critical thinking and patient outcomes

Critical Thinking in Nursing

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• Şefika Dilek Güven 3  

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Critical thinking is an integral part of nursing, especially in terms of professionalization and independent clinical decision-making. It is necessary to think critically to provide adequate, creative, and effective nursing care when making the right decisions for practices and care in the clinical setting and solving various ethical issues encountered. Nurses should develop their critical thinking skills so that they can analyze the problems of the current century, keep up with new developments and changes, cope with nursing problems they encounter, identify more complex patient care needs, provide more systematic care, give the most appropriate patient care in line with the education they have received, and make clinical decisions. The present chapter briefly examines critical thinking, how it relates to nursing, and which skills nurses need to develop as critical thinkers.

Graphical Abstract/Art Performance

Critical thinking in nursing.

This painting shows a nurse and how she is thinking critically. On the right side are the stages of critical thinking and on the left side, there are challenges that a nurse might face. The entire background is also painted in several colors to represent a kind of intellectual puzzle. It is made using colored pencils and markers.

(Adapted with permission from the Association of Science and Art (ASA), Universal Scientific Education and Research Network (USERN); Painting by Mahshad Naserpour).

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Unless the individuals of a nation thinkers, the masses can be drawn in any direction. Mustafa Kemal Atatürk

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Nevşehir Hacı Bektaş Veli University, Semra ve Vefa Küçük, Faculty of Health Sciences, Nursing Department, 2000 Evler Mah. Damat İbrahim Paşa Yerleşkesi, Nevşehir, Turkey

Şefika Dilek Güven

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Güven, Ş.D. (2023). Critical Thinking in Nursing. In: Rezaei, N. (eds) Brain, Decision Making and Mental Health. Integrated Science, vol 12. Springer, Cham. https://doi.org/10.1007/978-3-031-15959-6_10

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Nurses are critical thinkers

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Margaret McCartney: Nurses must be allowed to exercise professional judgment

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The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice. Nurses’ ability to recognize and respond to signs of patient deterioration in a timely manner plays a pivotal role in patient outcomes (Purling & King 2012). Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events (Tomlinson, 2015). The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement. Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010). At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction.

The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.

As lifelong learners, nurses are constantly accumulating more knowledge, expertise, and experience, and it’s a rare nurse indeed who chooses to not apply his or her mind towards the goal of constant learning and professional growth. Institute of Medicine (IOM) report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice. American Nurses Association (ANA), Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice (p.26)

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Purling A. & King L. (2012). A literature review: graduate nurses’ preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23–24), 3451–3465

Thompson, C., Aitken, l., Doran, D., Dowing, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50 (12), 1720 - 1726 Tomlinson, J. (2015). Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Medical Education, 15(103)

Competing interests: No competing interests

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.

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Developing critical thinking skills for delivering optimal care

Scott IA, Hubbard RE, Crock C, et al. Developing critical thinking skills for delivering optimal care. Intern Med J. 2021;51(4):488-493. doi: 10.1111/imj.15272

Sound critical thinking skills can help clinicians avoid cognitive biases and diagnostic errors. This article describes three critical thinking skills essential to effective clinical care – clinical reasoning, evidence-informed decision-making, and systems thinking – and approaches to develop these skills during clinician training.

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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?

4 reasons why critical thinking is so important in nursing, 1. critical thinking skills will help you anticipate and understand changes in your patient’s condition., 2. with strong critical thinking skills, you can make decisions about patient care that is most favorable for the patient and intended outcomes., 3. strong critical thinking skills in nursing can contribute to innovative improvements and professional development., 4. critical thinking skills in nursing contribute to rational decision-making, which improves patient outcomes., what are the 8 important attributes of excellent critical thinking in nursing, 1. the ability to interpret information:, 2. independent thought:, 3. impartiality:, 4. intuition:, 5. problem solving:, 6. flexibility:, 7. perseverance:, 8. integrity:, examples of poor critical thinking vs excellent critical thinking in nursing, 1. scenario: patient/caregiver interactions, poor critical thinking:, excellent critical thinking:, 2. scenario: improving patient care quality, 3. scenario: interdisciplinary collaboration, 4. scenario: precepting nursing students and other nurses, how to improve critical thinking in nursing, 1. demonstrate open-mindedness., 2. practice self-awareness., 3. avoid judgment., 4. eliminate personal biases., 5. do not be afraid to ask questions., 6. find an experienced mentor., 7. join professional nursing organizations., 8. establish a routine of self-reflection., 9. utilize the chain of command., 10. determine the significance of data and decide if it is sufficient for decision-making., 11. volunteer for leadership positions or opportunities., 12. use previous facts and experiences to help develop stronger critical thinking skills in nursing., 13. establish priorities., 14. trust your knowledge and be confident in your abilities., 15. be curious about everything., 16. practice fair-mindedness., 17. learn the value of intellectual humility., 18. never stop learning., 4 consequences of poor critical thinking in nursing, 1. the most significant risk associated with poor critical thinking in nursing is inadequate patient care., 2. failure to recognize changes in patient status:, 3. lack of effective critical thinking in nursing can impact the cost of healthcare., 4. lack of critical thinking skills in nursing can cause a breakdown in communication within the interdisciplinary team., useful resources to improve critical thinking in nursing, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. will lack of critical thinking impact my nursing career, 2. usually, how long does it take for a nurse to improve their critical thinking skills, 3. do all types of nurses require excellent critical thinking skills, 4. how can i assess my critical thinking skills in nursing.

• 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?

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Critical Thinking: The Development of an Essential Skill for Nursing Students

Ioanna v. papathanasiou.

1 Nursing Department, Technological Educational Institute of Thessaly, Greece

Christos F. Kleisiaris

2 Nursing Department, Technological Educational Institute of Crete, Greece

Evangelos C. Fradelos

3 State Mental Hospital of Attica “Daphne”, Greece

Katerina Kakou

Lambrini kourkouta.

4 Nursing Department, Alexander Technological Educational Institute of Thessaloniki, Greece

Critical thinking is defined as the mental process of actively and skillfully perception, analysis, synthesis and evaluation of collected information through observation, experience and communication that leads to a decision for action. In nursing education there is frequent reference to critical thinking and to the significance that it has in daily clinical nursing practice. Nursing clinical instructors know that students face difficulties in making decisions related to clinical practice. The main critical thinking skills in which nursing students should be exercised during their studies are critical analysis, introductory and concluding justification, valid conclusion, distinguish of facts and opinions, evaluation the credibility of information sources, clarification of concepts and recognition of conditions. Specific behaviors are essentials for enhancing critical thinking. Nursing students in order to learn and apply critical thinking should develop independence of thought, fairness, perspicacity in personal and social level, humility, spiritual courage, integrity, perseverance, self-confidence, interest for research and curiosity. Critical thinking is an essential process for the safe, efficient and skillful nursing practice. The nursing education programs should adopt attitudes that promote critical thinking and mobilize the skills of critical reasoning.

1. INTRODUCTION

Critical thinking is applied by nurses in the process of solving problems of patients and decision-making process with creativity to enhance the effect. It is an essential process for a safe, efficient and skillful nursing intervention. Critical thinking according to Scriven and Paul is the mental active process and subtle perception, analysis, synthesis and evaluation of information collected or derived from observation, experience, reflection, reasoning or the communication leading to conviction for action ( 1 ).

So, nurses must adopt positions that promote critical thinking and refine skills of critical reasoning in order a meaningful assessment of both the previous and the new information and decisions taken daily on hospitalization and use of limited resources, forces you to think and act in cases where there are neither clear answers nor specific procedures and where opposing forces transform decision making in a complex process ( 2 ).

Critical thinking applies to nurses as they have diverse multifaceted knowledge to handle the various situations encountered during their shifts still face constant changes in an environment with constant stress of changing conditions and make important decisions using critical thinking to collect and interpret information that are necessary for making a decision ( 3 ).

Critical thinking, combined with creativity, refine the result as nurses can find specific solutions to specific problems with creativity taking place where traditional interventions are not effective. Even with creativity, nurses generate new ideas quickly, get flexible and natural, create original solutions to problems, act independently and with confidence, even under pressure, and demonstrate originality ( 4 ).

The aim of the study is to present the basic skills of critical thinking, to highlight critical thinking as a essential skill for nursing education and a fundamental skill for decision making in nursing practice. Moreover to indicate the positive effect and relation that critical thinking has on professional outcomes.

2. CRITICAL THINKING SKILLS

Nurses in their efforts to implement critical thinking should develop some methods as well as cognitive skills required in analysis, problem solving and decision making ( 5 ). These skills include critical analysis, introductory and concluding justification, valid conclusion, distinguishing facts and opinions to assess the credibility of sources of information, clarification of concepts, and recognition conditions ( 6 , 7 ).

Critical analysis is applied to a set of questions that relate to the event or concept for the determination of important information and ideas and discarding the unnecessary ones. It is, thus, a set of criteria to rationalize an idea where one must know all the questions but to use the appropriate one in this case ( 8 ).

The Socratic Method, where the question and the answer are sought, is a technique in which one can investigate below the surface, recognize and examine the condition, look for the consequences, investigate the multiple data views and distinguish between what one knows and what he simply believes. This method should be implemented by nurses at the end of their shifts, when reviewing patient history and progress, planning the nursing plan or discussing the treatment of a patient with colleagues ( 9 ).

The Inference and Concluding justification are two other critical thinking skills, where the justification for inductive generalizations formed from a set of data and observations, which when considered together, specific pieces of information constitute a special interpretation ( 10 ). In contrast, the justification is deduced from the general to the specific. According to this, nurse starts from a conceptual framework–for example, the prioritization of needs by Maslow or a context–evident and gives descriptive interpretation of the patient’s condition with respect to this framework. So, the nurse who uses drawing needs categorizes information and defines the problem of the patient based on eradication, nutrition or need protection.

In critical thinking, the nurses still distinguish claims based on facts, conclusions, judgments and opinions. The assessment of the reliability of information is an important stage of critical thinking, where the nurse needs to confirm the accuracy of this information by checking other evidence and informants ( 10 ).

The concepts are ideas and opinions that represent objects in the real world and the importance of them. Each person has developed its own concepts, where they are nested by others, either based on personal experience or study or other activities. For a clear understanding of the situation of the patient, the nurse and the patient should be in agreement with the importance of concepts.

People also live under certain assumptions. Many believe that people generally have a generous nature, while others believe that it is a human tendency to act in its own interest. The nurse must believe that life should be considered as invaluable regardless of the condition of the patient, with the patient often believing that quality of life is more important than duration. Nurse and patient, realizing that they can make choices based on these assumptions, can work together for a common acceptable nursing plan ( 11 ).

3. CRITICAL THINKING ENHANCEMENT BEHAVIORS

The person applying critical thinking works to develop the following attitudes and characteristics independence of thought, fairness, insight into the personal and public level, humble intellect and postpone the crisis, spiritual courage, integrity, perseverance, self-confidence, research interest considerations not only behind the feelings and emotions but also behind the thoughts and curiosity ( 12 ).

Independence of Thought

Individuals who apply critical thinking as they mature acquire knowledge and experiences and examine their beliefs under new evidence. The nurses do not remain to what they were taught in school, but are “open-minded” in terms of different intervention methods technical skills.

Impartiality

Those who apply critical thinking are independent in different ways, based on evidence and not panic or personal and group biases. The nurse takes into account the views of both the younger and older family members.

Perspicacity into Personal and Social Factors

Those who are using critical thinking and accept the possibility that their personal prejudices, social pressures and habits could affect their judgment greatly. So, they try to actively interpret their prejudices whenever they think and decide.

Humble Cerebration and Deferral Crisis

Humble intellect means to have someone aware of the limits of his own knowledge. So, those who apply critical thinking are willing to admit they do not know something and believe that what we all consider rectum cannot always be true, because new evidence may emerge.

Spiritual Courage

The values and beliefs are not always obtained by rationality, meaning opinions that have been researched and proven that are supported by reasons and information. The courage should be true to their new ground in situations where social penalties for incompatibility are strict. In many cases the nurses who supported an attitude according to which if investigations are proved wrong, they are canceled.

Use of critical thinking to mentally intact individuals question their knowledge and beliefs quickly and thoroughly and cause the knowledge of others so that they are willing to admit and appreciate inconsistencies of both their own beliefs and the beliefs of the others.

Perseverance

The perseverance shown by nurses in exploring effective solutions for patient problems and nursing each determination helps to clarify concepts and to distinguish related issues despite the difficulties and failures. Using critical thinking they resist the temptation to find a quick and simple answer to avoid uncomfortable situations such as confusion and frustration.

Confidence in the Justification

According to critical thinking through well motivated reasoning leads to reliable conclusions. Using critical thinking nurses develop both the inductive and the deductive reasoning. The nurse gaining more experience of mental process and improvement, does not hesitate to disagree and be troubled thereby acting as a role model to colleagues, inspiring them to develop critical thinking.

Interesting Thoughts and Feelings for Research

Nurses need to recognize, examine and inspect or modify the emotions involved with critical thinking. So, if they feel anger, guilt and frustration for some event in their work, they should follow some steps: To restrict the operations for a while to avoid hasty conclusions and impulsive decisions, discuss negative feelings with a trusted, consume some of the energy produced by emotion, for example, doing calisthenics or walking, ponder over the situation and determine whether the emotional response is appropriate. After intense feelings abate, the nurse will be able to proceed objectively to necessary conclusions and to take the necessary decisions.

The internal debate, that has constantly in mind that the use of critical thinking is full of questions. So, a research nurse calculates traditions but does not hesitate to challenge them if you do not confirm their validity and reliability.

4. IMPLEMENTATION OF CRITICAL THINKING IN NURSING PRACTICE

In their shifts nurses act effectively without using critical thinking as many decisions are mainly based on habit and have a minimum reflection. Thus, higher critical thinking skills are put into operation, when some new ideas or needs are displayed to take a decision beyond routine. The nursing process is a systematic, rational method of planning and providing specialized nursing ( 13 ). The steps of the nursing process are assessment, diagnosis, planning, implementation, evaluation. The health care is setting the priorities of the day to apply critical thinking ( 14 ). Each nurse seeks awareness of reasoning as he/she applies the criteria and considerations and as thinking evolves ( 15 ).

Problem Solving

Problem solving helps to acquire knowledge as nurse obtains information explaining the nature of the problem and recommends possible solutions which evaluate and select the application of the best without rejecting them in a possible appeal of the original. Also, it approaches issues when solving problems that are often used is the empirical method, intuition, research process and the scientific method modified ( 16 ).

Experiential Method

This method is mainly used in home care nursing interventions where they cannot function properly because of the tools and equipment that are incomplete ( 17 ).

Intuition is the perception and understanding of concepts without the conscious use of reasoning. As a problem solving approach, as it is considered by many, is a form of guessing and therefore is characterized as an inappropriate basis for nursing decisions. But others see it as important and legitimate aspect of the crisis gained through knowledge and experience. The clinical experience allows the practitioner to recognize items and standards and approach the right conclusions. Many nurses are sensing the evolution of the patient’s condition which helps them to act sooner although the limited information. Despite the fact that the intuitive method of solving problems is recognized as part of nursing practice, it is not recommended for beginners or students because the cognitive level and the clinical experience is incomplete and does not allow a valid decision ( 16 ).

Research Process / Scientifically Modified Method

The research method is a worded, rational and systematic approach to problem solving. Health professionals working in uncontrolled situations need to implement a modified approach of the scientific method of problem solving. With critical thinking being important in all processes of problem solving, the nurse considers all possible solutions and decides on the choice of the most appropriate solution for each case ( 18 ).

The Decision

The decision is the selection of appropriate actions to fulfill the desired objective through critical thinking. Decisions should be taken when several exclusive options are available or when there is a choice of action or not. The nurse when facing multiple needs of patients, should set priorities and decide the order in which they help their patients. They should therefore: a) examine the advantages and disadvantages of each option, b) implement prioritization needs by Maslow, c) assess what actions can be delegated to others, and d) use any framework implementation priorities. Even nurses make decisions about their personal and professional lives. The successive stages of decision making are the Recognition of Objective or Purpose, Definition of criteria, Calculation Criteria, Exploration of Alternative Solutions, Consideration of Alternative Solutions, Design, Implementation, Evaluation result ( 16 ).

The contribution of critical thinking in decision making

Acquiring critical thinking and opinion is a question of practice. Critical thinking is not a phenomenon and we should all try to achieve some level of critical thinking to solve problems and make decisions successfully ( 19 - 21 ).

It is vital that the alteration of growing research or application of the Socratic Method or other technique since nurses revise the evaluation criteria of thinking and apply their own reasoning. So when they have knowledge of their own reasoning-as they apply critical thinking-they can detect syllogistic errors ( 22 – 26 ).

5. CONCLUSION

In responsible positions nurses should be especially aware of the climate of thought that is implemented and actively create an environment that stimulates and encourages diversity of opinion and research ideas ( 27 ). The nurses will also be applied to investigate the views of people from different cultures, religions, social and economic levels, family structures and different ages. Managing nurses should encourage colleagues to scrutinize the data prior to draw conclusions and to avoid “group thinking” which tends to vary without thinking of the will of the group. Critical thinking is an essential process for the safe, efficient and skillful nursing practice. The nursing education programs should adopt attitudes that promote critical thinking and mobilize the skills of critical reasoning.

CONFLICT OF INTEREST: NONE DECLARED.

Promoting critical thinking through an evidence-based skills fair intervention

Journal of Research in Innovative Teaching & Learning

ISSN : 2397-7604

Article publication date: 23 November 2020

Issue publication date: 1 April 2022

The lack of critical thinking in new graduates has been a concern to the nursing profession. The purpose of this study was to investigate the effects of an innovative, evidence-based skills fair intervention on nursing students' achievements and perceptions of critical thinking skills development.

Design/methodology/approach

The explanatory sequential mixed-methods design was employed for this study.

The findings indicated participants perceived the intervention as a strategy for developing critical thinking.

Originality/value

The study provides educators helpful information in planning their own teaching practice in educating students.

Critical thinking

Evidence-based practice, skills fair intervention.

Gonzalez, H.C. , Hsiao, E.-L. , Dees, D.C. , Noviello, S.R. and Gerber, B.L. (2022), "Promoting critical thinking through an evidence-based skills fair intervention", Journal of Research in Innovative Teaching & Learning , Vol. 15 No. 1, pp. 41-54. https://doi.org/10.1108/JRIT-08-2020-0041

Emerald Publishing Limited

Copyright © 2020, Heidi C. Gonzalez, E-Ling Hsiao, Dianne C. Dees, Sherri R. Noviello and Brian L. Gerber

Published in Journal of Research in Innovative Teaching & Learning . Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

Introduction

Critical thinking (CT) was defined as “cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge” ( Scheffer and Rubenfeld, 2000 , p. 357). Critical thinking is the basis for all professional decision-making ( Moore, 2007 ). The lack of critical thinking in student nurses and new graduates has been a concern to the nursing profession. It would negatively affect the quality of service and directly relate to the high error rates in novice nurses that influence patient safety ( Arli et al. , 2017 ; Saintsing et al. , 2011 ). It was reported that as many as 88% of novice nurses commit medication errors with 30% of these errors due to a lack of critical thinking ( Ebright et al. , 2004 ). Failure to rescue is another type of error common for novice nurses, reported as high as 37% ( Saintsing et al. , 2011 ). The failure to recognize trends or complications promptly or take action to stabilize the patient occurs when health-care providers do not recognize signs and symptoms of the early warnings of distress ( Garvey and CNE series, 2015 ). Internationally, this lack of preparedness and critical thinking attributes to the reported 35–60% attrition rate of new graduate nurses in their first two years of practice ( Goodare, 2015 ). The high attrition rate of new nurses has expensive professional and economic costs of $82,000 or more per nurse and negatively affects patient care ( Twibell et al. , 2012 ). Facione and Facione (2013) reported the failure to utilize critical thinking skills not only interferes with learning but also results in poor decision-making and unclear communication between health-care professionals, which ultimately leads to patient deaths.

Due to the importance of critical thinking, many nursing programs strive to infuse critical thinking into their curriculum to better prepare graduates for the realities of clinical practice that involves ever-changing, complex clinical situations and bridge the gap between education and practice in nursing ( Benner et al. , 2010 ; Kim et al. , 2019 ; Park et al. , 2016 ; Newton and Moore, 2013 ; Nibert, 2011 ). To help develop students' critical thinking skills, nurse educators must change the way they teach nursing, so they can prepare future nurses to be effective communicators, critical thinkers and creative problem solvers ( Rieger et al. , 2015 ). Nursing leaders also need to redefine teaching practice and educational guidelines that drive innovation in undergraduate nursing programs.

Evidence-based practice has been advocated to promote critical thinking and help reduce the research-practice gap ( Profetto-McGrath, 2005 ; Stanley and Dougherty, 2010 ). Evidence-based practice was defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient” ( Sackett et al. , 1996 , p. 71). Skills fair intervention, one type of evidence-based practice, can be used to engage students, promote active learning and develop critical thinking ( McCausland and Meyers, 2013 ; Roberts et al. , 2009 ). Skills fair intervention helps promote a consistent teaching practice of the psychomotor skills to the novice nurse that decreased anxiety, gave clarity of expectations to the students in the clinical setting and increased students' critical thinking skills ( Roberts et al. , 2009 ). The researchers of this study had an opportunity to create an active, innovative skills fair intervention for a baccalaureate nursing program in one southeastern state. This intervention incorporated evidence-based practice rationale with critical thinking prompts using Socratic questioning, evidence-based practice videos to the psychomotor skill rubrics, group work, guided discussions, expert demonstration followed by guided practice and blended learning in an attempt to promote and develop critical thinking in nursing students ( Hsu and Hsieh, 2013 ; Oermann et al. , 2011 ; Roberts et al. , 2009 ). The effects of an innovative skills fair intervention on senior baccalaureate nursing students' achievements and their perceptions of critical thinking development were examined in the study.

Literature review

The ability to use reasoned opinion focusing equally on processes and outcomes over emotions is called critical thinking ( Paul and Elder, 2008 ). Critical thinking skills are desired in almost every discipline and play a major role in decision-making and daily judgments. The roots of critical thinking date back to Socrates 2,500 years ago and can be traced to the ancient philosopher Aristotle ( Paul and Elder, 2012 ). Socrates challenged others by asking inquisitive questions in an attempt to challenge their knowledge. In the 1980s, critical thinking gained nationwide recognition as a behavioral science concept in the educational system ( Robert and Petersen, 2013 ). Many researchers in both education and nursing have attempted to define, measure and teach critical thinking for decades. However, a theoretical definition has yet to be accepted and established by the nursing profession ( Romeo, 2010 ). The terms critical literacy, CT, reflective thinking, systems thinking, clinical judgment and clinical reasoning are used synonymously in the reviewed literature ( Clarke and Whitney, 2009 ; Dykstra, 2008 ; Jones, 2010 ; Swing, 2014 ; Turner, 2005 ).

Watson and Glaser (1980) viewed critical thinking not only as cognitive skills but also as a combination of skills, knowledge and attitudes. Paul (1993) , the founder of the Foundation for Critical Thinking, offered several definitions of critical thinking and identified three essential components of critical thinking: elements of thought, intellectual standards and affective traits. Brunt (2005) stated critical thinking is a process of being practical and considered it to be “the process of purposeful thinking and reflective reasoning where practitioners examine ideas, assumptions, principles, conclusions, beliefs, and actions in the contexts of nursing practice” (p. 61). In an updated definition, Ennis (2011) described critical thinking as, “reasonable reflective thinking focused on deciding what to believe or do” (para. 1).

The most comprehensive attempt to define critical thinking was under the direction of Facione and sponsored by the American Philosophical Association ( Scheffer and Rubenfeld, 2000 ). Facione (1990) surveyed 53 experts from the arts and sciences using the Delphi method to define critical thinking as a “purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation, and inference, as well as an explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which judgment, is based” (p. 2).

To come to a consensus definition for critical thinking, Scheffer and Rubenfeld (2000) also conducted a Delphi study. Their study consisted of an international panel of nurses who completed five rounds of sequenced questions to arrive at a consensus definition. Critical thinking was defined as “habits of mind” and “cognitive skills.” The elements of habits of mind included “confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection” ( Scheffer and Rubenfeld, 2000 , p. 352). The elements of cognitive skills were recognized as “analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge” ( Scheffer and Rubenfeld, 2000 , p. 352). In addition, Ignatavicius (2001) defined the development of critical thinking as a long-term process that must be practiced, nurtured and reinforced over time. Ignatavicius believed that a critical thinker required six cognitive skills: interpretation, analysis, evaluation, inference, explanation and self-regulation ( Chun-Chih et al. , 2015 ). According to Ignatavicius (2001) , the development of critical thinking is difficult to measure or describe because it is a formative rather than summative process.

Fero et al. (2009) noted that patient safety might be compromised if a nurse cannot provide clinically competent care due to a lack of critical thinking. The Institute of Medicine (2001) recommended five health care competencies: patient-centered care, interdisciplinary team care, evidence-based practice, informatics and quality improvement. Understanding the development and attainment of critical thinking is the key for gaining these future competencies ( Scheffer and Rubenfeld, 2000 ). The development of a strong scientific foundation for nursing practice depends on habits such as contextual perspective, inquisitiveness, creativity, analysis and reasoning skills. Therefore, the need to better understand how these critical thinking habits are developed in nursing students needs to be explored through additional research ( Fero et al. , 2009 ). Despite critical thinking being listed since the 1980s as an accreditation outcome criteria for baccalaureate programs by the National League for Nursing, very little improvement has been observed in practice ( McMullen and McMullen, 2009 ). James (2013) reported the number of patient harm incidents associated with hospital care is much higher than previously thought. James' study indicated that between 210,000 and 440,000 patients each year go to the hospital for care and end up suffering some preventable harm that contributes to their death. James' study of preventable errors is attributed to other sources besides nursing care, but having a nurse in place who can advocate and critically think for patients will make a positive impact on improving patient safety ( James, 2013 ; Robert and Peterson, 2013 ).

Adopting teaching practice to promote CT is a crucial component of nursing education. Research by Nadelson and Nadelson (2014) suggested evidence-based practice is best learned when integrated into multiple areas of the curriculum. Evidence-based practice developed its roots through evidence-based medicine, and the philosophical origins extend back to the mid-19th century ( Longton, 2014 ). Florence Nightingale, the pioneer of modern nursing, used evidence-based practice during the Crimean War when she recognized a connection between poor sanitary conditions and rising mortality rates of wounded soldiers ( Rahman and Applebaum, 2011 ). In professional nursing practice today, a commonly used definition of evidence-based practice is derived from Dr. David Sackett: the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient ( Sackett et al. , 1996 , p. 71). As professional nurses, it is imperative for patient safety to remain inquisitive and ask if the care provided is based on available evidence. One of the core beliefs of the American Nephrology Nurses' Association's (2019) 2019–2020 Strategic Plan is “Anna must support research to develop evidence-based practice, as well as to advance nursing science, and that as individual members, we must support, participate in, and apply evidence-based research that advances our own skills, as well as nursing science” (p. 1). Longton (2014) reported the lack of evidence-based practice in nursing resulted in negative outcomes for patients. In fact, when evidence-based practice was implemented, changes in policies and procedures occurred that resulted in decreased reports of patient harm and associated health-care costs. The Institute of Medicine (2011) recommendations included nurses being leaders in the transformation of the health-care system and achieving higher levels of education that will provide the ability to critically analyze data to improve the quality of care for patients. Student nurses must be taught to connect and integrate CT and evidence-based practice throughout their program of study and continue that practice throughout their careers.

One type of evidence-based practice that can be used to engage students, promote active learning and develop critical thinking is skills fair intervention ( McCausland and Meyers, 2013 ; Roberts et al. , 2009 ). Skills fair intervention promoted a consistent teaching approach of the psychomotor skills to the novice nurse that decreased anxiety, gave clarity of expectations to the students in the clinical setting and increased students' critical thinking skills ( Roberts et al. , 2009 ). The skills fair intervention used in this study is a teaching strategy that incorporated CT prompts, Socratic questioning, group work, guided discussions, return demonstrations and blended learning in an attempt to develop CT in nursing students ( Hsu and Hsieh, 2013 ; Roberts et al. , 2009 ). It melded evidence-based practice with simulated CT opportunities while students practiced essential psychomotor skills.

Research methodology

Context – skills fair intervention.

According to Roberts et al. (2009) , psychomotor skills decline over time even among licensed experienced professionals within as little as two weeks and may need to be relearned within two months without performing a skill. When applying this concept to student nurses for whom each skill is new, it is no wonder their competency result is diminished after having a summer break from nursing school. This skills fair intervention is a one-day event to assist baccalaureate students who had taken the summer off from their studies in nursing and all faculty participated in operating the stations. It incorporated evidence-based practice rationale with critical thinking prompts using Socratic questioning, evidence-based practice videos to the psychomotor skill rubrics, group work, guided discussions, expert demonstration followed by guided practice and blended learning in an attempt to promote and develop critical thinking in baccalaureate students.

Students were scheduled and placed randomly into eight teams based on attributes of critical thinking as described by Wittmann-Price (2013) : Team A – Perseverance, Team B – Flexibility, Team C – Confidence, Team D – Creativity, Team E – Inquisitiveness, Team F – Reflection, Team G – Analyzing and Team H – Intuition. The students rotated every 20 minutes through eight stations: Medication Administration: Intramuscular and Subcutaneous Injections, Initiating Intravenous Therapy, ten-minute Focused Physical Assessment, Foley Catheter Insertion, Nasogastric Intubation, Skin Assessment/Braden Score and Restraints, Vital Signs and a Safety Station. When the students completed all eight stations, they went to the “Check-Out” booth to complete a simple evaluation to determine their perceptions of the effectiveness of the innovative intervention. When the evaluations were complete, each of the eight critical thinking attribute teams placed their index cards into a hat, and a student won a small prize. All Junior 2, Senior 1 and Senior 2 students were required to attend the Skills Fair. The Skills Fair Team strove to make the event as festive as possible, engaging nursing students with balloons, candy, tri-boards, signs and fun pre and postactivities. The Skills Fair rubrics, scheduling and instructions were shared electronically with students and faculty before the skills fair intervention to ensure adequate preparation and continuous resource availability as students move forward into their future clinical settings.

Research design

Institutional review board (IRB) approval was obtained from XXX University to conduct this study and protect human subject rights. The explanatory sequential mixed-methods design was employed for this study. The design was chosen to identify what effects a skills fair intervention that had on senior baccalaureate nursing students' achievements on the Kaplan Critical Thinking Integrated Test (KCTIT) and then follow up with individual interviews to explore those test results in more depth. In total, 52 senior nursing students completed the KCTIT; 30 of them participated in the skills fair intervention and 22 of them did not participate. The KCTIT is a computerized 85-item exam in which 85 equates to 100%, making each question worth one point. It has high reliability and validity ( Kaplan Nursing, 2012 ; Swing, 2014 ). The reliability value of the KCTIT ranged from 0.72 to 0.89. A t -test was used to analyze the test results.

A total of 11 participants were purposefully selected based on a range of six high achievers and five low achievers on the KCTIT for open-ended one-on-one interviews. Each interview was conducted individually and lasted for about 60 minutes. An open-ended interview protocol was used to guide the flow of data collection. The interviewees' ages ranged from 21 to 30 years, with an average of 24 years. One of 11 interviewees was male. Among them, seven were White, three were Black and one was Indian American. The data collected were used to answer the following research questions: (1) What was the difference in achievements on the KCTIT among senior baccalaureate nursing students who participated in the skills fair intervention and students who did not participate? (2) What were the senior baccalaureate nursing students' perceptions of internal and external factors impacting the development of critical thinking skills during the skills fair intervention? and (3) What were the senior baccalaureate nursing students' perceptions of the skills fair intervention as a critical thinking developmental strategy?

Inductive content analysis was used to analyze interview data by starting with the close reading of the transcripts and writing memos for initial coding, followed by an analysis of patterns and relationships among the data for focused coding. The intercoder reliability was established for qualitative data analysis with a nursing expert. The lead researcher and the expert read the transcript several times and assigned a code to significant units of text that corresponded with answering the research questions. The codes were compared based on differences and similarities and sorted into subcategories and categories. Then, headings and subheadings were used based on similar comments to develop central themes and patterns. The process of establishing intercoder reliability helped to increase dependability, conformability and credibility of the findings ( Graneheim and Lundman, 2004 ). In addition, methods of credibility, confirmability, dependability and transferability were applied to increase the trustworthiness of this study ( Graneheim and Lundman, 2004 ). First, reflexivity was observed by keeping journals and memos. This practice allowed the lead researcher to reflect on personal views to minimize bias. Data saturation was reached through following the recommended number of participants as well as repeated immersion in the data during analysis until no new data surfaced. Member checking was accomplished through returning the transcript and the interpretation to the participants to check the accuracy and truthfulness of the findings. Finally, proper documentation was conducted to allow accurate crossreferencing throughout the study.

Quantitative results

Results for the quantitative portion showed there was no difference in scores on the KCTIT between senior nursing students who participated in the skills fair intervention and senior nursing students who did not participate, t (50) = −0.174, p  = 0.86 > 0.05. The test scores between the nonparticipant group ( M  = 67.59, SD = 5.81) and the participant group ( M  = 67.88, SD = 5.99) were almost equal.

Qualitative results

Initial coding.

The results from the initial coding and generated themes are listed in Table 1 . First, the participants perceived the skills fair intervention as “promoting experience” and “confidence” by practicing previously learned knowledge and reinforcing it with active learning strategies. Second, the participants perceived the skills fair intervention as a relaxed, nonthreatening learning environment due to the festive atmosphere, especially in comparison to other learning experiences in the nursing program. The nonthreatening environment of the skills fair intervention allowed students to learn without fear. Third, the majority of participants believed their critical thinking was strengthened after participating. Several participants believed their perception of critical thinking was “enhanced” or “reinforced” rather than significantly changed.

Focused coding results

The final themes were derived from the analysis of patterns and relationships among the content of the data using inductive content analysis ( Saldana, 2009 ). The following was examined across the focused coding process: (1) factors impacting critical thinking skills development during skills fair intervention and (2) skills fair intervention a critical thinking skills developmental strategy.

Factors impacting critical thinking skills development . The factors impacting the development of critical thinking during the skills fair intervention were divided into two themes: internal factors and external factors. The internal factors were characteristics innate to the students. The identified internal factors were (1) confidence and anxiety levels, (2) attitude and (3) age. The external factors were the outside influences that affected the students. The external factors were (1) experience and practice, (2) faculty involvement, (3) positive learning environment and (4) faculty prompts.

I think that confidence and anxiety definitely both have a huge impact on your ability to be able to really critically think. If you start getting anxious and panicking you cannot think through the process like you need too. I do not really think gender or age necessarily would have anything to do with critical thinking.

Definitely the confidence level, I think, the more advanced you get in the program, your confidence just keeps on growing. Level of anxiety, definitely… I think the people who were in the Skills Fair for the first time, had more anxiety because they did not really know to think, they did not know how strict it was going to be, or if they really had to know everything by the book. I think the Skills Fair helped everyone's confidence levels, but especially the Jr. 2's.

Attitude was an important factor in the development of critical thinking skills during the skills fair intervention as participants believed possessing a pleasant and positive attitude meant a student was eager to learn, participate, accept responsibility for completing duties and think seriously. Participant 6 believed attitude contributed to performance in the Skills Fair.

I feel like, certain things bring critical thinking out in you. And since I'm a little bit older than some of the other students, I have had more life experiences and am able to figure stuff out better. Older students have had more time to learn by trial and error, and this and that.

Like when I had clinical with you, you'd always tell us to know our patients' medications. To always know and be prepared to answer questions – because at first as a Junior 1 we did not do that in the clinical setting… and as a Junior 2, I did not really have to know my medications, but with you as a Senior 1, I started to realize that the patients do ask about their meds, so I was making sure that I knew everything before they asked it. And just having more practice with IVs – at first, I was really nervous, but when I got to my preceptorship – I had done so many IVs and with all of the practice, it just built up my confidence with that skill so when I performed that skill during the Fair, I was confident due to my clinical experiences and able to think and perform better.

I think teachers will always affect the ability to critically think just because you want [to] get the right answer because they are there and you want to seem smart to them [Laugh]. Also, if you are leading in the wrong direction of your thinking – they help steer you back to [in] the right direction so I think that was very helpful.

You could tell the faculty really tried to make it more laid back and fun, so everybody would have a good experience. The faculty had a good attitude. I think making it fun and active helped keep people positive. You know if people are negative and not motivated, nothing gets accomplished. The faculty did an amazing job at making the Skills Fair a positive atmosphere.

However, for some of the participants, a positive learning environment depended on their fellow students. The students were randomly assigned alphabetically to groups, and the groups were assigned to starting stations at the Skills Fair. The participants claimed some students did not want to participate and displayed cynicism toward the intervention. The participants believed their cynicism affected the positive learning environment making critical thinking more difficult during the Skills Fair.

Okay, when [instructor name] was demonstrating the Chevron technique right after we inserted the IV catheter and we were trying to secure the catheter, put on the extension set, and flush the line at what seemed to be all at the same time. I forgot about how you do not want to put the tape right over the hub of the catheter because when you go back in and try to assess the IV site – you're trying to assess whether or not it is patent or infiltrated – you have to visualize the insertion site. That was one of the things that I had been doing wrong because I was just so excited that I got the IV in the vein in the first place – that I did not think much about the tape or the tegaderm for sterility. So I think an important part of critical thinking is to be able to recognize when you've made a mistake and stop, stop yourself from doing it in the future (see Table 2 ).

Skills fair intervention as a developmental strategy for critical thinking . The participants identified the skills fair intervention was effective as a developmental strategy for critical thinking, as revealed in two themes: (1) develops alternative thinking and (2) thinking before doing (See Table 3 ).

Develops alternative thinking . The participants perceived the skills fair intervention helped enhance critical thinking and confidence by developing alternative thinking. Alternative thinking was described as quickly thinking of alternative solutions to problems based on the latest evidence and using that information to determine what actions were warranted to prevent complications and prevent injury. It helped make better connections through the learning of rationale between knowledge and skills and then applying that knowledge to prevent complications and errors to ensure the safety of patients. The participants stated the learning of rationale for certain procedures provided during the skills fair intervention such as the evidence and critical thinking prompts included in the rubrics helped reinforce this connection. The participants also shared they developed alternative thinking after participating in the skills fair intervention by noticing trends in data to prevent potential complications from the faculty prompts. Participant 1 stated her instructor prompted her alternative thinking through questioning about noticing trends to prevent potential complications. She said the following:

Another way critical thinking occurred during the skills fair was when [instructor name] was teaching and prompted us about what it would be like to care for a patient with a fractured hip – I think this was at the 10-minute focused assessment station, but I could be wrong. I remember her asking, “What do you need to be on the look-out for? What can go wrong?” I automatically did not think critically very well and was only thinking circulation in the leg, dah, dah, dah. But she was prompting us to think about mobility alterations and its effect on perfusion and oxygenation. She was trying to help us build those connections. And I think that's a lot of the aspects of critical thinking that gets overlooked with the nursing student – trouble making connections between our knowledge and applying it in practice.

Thinking before doing . The participants perceived thinking before doing, included thinking of how and why certain procedures, was necessary through self-examination prior to taking action. The hands-on situational learning allowed the participants in the skills fair intervention to better notice assessment data and think at a higher level as their previous learning of the skills was perceived as memorization of steps. This higher level of learning allowed participants to consider different future outcomes and analyze pertinent data before taking action.

I think what helped me the most is considering outcomes of my actions before I do anything. For instance, if you're thinking, “Okay. Well, I need to check their blood pressure before I administer this blood pressure medication – or the blood pressure could potentially bottom out.” I really do not want my patient to bottom out and get hypotensive because I administered a medication that was ordered, but not safe to give. I could prevent problems from happening if I know what to be on alert for and act accordingly. So ultimately knowing that in the clinical setting, I can prevent complications from happening and I save myself, my license, and promote patient safety. I think knowing that I've seen the importance of critical thinking already in practice has helped me value and understand why I should be critically thinking. Yes, we use the 5-rights of medication safety – but we also have to think. For instance, if I am going to administer insulin – what do I need to know or do to give this safely? What is the current blood sugar? Has the patient been eating? When is the next meal scheduled? Is the patient NPO for a procedure? Those are examples of questions to consider and the level of thinking that needs to take place prior to taking actions in the clinical setting.

Although the results of quantitative data showed no significant difference in scores on the KCTIT between the participant and nonparticipant groups, during the interviews some participants attributed this result to the test not being part of a course grade and believed students “did not try very hard to score well.” However, the participants who attended interviews did identify the skills fair intervention as a developmental strategy for critical thinking by helping them develop alternative thinking and thinking before doing. The findings are supported in the literature as (1) nurses must recognize signs of clinical deterioration and take action promptly to prevent potential complications ( Garvey and CNE series 2015 ) and (2) nurses must analyze pertinent data and consider all possible solutions before deciding on the most appropriate action for each patient ( Papathanasiou et al. , 2014 ).

The skills fair intervention also enhanced the development of self-confidence by participants practicing previously learned skills in a controlled, safe environment. The nonthreatening environment of the skills fair intervention allowed students to learn without fear and the majority of participants believed their critical thinking was strengthened after participating. The interview data also revealed a combination of internal and external factors that influenced the development of critical thinking during the skills fair intervention including confidence and anxiety levels, attitude, age, experience and practice, faculty involvement, positive learning environment and faculty prompts. These factors should be considered when addressing the promotion and development of critical thinking.

Conclusions, limitations and recommendations

A major concern in the nursing profession is the lack of critical thinking in student nurses and new graduates, which influences the decision-making of novice nurses and directly affects patient care and safety ( Saintsing et al. , 2011 ). Nurse educators must use evidence-based practice to prepare students to critically think with the complicated and constantly evolving environment of health care today ( Goodare, 2015 ; Newton and Moore, 2013 ). Evidence-based practice has been advocated to promote critical thinking ( Profetto-McGrath, 2005 ; Stanley and Dougherty, 2010 ). The skills fair intervention can be one type of evidence-based practice used to promote critical thinking ( McCausland and Meyers, 2013 ; Roberts et al. , 2009 ). The Intervention used in this study incorporated evidence-based practice rationale with critical thinking prompts using Socratic questioning, evidence-based practice videos to the psychomotor skill rubrics, group work, guided discussions, expert demonstration followed by guided practice and blended learning in an attempt to promote and develop critical thinking in nursing students.

The explanatory sequential mixed-methods design was employed to investigate the effects of the innovative skills fair intervention on senior baccalaureate nursing students' achievements and their perceptions of critical thinking skills development. Although the quantitative results showed no significant difference in scores on the KCTIT between students who participated in the skills fair intervention and those who did not, those who attended the interviews perceived their critical thinking was reinforced after the skills fair intervention and believed it was an effective developmental strategy for critical thinking, as it developed alternative thinking and thinking before doing. This information is useful for nurse educators who plan their own teaching practice to promote critical thinking and improve patient outcomes. The findings also provide schools and educators information that helps review their current approach in educating nursing students. As evidenced in the findings, the importance of developing critical thinking skills is crucial for becoming a safe, professional nurse. Internal and external factors impacting the development of critical thinking during the skills fair intervention were identified including confidence and anxiety levels, attitude, age, experience and practice, faculty involvement, positive learning environment and faculty prompts. These factors should be considered when addressing the promotion and development of critical thinking.

There were several limitations to this study. One of the major limitations of the study was the limited exposure of students' time of access to the skills fair intervention, as it was a one-day learning intervention. Another limitation was the sample selection and size. The skills fair intervention was limited to only one baccalaureate nursing program in one southeastern state. As such, the findings of the study cannot be generalized as it may not be representative of baccalaureate nursing programs in general. In addition, this study did not consider students' critical thinking achievements prior to the skills fair intervention. Therefore, no baseline measurement of critical thinking was available for a before and after comparison. Other factors in the nursing program could have affected the students' scores on the KCTIT, such as anxiety or motivation that was not taken into account in this study.

The recommendations for future research are to expand the topic by including other regions, larger samples and other baccalaureate nursing programs. In addition, future research should consider other participant perceptions, such as nurse educators, to better understand the development and growth of critical thinking skills among nursing students. Finally, based on participant perceptions, future research should include a more rigorous skills fair intervention to develop critical thinking and explore the link between confidence and critical thinking in nursing students.

Initial coding results

Factors impacting critical thinking skill development during skills fair intervention

Skills fair intervention as a developmental strategy for critical thinking

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The Importance of Critical Thinking in Nursing

An American Association of Nurse Practitioners (AANP) survey found that a majority of nurse practitioners saw three or more patients per hour. Nurse practitioners see patients of all ages with a broad spectrum of potential ailments. Critical thinking skills in nursing improve patient outcomes by enabling evidence-based decision-making. 

Nurse practitioners gather considerable amounts of patient data through evaluations, tests and conversations. Each patient’s information can be interpreted and analyzed to determine the best courses of action for their health. A growing emphasis on critical thinking in nursing stems from the increasing importance of nurse practitioners in primary care.

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Growing need for critical thinking in nursing.

There is a significant shortage of primary care services throughout the United States. GoodRx identified 80% of counties as “health care deserts” or locations without easy access to necessary services. This data includes the following categories relevant to family nurse practitioners:

• 9% of counties lack enough primary care providers to serve the local population
• Residents in 20% of counties are at least 30 minutes away from hospitals
• Residents in 45% of counties are at least 20 minutes away from community health centers

“Health care deserts” are worsening because of a shortage of primary care physicians. The Association of American Medical Colleges ( AAMC ) estimates up to 48,000 more primary care providers are needed to meet patient care needs by 2034. This shortfall translates to a lack of preventive care and increased reliance on emergency care facilities.

The U.S. Bureau of Labor Statistics ( BLS ) projects a 52% growth in nurse practitioner roles by 2030. This growth is fueled not only by “health care deserts” but an aging population and public health threats like COVID-19. Critical thinking by nurse practitioners can overcome these challenges even with limited resources and stressful situations.

The Critical Thinking Process

The first step in incorporating critical thinking into patient care is understanding the critical thinking process. The National League for Nursing Accreditation Commission ( NLNAC ) defines critical thinking as:

“the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief based.”

Critical thinking in nursing does not move in a straight line because each patient is unique. There isn’t a one-size-fits-all diagnosis for patients because there isn’t a single type of patient. Nurse practitioners can apply the following steps in the Clinical Reasoning Cycle as they evaluate patient care decisions.

Consider the Situation

First impressions of new patients can distract from effective evaluations. Personal experiences and assumptions may lead to hasty conclusions about patient needs. The first step to critical thinking in nursing involves a dispassionate consideration of the facts.

Nurse practitioners often have the basic facts about their patients’ conditions before stepping into exam rooms. A simple repetition of the patient’s age and reported illness counters assumptions that can negatively impact patient care.

Collect Information

Critical thinking requires the synthesis of existing and new information for effective analysis. Nurse practitioners can pull useful details from patient charts and histories when they are available. An evaluation of visual appearance, speech, blood pressure and other metrics builds on this previous work.

Skilled practitioners automatically apply their knowledge of physiology, pharmacology and other areas during the collection process. They also keep best practices, cultural competence and ethics in mind while working with patients. This recall makes it easier to process information during diagnosis.

Process Information

There is a multi-step process for turning raw information into useful insights for patient care. Nurse practitioners effectively process patient data by:

• Analyzing information within the context of normal and abnormal ranges
• Separating relevant and irrelevant data while finding information gaps
• Focus on relationships between symptoms and cues
• Deduce potential causes of health problems
• Compare similar situations between current and past patients
• Predict potential outcomes and complications from treatment

Nurse practitioners are ready to diagnose patient conditions following this process. Depending on symptoms, they’ll have considered and eliminated multiple diagnoses based on careful consideration of the facts. This step also takes into consideration risks for other health issues without treatment.

Set Goals and Act

A patient’s course of treatment should follow the SMART model for goal-setting. The best treatment plans are Specific, Measurable, Achievable, Realistic and Timely to support the measurement of their efficacy. This model creates a repeatable process that is effective across patient demographics and conditions.

Critical thinking in nursing produces clear goals that are essential to patient adherence to treatment. Treatment plans may include prescribed medications, therapies and visits with specialists. Nurse practitioners collaborate with their patients and colleagues on supportive frameworks for effective treatment.

Evaluate and Reflect

Follow-up appointments provide opportunities for evaluation of treatment plans. Nurse practitioners compare past and present metrics when determining improvements in patient conditions. A useful method for evaluating success is whether the following rights of clinical reasoning were applied:

• Right cues 
• Right patient
• Right action
• Right reason

Frequent reflection on this process is essential for improvement as a nurse practitioner. Self-directed explorations of what should have been done and what could have happened in each case sharpen critical thinking skills. An understanding of what was learned in each case creates points of comparison for future patients.

Improving Your Critical Thinking

Critical thinking in nursing improves through thoughtful deliberation and frequent use. Nurse practitioners should speak with their colleagues and mentors about their applications of critical thinking. Frequent collaboration on patient care also places the focus on evidence-based care rather than personal assumptions.

Updated knowledge of nursing resources and tools makes it easier to implement critical thinking in nursing. Medical journals and continuing education courses reinforce what nurse practitioners have learned throughout their careers. Carson-Newman University provides a strong foundation for improved critical thinking through its Online MSN-FNP.

Preparing for Clinical Decisions at Carson-Newman

Carson-Newman’s innovative program prepares BSN & MSN-educated nurses for future roles as family nurse practitioners (FNPs). The in-person requirements for this 100% online degree are clinical placements and a three-day campus residency. Students can complete the Online MSN-FNP in as little as 32 months.

Every course in the program is taught by an experienced nurse educator who also practices in their community. Carson-Newman reinforces the importance of critical thinking in nursing with courses on topics including:

• Advanced Health Assessment
• Advanced Pathophysiology
• Advanced Primary Care Nursing for Adults

FNP students receive full support from Carson-Newman to identify clinical placements in their communities. They also receive one-on-one guidance from Student Success Advisors throughout their time at the University. This commitment to nursing education helped Carson-Newman reach the top third of graduate nursing programs in U.S. News & World Report's rankings.

Contact an enrollment advisor today to learn how Carson-Newman can prepare you for a role as an FNP.

Request Your Free Program Brochure

About carson-newman’s online fnp programs.

Founded in 1851, Carson-Newman is a nationally ranked Christian liberal arts university. An online, yet personal, learning environment connects you with fellow students, faculty, and staff. Faith and learning are combined to create evidence-based online graduate nursing programs designed to transform you into a more autonomous caregiver.

Through its online program and student-centric curriculum, Carson-Newman provides a life-changing education where students come first. Designed for working nurses, Carson-Newman’s affordable FNP programs feature 100% online coursework with no mandatory log-in times, clinical placement service, and exceptional individualized support that prepare graduates to pass the FNP licensure exam.

If you’re ready for the next step in your nursing career, consider the online Master of Science in Nursing – Family Nurse Practitioner offered by Carson-Newman University and accredited by the CCNE.

For those who already hold an MSN degree, consider pursuing a Post-Master’s FNP Certificate to enjoy all the leadership opportunities, job satisfaction and autonomy of a family primary care provider. For more information, visit onlinenursing.cn.edu.

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Evidence-based practice improves patient outcomes and healthcare system return on investment: Findings from a scoping review

Affiliations.

• 1 Helene Fuld Health Trust National Institute for Evidence-Based Practice in Nursing & Healthcare, College of Nursing, The Ohio State University, Columbus, Ohio, USA.
• 2 St. John Fisher University, Wegmans School of Nursing, Rochester, New York, USA.
• 3 Sinai Hospital, Baltimore, Maryland, USA.
• 4 Summa Health System, Akron, Ohio, USA.
• 5 The Ohio State University, College of Nursing, Columbus, Ohio, USA.
• 6 Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
• 7 Family CareX, Denver, Colorado, USA.
• 8 Affiliate Faculty, VCU Libraries, Health Sciences Library, Virginia Commonwealth University School of Nursing, Richmond, Virginia, USA.
• PMID: 36751881
• DOI: 10.1111/wvn.12621

Background: Evidence-based practice and decision-making have been consistently linked to improved quality of care, patient safety, and many positive clinical outcomes in isolated reports throughout the literature. However, a comprehensive summary and review of the extent and type of evidence-based practices (EBPs) and their associated outcomes across clinical settings are lacking.

Aims: The purpose of this scoping review was to provide a thorough summary of published literature on the implementation of EBPs on patient outcomes in healthcare settings.

Methods: A comprehensive librarian-assisted search was done with three databases, and two reviewers independently performed title/abstract and full-text reviews within a systematic review software system. Extraction was performed by the eight review team members.

Results: Of 8537 articles included in the review, 636 (7.5%) met the inclusion criteria. Most articles (63.3%) were published in the United States, and 90% took place in the acute care setting. There was substantial heterogeneity in project definitions, designs, and outcomes. Various EBPs were implemented, with just over a third including some aspect of infection prevention, and most (91.2%) linked to reimbursement. Only 19% measured return on investment (ROI); 94% showed a positive ROI, and none showed a negative ROI. The two most reported outcomes were length of stay (15%), followed by mortality (12%).

Linking evidence to action: Findings indicate that EBPs improve patient outcomes and ROI for healthcare systems. Coordinated and consistent use of established nomenclature and methods to evaluate EBP and patient outcomes are needed to effectively increase the growth and impact of EBP across care settings. Leaders, clinicians, publishers, and educators all have a professional responsibility related to improving the current state of EBP. Several key actions are needed to mitigate confusion around EBP and to help clinicians understand the differences between quality improvement, implementation science, EBP, and research.

Keywords: evidence-based decision making; evidence-based practice; healthcare; patient outcomes; patient safety; return on investment.

© 2023 The Authors. Worldviews on Evidence-based Nursing published by Wiley Periodicals LLC on behalf of Sigma Theta Tau International.

Publication types

• Systematic Review
• Delivery of Health Care*
• Evidence-Based Practice* / methods
• Quality Improvement