Nurses often engage in critical thinking without identifying that they are using those skills because, for many, the process is automatic. Yet, as the health care environment becomes more complex and nurses are faced with unique patient care situations on a daily basis, critical thinking skills must be excellent and become a routine process.
Upon completion of this module, the learner will be able to do the following:
Define critical thinking
Describe Reflection, Simulation and Problem-based Learning
Apply reflection, simulation and problem-based learning in critical thinking exercises
Apply critical thinking to educational and to practice situations
You are starting on third shift. You’re assigned to the medical surgical unit tonight and you have one patient that you are concerned about, Mrs., R. The patient does not present as the previous nurse reported. Your report stated that she is resting comfortably and is scheduled for surgery tomorrow. All vitals were reported as normal and her family just left for the night. Mrs. R is scheduled for hip surgery in the morning due to an injury that occured from a fall at home. She is currently on a morphine pump, has a history of being a smoker and was on Coumadin in the recent past for a blood clot. Upon your assessment, you note that Mrs. R is groggy but will open her eyes when you call her name. Her respirations are shallow, and her blood pressure and pulse are within normal ranges. She is on oxygen, and her saturation is 90%. Something just doesn’t seem right to you. You place a continuous oxygen monitor on her finger and decide to monitor her throughout the night.
At 6 AM as you are preparing your reports for the shift change, the nursing technician comes to you and states she cannot rouse Mrs. R. You go to the room and immediately notice her shallow respirations, her blood pressure has dropped, and her pulse is weak. You call respiratory therapy; the attending physician and you continue to monitor her vital signs documenting your report. You and the respiratory therapist decide to call for an evaluation for an ICU transfer.
As a clinical nursing instructor, you have six students on a psychiatric floor. Suddenly, one of the patients becomes agitated and begins to throw items across the room. The nurse comes in to try to calm the patient, but it does not work. The staff ends up calling security. The patient becomes more belligerent and is forcibly taken the patient to the seclusion room where an injection is administered. A few of your students are visibly shaken. Others are asking questions about what was done and what could have been done differently. This is a good learning opportunity. In post-conference you ask each student to write a reflection on what happened and what might have been done differently to help this patient. As a group, you have a discussion on evidence-based practices and intervention on handling such a patient.
These are scenarios that nurses encounter daily. The first case shows how the nurse thinks and proceeds with interventions. The second case shows how the instructor uses the incident to help students learn about dealing with agitated patients. Fortunately, nurses are trained to assess data finding and make decisions on what interventions need to be performed. Several nursing organizations promote this type of learning in nursing school as well as when in practice. It is never too early or late to start thinking about thinking. We call this process critical thinking, and it is a process that is an integral part of nursing.
For the past twenty years, nursing faculty and clinical educators have stressed the importance of critical thinking as a basic part of nursing practice. The American Association of Colleges of Nursing (AANC) as well as the National League for Nursing (NLN), state the significance of learning critical thinking skills to help improve patient outcomes (Naber & Wyatt, 2014). This is despite a lack of a definitive definition for nursing specifically and reported lack of ability of nurses to critically think using non-nursing evaluations (Castledine, 2011; Morrall & Goodman, 2012). However, it has been shown that nurses do not use critical thinking skills in linear pattern that is based solely on cognitive application. Instead, studies show that nurses use a variety of skills that includes cognition, experience, ways of knowing, and theoretical knowledge (Lasater, 2011; Chan, 2013; Scheffer & Rubenfeld 2000; Alfaro-Lefevre, 2009). There is a need then for nurse educators at all service levels to gain an understanding of how critical thinking is used by nurses as well as how to promote critical thinking in practice.
As the health care environment becomes more complex and focused on patient outcomes, critical thinking as a component of competencies is being emphasized in both education and practice. Research indicates that there are several components of critical thinking including affective as well as cognitive (Chan, 2013). These include open-mindedness, flexibility, self-reflection, information getting, and analyzing. Using critical thinking along with evidence-based practice can improve patient outcomes (Paul, 2014). Furthermore, studies show that when nurse managers use critical thinking skills themselves and promote critical thinking skills, it creates a positive work environment where increase job satisfaction and work performance is improved (Zori et al 2010).
Nurses use critical thinking in the daily care of patients sometimes without even knowing that they are using it. However, critical thinking is an integral part of nursing competencies that are first addressed in the education setting and continued into practice. Unfortunately, studies show that there are gaps in critical thinking knowledge for both the transition of new nurses into practice as well as for seasoned nurses (Rush et al, 2013). Fortunately, several tools exist for educators to help both educators and practicing nurses enhance their critical thinking skills.
Despite the lack of a clear definition of what critical thinking is in nursing practice and education, there are several characteristics of critical thinking that seem to pertain specifically to nursing. An overall structure to critical thinking can be seen as gathering and seeking information, questioning and investigating, analyzing, evaluating and inference, problem-solving, and the use of theory (Chan, 2013). Paul and Scriven (1986) is still used today as bases for the definition, which states that critical thinking is generated by observation, reflection, experience, reasoning and communication. Furthermore, Dwyer, Hogan, and Stewart (2014) state that critical thinking is a process of metacognition using purposeful reflection to discover solutions. Morrall and Goodman (2013) reflect on the need for nurses to use transformative thinking or thinking about thinking to engage fully in critical thinking in practice. Ennis (2011) defines critical thinking as reflective and reasonable forms of thinking in order to devise an action or decision. Watson and Glaser (1980) felt that critical thinking is comprised of attitudes as well as knowledge. Although these theorists’ ideas span several decades, it is obvious that the main ideas behind critical thinking in nursing is that knowledge is only one requirement of the process. The ability of nurses to think, reason and draw conclusions is an integral part of the definition. Furthermore, these definitions address the ideas that education of nurses is only one aspect of how these abilities are attained. Experience, communication, reflection, and observation are also needed to critically think as a nurse.
Critical thinking ability has been the outcome of nursing education for decades. There is, however, controversy as to how critical thinking is taught, how it promotes quality care, and how it impacts patient outcomes (Raymond-Seniuk and Profetto-McgGrat, 2011). Several strategies have been researched to help nurses to gain critical thinking skills both in education and in practice. Reflection, simulation, and problem tasks will be addressed here.
Reflection is a method that can be used to analyze a situation and to examine any concerns (Carter et al, 2013). It has been suggested that reflection is both intellectual to gain knowledge and affective where it can explore experiences. Reflection can help to develop new insight and clarification on a situation (Urbas-Llewellyn, 2013). The process can be verbal or written, and it should not be assumed that nurses know how to reflect to gain knowledge (Asselin & Fain, 2013). However, it is a skill that needs to be fostered and practiced to gain insight into critical thinking.
Interaction and writing are two techniques that foster critical thinking (Carter, et al, 2013). Students and practicing nurses can tell the story of an event that has occurred. A facilitator can ask probing questions to help gain insight or a group can discuss the event, the impact, concerns and alternative outcomes. According to Dewey who first popularized reflection, there are five phases in the process: identify situations, stated the problem, discuss the pertinent facts, elaborate on the problem and facts, integrate or test new ideas (Asselin, Schwarts-Barcott & Osterman, 2013). In other words, reflection is an active engagement that causes a cognitive review of a situation and attempts to develop new solutions. Schon (1983) used the terms reflection –in-action and reflection-on-action. Reflection-in-action occurs when reflection takes place during the event and reflection-on-action refers to reflective thinking after the event. Research postulates that each have merit and aid in learning to think.
While administering medications the nurse starts to think about better ways to educate patients on their medications. Can the nurse assess the cognitive level of the patient and teach different aspects of medication administration to the patient during each medication pass. The nurse begins to devise a plan on what to teach first and how to document each teaching. This is an example of what reflection-in-action.
After the death of a patient caused by a bed sore infection, several nurses decide to get together and discuss the wound care. They review the situation, studying facts and allowing each nurse to voice a thought or emotion. Together, the group devised an evidenced-based plan to aid in wound care.
Simulation is not a new concept in educating professionals. Aviators have used simulation as a technique for pilot training. Nuclear power industries have used simulation for disaster training and the military uses simulation for training in various situations. The use of simulation in health care has also become a mainstay to allow practitioners to practice skills in a safe environment. In fact, the Institute of Medicine’s on nurse working environments have recommended simulation as a training tool for nursing. Additionally, the Robert Wood Johnson Initiative In The Future of Nursing report and The Carnegie Foundation for the Advancement of Teaching both state that simulation is an effective strategy for the education of nursing students (Aebersold & Tschannen, 2013).
Simulation allows the learner to practice skills and acquire new knowledge using real-world situations in a non-real environment (Goodstone et al, 2013). Several studies have shown that simulation with high-fidelity patient models can promote critical thinking and decision-making. Although, data is mixed as to the extent of the impact simulation on critical thinking when compared to other learning activities. Simulation in the virtual environment has also been developed to aid in the learning process. Several program exist that can focus on particular diagnoses or skills. All of which have been shown to improve clinical performance and cognitive skills (Tschannen, Aebesold, McLaughllin, Bowen & Fairchild, 2012).
Typically, simulations involve some type of preparation including research or data gathering. The student in the simulation uses this information to complete the assignment and upon completion discusses the outcomes with the instructor or in a group using reflective techniques. The facilitator or instructor then provides additional feedback or Socratic questions to further the students’ understanding and insight.
Problem-based learning is an approach to critical thinking that uses a specific situation and asks the learner to research and apply knowledge to solve a problem (Savery, 2015). Situations presented are often complex and work best in a group setting. This helps the learner to analyze, evaluate and to effectively communication problems and solutions. According to Savery (2015) this type of learner-centered approach motivates the student because it creates responsibility to find a problem and a solution in the given data. Typically, the situations provided are loosely devised and presented just like situations in real life would be for nurses. This creates the need for a self-direct inquiry into the data and possible solutions. Often, cases are presented over a period of time to further facilitate learning.
Some research has shown that problem-based learning is best facilitated in a group where collaboration can take place and scaffolding, or social interaction can be facilitated (Kim, Sharma, Land & Furling, 2013). The collaboration and peer interaction encourages thought beyond each individual’s ability to improve synthesis and analytical skills (Kim, Sharma, Land, &Furling, 2013; Aebersol & Tschannen, 2013).
Case based learning, although also useful in gaining critical thinking skills, only helps the learned understand the specific terminology and see each element of the problem in a well-constructed situation. The case based learning give the learner all the information. There is no need for self-directed research or inquiry. The learner needs to be able to apply knowledge toward a goal or solution. The outcome is already stated in case based learning, therefore, there is less for the learner to think about and the learning is not self-directed (Savery, 2015).
Students are given a problem based learning case that involves a problem. The student will be given the initial consultation and assessment results along with laboratory results, medication prescribed, and history. Students can review symptoms, medication list, diagnostics as well as health beliefs, cultural issues, and evidence based practices. The actual diagnosis may or may not be given. The facilitator also has instructions that give an overview of the case and current presentation of the situation.
First session: Your patient for today is Mary, a 23-year-old single female who attends the nearby college. Mary has lost 80 lbs over the last six months. Her previous weight was 183 and she is 5’7”. She was admitted with malnutrition and issues with her electrolytes. She thinks she looks great and is happy she can wear a size 4. Her Hemoglobin is 3.4 and hematocrit is 18. Mary is not concerned with malnutrition and states she is not sure why she is here. The practitioner who admitted her would like you to assist Mary with learning healthy eating habits and weight management.
Here students are asked to define the problem and what issues need to be addressed. What do they already know about Mary and what information is still needed? Students can formulate additional interview questions and research the data that they already have and formulate interventions. The facilitator may add data or situations leading to additional research and problem solving.
Problem-based learning is well known for bringing potential authentic problems to students to promote higher order thinking. Students must be able to formulate solutions with very little information, just like real life nursing. As the student and facilitator continue through the problem, information can be added to facilitate additional learning (Kim, Sharma, Land & Furlong, 2013).
In clinical practice, nurses continually use logical, reasoning and critical thinking to assess patients and monitor outcomes (Rober & Petersen, 2013). An example is when a patient is given a chemo oral medication for the treatment of cancer. The nurse must follow a procedure to monitor the effectiveness of the medication and make judgments about compliance, side effects, and education. The nurse must be familiar with evidence-based practices and have an understanding of what questions to ask the patient and what to look for in an assessment. For example, what constitutes toxicity? What are the signs reported when the medication is effective? What critical lab values to observe and what do they mean?
Nurses often make decision that directly impact patient care and outcomes. For example, depending on the facility, nurses may need to know when to apply oxygen, when to initiate CPR, or when to call in to the prescribing provider. Critical thinking in nursing practice is an essential attribute for nurses. It may entail thinking about different perspectives, exploring data, and autonomous thought (Land, Beach, patrician, & Martin, 2013). However, studies have shown that although educators rank critical thinking as an important attribute for nursing students, it is the lowest competency observed (Rober & Petersen, 2013). Furthermore, it is also noted that most hospitals to not do not test critical thinking skills prior to hiring (Jones, 2010).
Benner (2001) states that proficiency and learning occur over time as the nurse encounters various situations. The novice nurse has academic knowledge but little experience, whereas, the expert nurse can use their vast experiences to draw upon to make clinical decisions. Benner (2001) model of Novice to Expert in nursing practice suggests that clinical decisions and critical thinking is learned overtime through practice using academic knowledge. Thus, making a possible case for more intense nursing orientations and ongoing nursing education in practice.
Having a multifaceted knowledge base will promote critical thinking and enhance patient safety. As RNs make decisions daily on patient care and outcomes, critical thinking skills are imperative to practice and maintain. As critical thinking is not well defined, it can be said that it thinking about thinking or a higher order of thinking. It is an active process that uses various reasoning skills such as inductive, deductive, inferential, analytical and evaluative as the foundation (Lang, Beach, Parician, & Martin, 2013).
Although there are concerns that nurses lack critical thinking skills, studies show that nurses do not think in a linear pattern. Instead, nurses use experience, ways of knowing, and theory as well as cognition. There are several ways in which to help students and practicing nurses learn and enhance critical thinking skills. It should also be assumed that nurses know how to practice critical thinking.
Three exercises presented here are reflection, simulation, and problem-based learning. There are other methods to practice critical thinking, however; most are beyond the scope of this article. Reflection is the process of reviewing what is happening or what has happened to develop a better perspective on the situation and possibly discussing ideas in a group. Simulation is the technical ability to provide learners with life-like situations to practice academic knowledge on high fidelity patient manikins or in a virtual environment. Simulation provides a safe environment for practice. Lastly, problem-based learning gives the learner a brief, ill-structured case that makes the learner take the lead in researching symptoms and developing outcomes. Each of the exercises discussed here have the best results when done in a group.
Aebersold, M., & Tschannen, D. (2013). Simulation in Nursing Practice: The Impact on Patient Care. Online Journal of Issues in Nursing, 18(2), 1-1 1p. doi:10.3912/OJIN.Vol18No02Man06
Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgment: A practical approach to outcome-focused thinking: Saunders.
Asselin, M. E., Schwartz-Barcott, D., & Osterman, P. A. (2013). Exploring reflection as a process embedded in experienced nurses' practice: a qualitative study. Journal of Advanced Nursing, 69(4), 905-914 910p. doi:10.1111/j.1365-2648.2012.06082.x
Asselin, M., & Fain, J. (2013). Effect of reflective practice education on self-reflection, insight, and reflective thinking among experienced nurses: a pilot study. Journal for nurses in professional development, 29(3), 111.
Benner, P. E. (2001). From novice to expert: Excellence and power in clinical nursing practice: Pearson.
Carter, L., Rukholm, E., Mossey, S., Viverais-Dresler, G., Bakker, D., & Sheehan, C. (2013). Critical thinking in the online nursing education setting: Raising the bar. Canadian Journal of University Continuing Education, 32(1).
Castledine, G. (2010). Critical thinking is crucial. British journal of nursing (Mark Allen Publishing), 19(4), 271.
Chan, Z. C. (2013). A systematic review of critical thinking in nursing education.Nurse Education Today, 33(3), 236-240.
Dwyer, C. P., Hogan, M. J., & Stewart, I. (2014). An integrated critical thinking framework for the 21st century. Thinking Skills and Creativity, 12, 43-52.
Ennis, R. (2011). The nature of critical thinking: An outline of critical thinking dispositions and abilities. Robert H. Ennis' Academic Web Site. Recuperado el, 20.
Goodstone, L., Goodstone, M. S., Cino, K., Glaser, C. A., Kupferman, K., & Dember-Neal, T. (2013). Effect of simulation on the development of critical thinking in associate degree nursing students. Nursing education perspectives, 34(3), 159-162.
Kim, K., Sharma, P., Land, S. M., & Furlong, K. P. (2013). Effects of active learning on enhancing student critical thinking in an undergraduate general science course. Innovative Higher Education, 38(3), 223-235.
Lang, G. M., Beach, N. L., Patrician, P. A., & Martin, C. (2013). A cross-sectional study examining factors related to critical thinking in nursing. Journal for nurses in professional development, 29(1), 8-15.
Lasater, K. (2011). Clinical judgment: The last frontier for evaluation. Nurse education in practice, 11(2), 86-92.
Morrall, P., & Goodman, B. (2013). Critical thinking, nurse education and universities: Some thoughts on current issues and implications for nursing practice. Nurse education today, 33(9), 935-937.
Naber, J., & Wyatt, T. H. (2014). The effect of reflective writing interventions on the critical thinking skills and dispositions of baccalaureate nursing students. Nurse education today, 34(1), 67-72.
Paul, S. A. (2014). Assessment of critical thinking: A Delphi study. Nurse Education Today, 34(11), 1357-1360.
Raymond-Seniuk, C., & Profetto-McGrath, J. (2011). Can One Learn to Think Critically?–A Philosophical Exploration. The open nursing journal, 5, 45.
Robert, R., & Petersen, S. (2013). Critical thinking at the bedside: providing safe passage to patients. Medsurg nursing: official journal of the Academy of Medical-Surgical Nurses, 22(2), 85.
Rush, K. L., Adamack, M., Gordon, J., Lilly, M., & Janke, R. (2013). Best practices of formal new graduate nurse transition programs: an integrative review. International journal of nursing studies, 50(3), 345-356.
Savery, J. R. (2015). Overview of problem-based learning: Definitions and distinctions. Essential Readings in Problem-Based Learning: Exploring and Extending the Legacy of Howard S. Barrows, 5.
Scheffer, B. K., & M Gaie Rubenfeld MS, R. (2000). A consensus statement on critical thinking in nursing. Journal of Nursing Education, 39(8), 352.
Schön, D. A. (1983). The reflective practitioner: How professionals think in action (Vol. 5126): Basic books.
Scriven, M., & Paul, R. (1987). Defining critical thinking: A draft statement for the National Council for Excellence in Critical Thinking. Retrieved December 8, 2009 from the Foundation for Critical Thinking.
Tschannen, D., Aebersold, M., McLaughlin, E., Bowen, J., & Fairchild, J. (2012). Use of virtual simulations for improving knowledge transfer among baccalaureate nursing students. Journal of Nursing Education and Practice, 2(3), p15.
Urbas-Llewellyn, A. (2013). Critical Reflection as a Learning Tool for Nurse Supervisors: A Hermeneutic Phenomenological Study. UNIVERSITY OF PHOENIX.
Watson, G. (1980). Watson-Glaser critical thinking appraisal: Psychological Corporation San Antonio, TX.
Zori, S., Nosek, L. J., & Musil, C. M. (2010). Critical thinking of nurse managers related to staff RNs’ perceptions of the practice environment. Journal of Nursing Scholarship, 42(3), 305-313. 3