relevant

Valido is sanguine about how he had to shift the focus of his research on a new dengue vaccine from examining the standard parameters of mass rollout to focusing on the vaccine’s  acceptability in one city, Quezon, the biggest city in the Philippines.

Sanofi Pasteur’s Dengvaxia vaccine was approved in the Philippines in December 2015 , and the government started to roll it out to primary school children in 2016. However, in late 2017, Sanofi issued a statement reporting that, in rare cases, the vaccine could increase the risk of severe dengue illness in children who had never had the disease if they contracted the virus after being vaccinated. A public outcry followed , and the health department suspended the vaccine programme soon afterwards.

“While we were conducting the research, an update on the vaccine information caused a media frenzy which eventually led to its suspension and eventual cancellation,” he says. “We had to change the research and eventually looked at the change in the acceptability of the vaccine pre- and post-controversy.”

“The programme teaches you to be critical and relevant, and I had to change my research to remain relevant,” Valido says.“At the time, the Philippines was the only country implementing mass dengue vaccination in schools.”

Dengvaxia has since been approved in a number of countries, including the US – but only for people clinically proven to have had dengue in the past.

Valido enjoyed the opportunity to dissect the Filippino government’s plans for the vaccine’s implementation, focusing on “strategic actions, context and health system thinking.” 

New insights into managing parasitic diseases

Meanwhile, Nath’s research into parasitic diseases gave him new insights into how they can be both managed and prevented.

“In developed countries, most parasitic diseases have been either eradicated or controlled, but the scenario is quite different in lower-income countries, where many diseases remain a serious constraint to public health safety,” says Nath.

“Through the TDR training programme,” he says, “I learned to investigate the problems in preventing these diseases in greater detail and pave the way to find an implementable solution for policy-makers to mitigate the burden.”

Preparing for the future

Following his studies at UGM, Nath continued his research training, completing a PhD in Medicine from the Chungbuk National University, in Korea, in the area of One Health.  He is now an Associate Professor in the Department of Parasitology at Sylhet Agricultural University in Bangladesh.

 In a sense he has come full-circle - bringing knowledge amassed through years of study abroad back to his home country to ponder issues that he wondered about since his youth.  

“I am now actively engaged with helminthiasis elimination and biobanking of parasites projects,” says Nath, who is currently also the director of Bangladesh’s Parasite Resource Bank, where he is investigating the interactions between human, animal, and environmental parasites, following the One Health approach. 

Meanwhile, Valido is working on the biomedical aspects of infectious diseases as a post-doctoral researcher at Swiss Paraplegic Research, where he is exploring the interaction of microbiomes and the spinal cord. He started this work while completing his PhD in Health Sciences at the University of Lucerne in Switzerland. 

Few scientists understand the biomedical aspects of infectious diseases and “the complexity of public health designs to improve health programmes, guide health policies and identify key health infrastructure,” Valido observes. The TDR training helped him to build that interdisciplinary skill set.

This is the first article in a series on TDR’s research capacity strengthening programme - building skills of public health researchers, implementers, health practitioners and policy-makers in the fast-developing field of implementation research for improving uptake of effective health interventions.

TDR’s postgraduate training scheme