2. When was the patient’s last bowel movement?
3. Who is the patient’s emergency contact person?
4. Describe the patient’s current level of pain.
5. What information is in the patient’s medical record?
Critical thinking in nursing is the foundation that underpins safe, effective, and patient-centered care.
Critical thinking skills empower nurses to navigate the complexities of their profession while consistently providing high-quality care to diverse patient populations.
Potter, P.A., Perry, A.G., Stockert, P. and Hall, A. (2013) Fundamentals of Nursing
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Working in health care requires quick thinking and confident decision-making to care for patients. While nurses use a broad range of technical skills to provide quality care, an essential skill that’s easy to overlook is critical thinking. Nursing professionals should explore the benefits of critical thinking skills in nursing, how to apply them, and the ways that advanced education can sharpen their ability to make precise decisions.
Critical thinking is the process of evaluating facts, interpreting information, and analyzing situations to make informed decisions in various situations. Finding the correct answer to a complex problem isn’t easy. When situations don’t have clear answers and many factors to consider, critical thinking can help individuals move forward and make decisions.
Critical thinking competencies can be applied to a wide range of workplaces and personal situations. In nursing, critical thinking skills can help deliver effective care, handle a patient crisis, and assess the efficacy of treatment plans.
The fast-paced nursing environment requires prompt, data-driven decisions. Nurses use critical thinking daily, reviewing information and making decisions to promote quality care for patients. The following benefits of critical thinking highlight the importance of this skill in nursing careers:
Improves decision-making speed. A critical thinking mindset can help nurses make timely, effective decisions in difficult situations. A systematic method to evaluate decisions and move forward is a powerful tool for nurses.
Refines communication. Improving professional communication allows for factual, efficient, and empathetic conversations with patients and other health care professionals.
Promotes open-mindedness. It’s easy to overlook certain opinions or viewpoints in a high-pressure situation. Thankfully, critical thinking promotes open-mindedness in exploring solutions.
Combats bias. A critical look at different behaviors, contexts, and viewpoints can be helpful for identifying and addressing bias. Nurses must actively seek out ways to confront and remove bias in the workplace.
There are many ways to apply critical thinking skills to nursing situations. The nursing process is a five-step process to assist nurses in applying critical thinking skills to their daily duties. Experienced nurses and professionals considering a career change to nursing should review the steps as part of their critical thinking process.
Assessing a patient means far more than taking their vital signs. It also includes collecting sociocultural and psychological data. Lifestyle factors and experiences can affect the treatment process and approach, so skilled nurses review these areas before moving toward the next step, diagnosis.
For example, if a patient reports dizziness or shortness of breath, a nurse should not only check the patient’s temperature, blood pressure, and heart rate but also ask about their family history and recent events.
During the second step, a nurse’s assessment and critical thinking skills produce a clinical judgment. Nurses need to carefully consider all the factors included in the first step. When necessary, consult with other health care professionals before reaching a diagnosis or communicating that diagnosis with the patient.
Discussing a patient’s assessment with other health care professionals requires critical thinking, as the information provided about vital signs, recent events, and family history are key components of this step.
A nurse may be responsible for setting goals and planning a treatment plan for patients. The third step can include setting measurable, achievable goals. Nurses also coordinate care with other health care professionals.
Goals can be simple or complex, depending on the assessment and diagnosis. For example, one patient’s goals may include eating three meals a day, while another’s may include having multiple medications, specialist visits, and physical therapy activities as part of their treatment plan.
Critical thinking is needed to implement the nursing process, finding ways to carry out the plan with empathy. It’s also important for nurses to document care throughout the fourth step of the process.
For example, nurses should review patient history and consider symptoms before administering medication. Nursing professionals should also think critically about which patients to see first and how to prioritize patients who may need critical attention.
Nurses need to continue to evaluate and review the patient’s condition using critical thinking. Evaluation allows nursing professionals to review patient conditions, recommend care plan modification, and consider overall patient status.
For example, identifying whether patients may be ready for a care plan modification or another change in care requires critical thinking and a clear, focused evaluation of multiple patient factors.
Critical thinking is integral to success in the health care field. Thankfully, many ways are available for nurses to improve their critical thinking skills. Below are training, mentoring, and education options for fostering critical thinking.
Because critical thinking is so critical to the daily duties of nurses, experience in the field can improve their ability to evaluate situations and make data-driven decisions. Working firsthand with patients and alongside skilled professionals is a powerful way to see and apply critical thinking in real-world scenarios.
Nurses should seek mentorship opportunities for personalized, side-by-side instruction and inspiration from fellow professionals. Mentorships can be either formal or informal opportunities to learn from skilled nurses and health care professionals to promote critical thinking.
Many continuing education opportunities are available for nurses. Professionals looking to improve their critical thinking skills should consider enrolling in a course that promotes reflection, evaluation, and analytical thinking.
Expand your critical thinking skills in nursing by enrolling in a program to earn a degree in the field. The University of Tulsa offers an accelerated online RN to Bachelor of Science in Nursing (RN to BSN) program for students to earn their BSN in as little as 12 months. Take 30 credits of online courses to expand your medical knowledge, general education, and critical thinking abilities. Review the features of this online opportunity to see if it’s the right decision for your career.
Recommended Readings:
The Benefits of Nurse Mentoring
Hospice Nurse: Job Description and Salary
Work-From-Home Safety Checklist: Securing Your Virtual Workspace
American Nurses Association, The Nursing Process
American Nurses Association, What Are the Qualities of a Good Nurse?
Forbes , “The Power of Critical Thinking: Enhancing Decision-Making and Problem-Solving”
Indeed, “Critical Thinking in Nursing (Definition and Vital Tips)”
Indeed, “Critical Thinking Skills in Nursing: Definition and Improvement Tips”
Indeed, “15 Essential Nursing Skills to Include on Your Resume”
StatPearls, “Nursing Process”
University of Tulsa
Aug 23, 2024
Aug 21, 2024
Thinking how to nurse is thinking like a nurse. Florence Nightingale (1860) wrote on her notes that women who have charge of the other’s health—to which the application of her integrated experiences must teach herself to think how to nurse, a self-learning acquired from “hints”.
Perhaps, Nightingale referred “hints” as the use of critical thinking skills in patient’s care. The ability to think critically was the foundation of nursing practice started from historic times and is becoming one of the key performance indicators for both students and nursing professionals nowadays.
Educational system continues to evolve and progresses heeding to the needs of the society, and parallel to the changing educational structure and methodology. However, Haber (2020) reported that only 75% of employers claim that the students they hire who underwent 12 or more years of formal education lack of critical thinking and problem-solving abilities despite the progress in the educational system.
Critical thinking skills, a fundamental skill that plays a pivotal role in our daily survival. In general terms, the skill will not stop in memorization, the process goes beyond connecting the dots from one to concept to another, problem-solving techniques, think creatively, and apply the learned knowledge in new ways (Walden University, 2020). Kaminske (2019), defines critical thinking skills as a domain-specific skill on the ability to solve problems and make effective decisions that require expertise to be applied in a range of situations and scenarios.
In the nursing practice, Critical thinking skill works in assimilation with critical reasoning as a practice-based discipline of decision-making to the health care professionals. Critical thinking is the process of the intentional higher level of thinking to identify patient’s health care needs and appraise evidence-based practice to make choices in the delivery of care.
On the other hand, clinical reasoning as integrated to clinical thinking in application to clinical situation works as a cognitive process to utilized thinking strategies to gather and critically analyze the data concerning the health care needs of the patient, organized the information according to its prioritization, and formulate efficient nursing care plans to improve patient’s outcomes (Berman, et al., 2016).
“Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action”, a precise definition presented by Michael Scriven and Richard Paul at the Eighth Annual International Conference on Critical Thinking and Education Reform during the summer of 1987 (Lakhanigam, 2017).
Lakhanigam added the definition published by the Journal of Nursing Education in 2010 that describes critical thinking as the process involving interpretation and analysis of the problem, reasoning to find a solution, applying, and finally evaluation of the outcomes”. Regis College (2020), emphasized the use of deductive reasoning in observation, analyzing information, formulate conclusions, and performing appropriate actions in a self-directed process .
From the ancient theory of “tabula rasa”, as describes in Wikipedia (2020) that humans are born without built-in mental content, and all knowledge is collected by the brain from experiences and perceptions. In this computer age, a neurologist discovered neurological pathways on how to re-program or reformat our brains like computers by analyzing how the brain appears to process, recognize, remember and transfer information at the level of neural circuits, synapses and neurotransmitters. Willis (2012) discussed the brain’s neuroplastic response to stimulation called neuroplasticity. The information is processed in the reflective and cognitive functions of prefrontal cortex wherein learning incorporated into networks of longterm conceptual memory.
Neuroplasticity is greatly affected by stress, boredom and frustration as seen in the neuroimaging scans of students showed that active metabolic states block the processing in the prefrontal cortex. In response to stress, the amygdala as the switching station became hyperactive resulting to switches of input and output away from the prefrontal cortex down to the control of the lower reactive brain, this response is called fight/flight/freeze (act out/zone out). In this situation, the lower brain’s reactive behaviours are in control. This will result in the loss of information access to the prefrontal cortex and new learning is not retained.
Elseways, Knowles (1984) four principles of andragogy of adult learning included (a.) experiences from mistakes that provide the basis for the learning activities; and (b.) the importance of problems and crisis, as adult learning is problem-centred rather than content-oriented; as well as (c.) involvement in the planning and evaluation of learning; and lastly, (d.) that adults are most interested in a subject that is relevant to their job and personal life.
Learning and thinking as applied in a higher-level context, Ausubel’s assimilation theory may recount the theories on critical thinking. In this theory, Ausubel claimed that learning occurs as a result of the interaction between the acquired learning and the cognitive structure in application to practice (Seel, 2012). Moreover, critical analysis and differentiation of interrelationships between concepts called concept mapping refines the knowledge into a more organized, precise, specific, and integrated learning.
In different circumstances, nursing as a professional working in a toxic environment of the sick, pained, hopeless, weak, and dying patients; bullying, queen bee syndrome, and seniority egoism of colleagues; and backbreaking workloads—have reported cases of work-related boredom and stress. The application of the three theories may improve mentoring-learning strategies in meaningful nursing education and training.
Theories on learning acquisition from the collection of information, physiologic processing on cognitive-reflective functions of the brain, concept mapping, and internal/external utilization of knowledge in application to critical thinking are the frameworks of a skilled critical thinker.
Health care system can go a long way, achieving a considerable success having employees that possess the ability to think critically thus decreasing errors in clinical judgments. For this purpose, every nurse is required to obtain the characteristics of an excellent skilled critical thinker.
The study of Scheffer and Rubenfeld revealed the common qualities among internationally diverse expert nurses from nine different countries supporting the idea of critical thinking in nursing that encompasses logic and reasoning (Berman, et. Al., 2016), and that includes:
Undeniably, nurses with critical thinking ability diversified with effective problem-solving and efficient decision-making skills are the most in-demand and highly valued in the field of the health care industry and academe.
As a nurse striding in the most complicated, stressful and multi-tasking job, you are responsible for making life-changing decisions under the pressure of time and emotions. These reasons as to why critical thinking skills in nursing practice plays a vital role in the care of the patient. Luna (2020), cited seven importance of critical thinking skills in the practice of nursing, such as:
Critical thinking skill is needed in problems identification and implementation of interventions resulting in improved patients outcomes, as well as development in nursing practice by providing new insights on the learned knowledge. Feedback and reflections provide interconnections between nursing research , critical thinking and the nursing practice (Berman, et. Al., 2016).
Critical thinking skill is an ability beyond thinking rationally and clearly. It is a process of thinking independently and working at your own feet in formulating own opinions or new theory by utilizing critical analysis on the interrelationship of two or more ideas and delineating conclusions without external control (Wabisabi Learning, 2020).
Modified Wabisabi Learning’s 12 Solid Strategies for Teaching Critical Thinking Skills, and its Application to Nursing Education, Training and Practice:
1. Practice on Eloquence in Question and Answer (Solution Fluency)
Mastery requires ample amount of practice to become highly skilled in critical thinking. Accustom to deliberate open discussions encouraging brainstorming on issues affecting the practice and daily living by using explicit open-ended questions and comprehensive instructions for problem-solving may provide opportunities to apply knowledge into practice as well as encouraging the transfer of ideas between domains (Haber, 2020). Brainstorming is an excellent learning tool to exercise critical thinking (Walden University, 2020) particularly if applied in a situational crisis or a hospital scenario.
2. Create a Foundation
From the theory of back to basic, mastery of low-level skills is a requirement in preparatory to the application of critical thinking skills (Kaminske, 2019).
Learning experiences from theoretical and experiential knowledge are good foundations to start critical thinking. Moreover, practicing thinking skills obtained from theoretical and experiential undertakings improve intellectual ability (Berman, et. al., 2016). Practical understanding and specialization on a particular focus may excel you more in thinking critically. The competence and skills acquired from clinical experience are the most essential learning in developing clinical judgment.
3. Consult the Classics
Nursing theorists and their work are the best examples of consulting the classics. In critical thinking, nurses identify claims based on facts, conclusions, judgment/opinions and evidence-based practice. Exploring nursing theorists and their works are like exploring great minds, acquiring lessons on character motivation, refuting theories or formulating a new theory from existing theory. Case studies and in-depth objective critiques of nursing theories may not only promote critical thinking but act as a leverage to bridge the gap between theory and practice.
4. Create an Environment for Open Communication
During clinical rounds, nurses and/or students with a clinical instructor are engaged into thinking process by providing the opportunity to communicate assessment data, collaborate ideas, formulate nursing care plan, and discuss the various context of the situation from different perspectives (Di Vito-Thomas, 2005).
5. Use Information Fluency
Information fluency is mastering the proper use of information and to the ability to intuitively analyze and interpret it in unearthing knowledge and appropriate facts useful in solving a problem (Wabisabi Learning, 2020).
Knowledge of medical conditions, procedures and its connections to patient’s care are important in building critical thinking. Learning from available resources like medical journals, surfing the internet, and meaningful dialogue with colleagues can increase your medical know-how (Jillings, 2020).
6. Utilize Peer Groups
Peer groups, particularly well experienced and highly skilled colleagues are an excellent source of information, questions, and problem-solving techniques as it expands thinking and viewpoints. It also develops interpersonal skills like teamwork and resolving conflicts (Berman, et. Al., 2016).
7. Try One Sentence of Reflections at a time
Reflections will teach the learner to apply their knowledge, logic and reasoning by explaining themselves in a low-pressure setting. It provides an opportunity to explore situations with a different approach and better solutions for future use (Jillings, 2020).
The mastery of metacognition helps the learner to use reflection in defining clinical experiences and explore ways on how to improve it. Recollecting facts and events in patient’s care may integrate the learner into different concepts by connecting different ideas from one another (Di Vito-Thomas, 2005).
8. Problem-solving with Reasoning
Understanding rationale, the sets of reasons or logical basis for a course of action assist the learners to gain a broad knowledge of the topic and promotes a higher level of understanding. Problem-solving guided by rationale is a technique to the use of deductive and inductive reasoning in the thinking process (Di Vito-Thomas, 2005).
9. Roleplaying and Return Demonstration
Role-playing is a self-directed activity that encourages analytic and creative thinking. It helps the learner to internalize empathy while compromising in portraying a role or another persona creating a wider chance for memory retention.
Practice and repetition of observed procedures during return demonstration creates an avenue for re-thinking ways on how to do a task properly with ease in your own phase as you implement it by yourself.
10. Thinking and Speaking With Sketch (Concept Mapping)
Incorporating a concept with multiple perspectives and connecting complex ideas in a structured way to search for potential solutions. These processes create an abstract concept that encourages logical arguments used in critical thinking (Kaminske, 2019).
Interactive activities such as case study with a panel discussion, observing clinical dynamics during in-depth arguments, making a multidisciplinary joint care plan for patient promotes an environment for critical thinking thus facilitating the development of clinical judgment (Di Vito-Thomas, 2005).
11. Do Some Prioritizing and Decision-making
Make critical thinking as a culture and not just an activity by encouraging decision-making. Prioritizing through analyzing information, applying knowledge, and evaluating a prospected solution are the cornerstones of decision-making. This will allows the learner to apply learned theories to a different scenario by weighing the advantages and disadvantages of different solutions and option in deciding best practices.
12. Correct Misconceptions and Personal Bias
Personal beliefs greatly influence one’s ability to think critically as people always seek out ideas that conform to their own beliefs (Kaminske (2019). Several factors that act as the pitfalls in critical thinking are misconceptions, personal bias, and assumptions—which can bring a learner into a wrong direction. A discussion with colleagues who have mastery in evidence-based practice and conducting more in-depth investigations can give ideas and extends point of view (Jillings, 2020).
Analytical skills through keen observation, understanding important data, and identifying a pattern of recognition; problem-solving capacity by connecting relationship of phenomena, data interpretation guided by significance and rationale; and use of reflection and evaluation abilities in formulating conclusion are the important factors in clinical judgment and decision-making.
Critical thinking is a learned skill resulted from a rolled-up innate curiosity in the application of strong theoretical and experiential foundations in solving clinical problems that direct to the best care decision, which produce positive patient outcomes and improve patient care services.
In this era of technological advancement where machine replaces almost of everything, critical thinking still plays an important role in the nursing practice. Nurses who can manipulate complex clinical situations with efficient skills on critical/analytical thinking, problem-solving and decision-making are often in the front line to compete for the position with greater autonomy and higher chances for opportunities.
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Learning objectives.
By the end of this section, you will be able to:
Thinking is something we usually do subconsciously, because we are not usually “thinking about thinking.” However, with the ever-increasing autonomy being afforded to nurses, there is also an increased need for nurses to be able to critically think effectively and intentionally. Being able to critically think helps nurses’ problem solve, generate solutions, and make sound clinical judgments that affect the lives of their patients. Keep reading to learn more about how nurses use critical thinking in practice and how you can develop your own critical thinking skills.
Nurses make decisions while providing patient care by using critical thinking and clinical reasoning. In nursing, critical thinking is a broad term that includes reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” On the other hand, clinical reasoning is defined as a complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions. Each of these types of thinking is described in more detail in the following sections.
The term cognitive thinking refers to the mental processes and abilities a nurse uses to interpret, analyze, and evaluate information in their practice. Basically, it encompasses how nurses think about the practice decisions they are making. Cognitive thinking and critical thinking go hand in hand because nurses must be able to use their knowledge and mental processes to devise solutions and actions when caring for patients. Using critical thinking means that nurses take extra steps to maintain patient safety and do not just follow orders. It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research. Critical thinkers possess certain attitudes that foster rational thinking:
Cognitive thinking is significant to nursing because it provides a foundation on which nurses can make rapid and accurate decisions in clinical practice. Nurses must be able to think quickly and make informed decisions to promote optimal patient outcomes.
To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process. Effective thinking in nursing involves the integration of clinical knowledge and critical thinking to make the best decisions for patients. For example, if a nurse was caring for a patient who presents with hypertension and new-onset left-sided weakness, it is important that the nurse be able to quickly consider potential causes for the weakness and implement immediate stroke protocols. Without the ability to critically think, the nurse may overlook the weakness as being unrelated to the hypertension and not consider the possibility of stroke, leading to a poor patient outcome. Thus, it is imperative that nurses develop effective thinking skills.
The term inductive reasoning involves noticing cues, making generalizations, and creating hypotheses. Cues are data that fall outside of expected findings and give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A generalization is a judgment formed on the basis of a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes clearer. On the basis of generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. Remember, a hypothesis is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored. No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to act quickly, especially in emergency situations. They can see how certain objects or events form a pattern (or a generalization) that indicates a common problem.
Consider this example: A nurse assesses a patient who has undergone surgery and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.
Another type of critical thinking is deductive reasoning ; it is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.
Think about this example: On the basis of research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking, because the intervention is applied to all patients regardless of whether they have difficulty sleeping or not.
Rationalizing the purpose of thinking is probably not something you do often, but it is the foundational first step in critical thinking. To effectively use critical thinking in practice, the nurse must first identify the purpose of thinking. For example, the nurse is caring for a patient who presents with fever, tachycardia, and shortness of breath. The patient also has an open, infected wound on the left foot that is not healing. The nurse must recognize that the patient is exhibiting signs and symptoms that may be indicative of an underlying problem. At this point, the nurse must be able to identify that the purpose of thinking with regard to the patient is to consider what might be happening with the patient and formulate a plan of care. This begins the process of critical thinking, which involves several steps: thinking ahead, thinking in action, and reflection on thinking.
Thinking ahead in nursing involves considering what may be going on with the patient to anticipate potential outcomes and complications that may arise. Remember competent nurses are proactive versus reactive. Reactive nursing is letting situations arise and then responding to the change, but proactive nursing is recognizing cues behaviors and patterns that are leading up to a complicated event. Additionally, the nurse will formulate goals of care and must try to anticipate specific needs the patient will have. Considering the patient discussed in the preceding paragraph, the nurse should begin the process of thinking ahead about potential outcomes and complications. The nurse may hypothesize that the patient is starting to develop sepsis from the open wound on the foot so severe sepsis and/or septic shock could be a complication to begin preparing for. The nurse thinks ahead about goals of care for the patient and determines that wound care to prevent infection spread and sepsis is the priority goal at this time.
Thinking in action encompasses the thought processes occurring while the nurse is performing interventions. So, if the nurse in our example begins performing wound care, they are thinking about the best dressing to use, how to clean the wound, and if antibiotics should be considered. All of these thoughts are likely occurring as the nurse is providing the care; thus, they are examples of how the nurse is using thinking in action.
After performing interventions or making decisions, the nurse should reflect on the thinking that occurred. The nurse will use this thinking process to determine if the decision was reactive or responsive. Reactive decision-making involves responding to situations after they have occurred, often in a hurried or unplanned manner. These decisions tend to be impulsive and are driven by immediate needs or crises. Responsive decisions, on the other hand, involve careful deliberation about how to address a situation based on careful consideration of information. In our example, the nurse’s decision appears to have been responsive. The patient was exhibiting some altered vital signs, but nothing indicated that the situation had become emergent yet. The nurse was able to think carefully about the patient’s situation and determine that wound care was the highest priority and begin to implement care in a calm, deliberate manner. In an ideal world, all nursing decisions would be responsive, but in a lot of cases, they must be reactive because of situation severity and medical emergencies.
During the outset of the critical thinking process, nurses must judge whether their knowledge is accurate, complete, factual, timely, and relevant. This can be done by applying knowledge to nursing practice in a multitude of ways, including drawing from past education and experience in nursing and using professional resources and standards. Each of these is discussed in more detail in the following sections.
Becoming a nurse requires years of schooling, which contributes to the development of a robust knowledge base. Nurses receive formal education and training that provides them foundational knowledge in anatomy, physiology, pharmacology, and patient care techniques, among many others. Additionally, nurses are required to complete continuing education courses specific to their chosen practice setting, further developing their knowledge base. When applying knowledge in practice, nurses can draw from their knowledge base and make informed decisions about patient care.
Nursing is considered a practice. Nursing practice means we learn from our mistakes and our past experiences and apply this knowledge to our next patient or to the next population we serve. As nurses gain more experience, they can use what they have learned in practice and apply it to new patient situations. Each new encounter with a patient presents unique challenge and learning opportunities that contribute to the development of clinical expertise. Reflecting on these experiences allows nurses to recognize patterns, anticipate patient outcomes, and refine their decision-making processes. Whether they are identifying effective nursing interventions for common conditions, adapting care plans to individual patient needs, or navigating complex situations with compassion, nurses draw upon their accumulated knowledge base from clinical experience to provide high-quality, patient-centered care. Through reflection and continuous learning from past experiences, nurses enhance their clinical skills, ultimately improving patient outcomes.
In addition to foundational knowledge bases and experience, nurses can also use professional resources and standards to gain and apply knowledge in practice. Nurses can refer to clinical practice guidelines that have been established by professional organizations and healthcare institutions to help provide a framework for implementing nursing interventions based on the best evidence. By following the guidelines, nurses are ensuring that their care aligns with established standards and promotes optimal patient outcomes. Additionally, nurses should remain up to date about new and emerging research in their practice area, which can be obtained by reading professional journals and publications and attending conferences, workshops, and other trainings. Nurses can use the information learned from these resources to influence practice and ensure the highest standards of care are being performed in their practice setting. By staying informed about the latest developments in nursing and health care, nurses enhance their knowledge base and can adapt their practice to incorporate new evidence and innovations. Along with professional development and staying current with professional practices, nursing students should actively seek and join professional organizations such as critical care nursing or oncology nursing societies because this will lead the student to become expert in that subject and stay relevant with current evidence and practice guidelines.
Qsen competency: evidence-based practice.
Definition: Providing quality patient care based on up-to-date, theory-derived research and knowledge, rather than personal beliefs, advice, or traditional methods.
Knowledge: The nurse will describe how the strength and relevance of available evidence influences the choice of intervention in provision of patient-centered care.
Skill: The nurse will:
Attitude: The nurse will appreciate the importance of regularly reading relevant professional journals.
After determining the best course of action based on the application of knowledge, the nurse can critique the decisions that were made. Specifically, the nurse will use self-reflection to review their actions and thoughts that led them to the decision. The nurse will consider the outcomes of their chosen interventions, reflect on the effectiveness of their approach, and identify areas of improvement. Additionally, the nurse may seek feedback from colleagues to obtain different perspectives about decisions made. Soliciting input from others helps the nurse gain insight and learn from their peers to further inform their future practice. Reflection questions that the nurse may ask themselves to critique their decision include the following:
Certain behaviors that demonstrate the knowledge, skills, and attitudes that promote critical thinking are called critical thinking indicators (CTIs) . Critical thinking indicators are tangible actions that are performed to assess and improve your thinking skills.
There are many models and frameworks within nursing and other disciplines that attempt to explain the process of critical thinking. One of the most popular is Alfaro-LeFevre’s 4-Circle CT Model (Alfaro-LeFevre, 2016). This model breaks critical thinking into four components: personal characteristics, intellectual and cognitive abilities, interpersonal abilities and self-management, and technical skills. These four components overlap, forming interconnections in critical thinking.
Learn more here about the 4-Circle CT Model and see an illustration of it.
Personal CTIs are behaviors that are indicative of critical thinkers. Some of these behaviors that are most relevant to nursing include:
Personal knowledge and intellectual skills encompass the knowledge gained from nursing school and clinical experiences. Examples of each of these kinds of skills are listed in Table 28.3 .
Personal Knowledge | Intellectual Skills |
---|---|
Interpersonal and self-management skills encompass the knowledge and skills needed for effective collaboration. These include:
Technical skills in nursing refer to the practical abilities and competencies that nurses use in the delivery of patient care. These skills are typically learned through education, training, and hands-on experience. Some common technical skills in nursing include:
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By Hannah Meinke on 07/05/2021
The nursing profession tends to attract those who have natural nurturing abilities, a desire to help others, and a knack for science or anatomy. But there is another important skill that successful nurses share, and it's often overlooked: the ability to think critically.
Identifying a problem, determining the best solution and choosing the most effective method to solve the program are all parts of the critical thinking process. After executing the plan, critical thinkers reflect on the situation to figure out if it was effective and if it could have been done better. As you can see, critical thinking is a transferable skill that can be leveraged in several facets of your life.
But why is it so important for nurses to use? We spoke with several experts to learn why critical thinking skills in nursing are so crucial to the field, the patients and the success of a nurse. Keep reading to learn why and to see how you can improve this skill.
You learn all sorts of practical skills in nursing school, like flawlessly dressing a wound, taking vitals like a pro or starting an IV without flinching. But without the ability to think clearly and make rational decisions, those skills alone won’t get you very far—you need to think critically as well.
“Nurses are faced with decision-making situations in patient care, and each decision they make impacts patient outcomes. Nursing critical thinking skills drive the decision-making process and impact the quality of care provided,” says Georgia Vest, DNP, RN and senior dean of nursing at the Rasmussen University School of Nursing.
For example, nurses often have to make triage decisions in the emergency room. With an overflow of patients and limited staff, they must evaluate which patients should be treated first. While they rely on their training to measure vital signs and level of consciousness, they must use critical thinking to analyze the consequences of delaying treatment in each case.
No matter which department they work in, nurses use critical thinking in their everyday routines. When you’re faced with decisions that could ultimately mean life or death, the ability to analyze a situation and come to a solution separates the good nurses from the great ones.
Nursing school offers a multitude of material to master and upholds high expectations for your performance. But in order to learn in a way that will actually equip you to become an excellent nurse, you have to go beyond just memorizing terms. You need to apply an analytical mindset to understanding course material.
One way for students to begin implementing critical thinking is by applying the nursing process to their line of thought, according to Vest. The process includes five steps: assessment, diagnosis, outcomes/planning, implementation and evaluation.
“One of the fundamental principles for developing critical thinking is the nursing process,” Vest says. “It needs to be a lived experience in the learning environment.”
Nursing students often find that there are multiple correct solutions to a problem. The key to nursing is to select the “the most correct” solution—one that will be the most efficient and best fit for that particular situation. Using the nursing process, students can narrow down their options to select the best one.
When answering questions in class or on exams, challenge yourself to go beyond simply selecting an answer. Start to think about why that answer is correct and what the possible consequences might be. Simply memorizing the material won’t translate well into a real-life nursing setting.
As you know, learning doesn’t stop with graduation from nursing school. Good nurses continue to soak up knowledge and continually improve throughout their careers. Likewise, they can continue to build their critical thinking skills in the workplace with each shift.
“To improve your critical thinking, pick the brains of the experienced nurses around you to help you get the mindset,” suggests Eileen Sollars, RN ADN, AAS. Understanding how a seasoned nurse came to a conclusion will provide you with insights you may not have considered and help you develop your own approach.
The chain of command can also help nurses develop critical thinking skills in the workplace.
“Another aid in the development of critical thinking I cannot stress enough is the utilization of the chain of command,” Vest says. “In the chain of command, the nurse always reports up to the nurse manager and down to the patient care aide. Peers and fellow healthcare professionals are not in the chain of command. Clear understanding and proper utilization of the chain of command is essential in the workplace.”
“Nurses use critical thinking in every single shift,” Sollars says. “Critical thinking in nursing is a paramount skill necessary in the care of your patients. Nowadays there is more emphasis on machines and technical aspects of nursing, but critical thinking plays an important role. You need it to understand and anticipate changes in your patient's condition.”
As a nurse, you will inevitably encounter a situation in which there are multiple solutions or treatments, and you'll be tasked with determining the solution that will provide the best possible outcome for your patient. You must be able to quickly and confidently assess situations and make the best care decision in each unique scenario. It is in situations like these that your critical thinking skills will direct your decision-making.
While critical thinking skills are essential at every level of nursing, leadership and management positions require a new level of this ability.
When it comes to managing other nurses, working with hospital administration, and dealing with budgets, schedules or policies, critical thinking can make the difference between a smooth-running or struggling department. At the leadership level, nurses need to see the big picture and understand how each part works together.
A nurse manager , for example, might have to deal with being short-staffed. This could require coaching nurses on how to prioritize their workload, organize their tasks and rely on strategies to keep from burning out. A lead nurse with strong critical thinking skills knows how to fully understand the problem and all its implications.
Their solutions will take into account all their resources and possible roadblocks.
They’ll weigh the pros and cons of each solution and choose those with the greatest potential.
Finally, they will look back on the issue and evaluate what worked and what didn’t. With critical thinking skills like this, a lead nurse can affect their entire staff, patient population and department for the better.
You’re now well aware of the importance of critical thinking skills in nursing. Even if you already use critical thinking skills every day, you can still work toward strengthening that skill. The more you practice it, the better you will become and the more naturally it will come to you.
If you’re interested in critical thinking because you’d like to move up in your current nursing job, consider how a Bachelor of Science in Nursing (BSN) could help you develop the necessary leadership skills.
EDITOR’S NOTE: This article was originally published in July 2012. It has since been updated to include information relevant to 2021.
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Tuan van nguyen.
1 Faculty of Nursing and Medical Technology, Can Tho University of Medicine and Pharmacy, Can Tho Vietnam
2 School of Nursing, College of Medicine, Chang Gung University, Taoyuan Taiwan
3 Department of Rheumatology, Chang Gung Memorial Hospital, Linkou Taiwan
4 Department of Nursing, College of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
The data that support the findings of this study are available from the corresponding author upon reasonable request.
To measure the level of critical thinking among Vietnamese professional nurses and to identify the related factors.
A cross‐sectional design was used.
The total sample included 420 professional nurses. Data were collected from July to September 2019 in three public hospitals located in Southwestern Vietnam. The level of critical thinking was measured using the Vietnamese version of the Nursing Critical Thinking in Clinical Practice Questionnaire. The data were analysed using the independent Student's t tests, ANOVA, Pearson's correlation and regression analysis.
Most of the participants had a low (48.3%) or moderate (45.5%) level of critical thinking. Age, gender, ethnicity, education level, health condition, duration of working as a nurse, duration of working in the current hospital, having heard the term “critical thinking” and work position had an impact on the critical thinking ability. Work position and gender explained 11% of the total variance in critical thinking ability.
Critical thinking is defined as the cognitive process of reasoning that involves trying to minimize errors and to maximize positive outcomes while attempting to make a decision during patient care (Zuriguel‐Pérez et al., 2015 ). The importance of critical thinking in nursing practice has been identified in the literature (Chang et al., 2011 ; Ludin, 2018 ; Mahmoud & Mohamed, 2017 ; Yurdanur, 2016 ; Zuriguel‐Pérez et al., 2015 ). The current nursing environment has become more complex and demanding, especially regarding the acuity and safety of patients and the rapid turnover rate of hospitalization. If professional nurses want to provide high‐quality care, critical thinking is required (Berkow et al., 2011 ; Brunt, 2005 ; Fero et al., 2009 ; Zuriguel‐Pérez et al., 2015 ). Nurses are often the first‐line professionals to observe and provide direct care for patients. Therefore, critical thinking is a necessary skill for them to be able to analyse clinical situations in order to make fast and correct decisions (Lee et al., 2017 ). More importantly, critical thinking can also improve patient outcomes by preventing habitual thinking that may lead to incorrect medication or procedures (Fesler‐Birch, 2005 ). The critical thinking ability of nurses can have an impact on the patient's safety, and it is a priority in educational programs for healthcare providers (Berkow et al., 2011 ; Buerhaus et al., 2006 ). We can identify those with poor critical thinking and provide in‐service education. Although critical thinking has been shown that is influenced by the experience and knowledge acquired during clinical practice (Zuriguel‐Pérez et al., 2015 ), other personal information needs to be considered to clarifying. Therefore, it is essential to measure the levels of critical thinking and to identify the work‐related and personal‐related factors that influence the critical thinking of nurses.
The literature has identified that there is a relationship between leadership and positive patient outcomes, such as fewer medication errors and nosocomial infections, lower patient mortality and higher patient satisfaction (Van Dyk et al., 2016 ; Wong, 2015 ). Alongside leadership, critical thinking is an important factor that supports the management. They can apply critical thinking skills in decision‐making and problem‐solving, and they can develop strategies that help staff nurses to improve their critical thinking ability (Van Dyk et al., 2016 ; Wong, 2015 ; Zuriguel‐Pérez et al., 2018 ). Thus, the ability to think critically is necessary for nurses because it will help them to effectively make decisions and to solve problems in practice.
Although the importance of critical thinking in nursing practice has been identified, a limited number of studies have been conducted in this population. Particularly, few hospitals have evaluated the critical thinking skills of nurses before employment or during the clinical competency evaluation (Lang et al., 2013 ). By reviewing 90 articles to assess the current state of the scientific knowledge regarding critical thinking in nursing, Zuriguel‐Pérez et al., ( 2015 ) found that only 16 studies used working nurses as participants. Furthermore, Zuriguel‐Pérez et al., ( 2018 ) reported that few studies have explored the critical thinking ability of nurse managers (NMs). Moreover, several studies have identified that working nurses have a low (Lang et al., 2013 ; Yurdanur, 2016 ) or moderate level of critical thinking (Chang et al., 2011 ; Lang et al., 2013 ; Zuriguel‐Pérez et al., 2018 ). To the researchers’ knowledge, no studies have investigated this issue in Vietnam.
In order to improve the quality and safety of patient care, various types of professional nurses have been established, such as Registered Nurses (RNs), NMs and administrative assistants (AAs). RNs provide direct care to the patients, NMs are responsible for forwarding management and delivering expert clinical care for patients, and AAs are an integral part of maintaining the quality of patient care. The AAs perform administrative tasks (e.g. filing, taking meeting minutes and distributing them and undertaking regular reports) that help NMs to spend more time assisting staff nurses and taking care of patients (Locke et al., 2011 ). Therefore, RNs, NMs and AAs need to cooperate to help patients to regain their health.
In Vietnam, professional nurses work in three different positions, which are NMs, general nurses (GNs) and AAs (Ministry of Health, 1997 ). Specifically, NMs are recognized as head nurses in Western countries, and their responsibilities are in charge of organizing and implementing comprehensive patient care and conduct a variety of administrative work (e.g. planning and assigning work to nurses, planning the acquisition of tools and consumables, checking care sheets, recording daily labour). GNs are similar to RNs in Western countries, and they provide direct and comprehensive care to patients. AAs perform administrative tasks (e.g. keeping records about the hospitalized and discharged patients, preserving medical records, managing daily medications). They also participate in patients care if necessary (Ministry of Health, 1997 , 2011 ). Although the roles of these three types of professional nurses are different, their final goal is the same to provide holistic care for patients. With the cooperation and effort of these three types of professional nurses, patients can recover. Therefore, more surveys are needed that examine these participants’ level of critical thinking and the associated work‐related factors.
Previous studies have also found that several personal‐related factors are associated with the nurses' critical thinking ability, which are age, gender, ethnicity, education qualification, working experience and shift work (Chang et al., 2011 ; Feng et al., 2010 ; Howenstein et al., 1996 ; Lang et al., 2013 ; Ludin, 2018 ; Mahmoud & Mohamed, 2017 ; Ryan & Tatum, 2012 ; Wangensteen et al., 2010 ; Yildirim et al., 2012 ; Yurdanur, 2016 ; Zuriguel‐Pérez et al., 2018 ). However, the relationships between the critical thinking ability and these variables are inconsistent. For example, age and critical thinking have been found to be positively correlated (Chang et al., 2011 ; Ludin, 2018 ; Zuriguel‐Pérez et al., 2018 ), negatively correlated (Howenstein et al., 1996 ) and not related (Lang et al., 2013 ; Mahmoud & Mohamed, 2017 ; Yurdanur, 2016 ). Gender and critical thinking have been reported with a statistically significant relationship (Liu et al., 2019 ; Ludin, 2018 ) and no relationship (Mahmoud & Mohamed, 2017 ; Wangensteen et al., 2010 ). Level of education and critical thinking have been found in a positive association (Chang et al., 2011 ; Ludin, 2018 ) and not association (Lang et al., 2013 ; Mahmoud & Mohamed, 2017 ). Year of experiences and critical thinking have been shown to be positively correlated (Chang et al., 2011 ; Ludin, 2018 ), negatively correlated (Howenstein et al., 1996 ) and not related (Lang et al., 2013 ; Mahmoud & Mohamed, 2017 ). Those inconsistent findings indicated the relationships between the personal‐characteristics and the critical thinking ability of professional nurses need further exploration. Therefore, this study aimed to examine the level of critical thinking of professional nurses and to explore the work‐related and personal‐related factors. This is the first study to investigate this issue in Vietnam. The results of the current study will make a significant contribution to the literature because it will provide thorough descriptions of the critical thinking of professional nurses and its associated factors. Furthermore, the findings may be used as a baseline for nurse managers and nurse educators to propose further strategies to improve this ability in professional nurses.
A cross‐sectional design was used. The Strengthening the Reporting of Observational Studies in Epidemiology guidelines were applied in this report (Von Elm et al., 2014 ).
Data collection was carried out from July to September 2019 in three representative and major public hospitals located in the Southwestern region of Vietnam. These hospitals have the same organizational structure, role of treating, operation of professional nursing and provide similar quality of health care to people around that area. The total numbers of professional in these three hospitals nurses were around 1,200. Besides, our study has two steps. The first step was to translate the English version of the Nursing Critical Thinking in Clinical Practice Questionnaire (N‐CT‐4 Practice) into the Vietnamese version. In that step, we used data as a pilot study to estimate the sample size in the second step, which was reported here. Sample size calculation was done by the formula: n = 1.96 2 × p × (1‐p)/0.05 2 , where p = .46 came from the poor level of critical thinking among nurses in the first step and 0.05 indicated the acceptable margin of error (5.0%); 382 participants were required by this formula. An additional 10% of participants were done to adjust for potential failures such as withdrawals or missing data (Suresh & Chandrashekara, 2012 ). Therefore, in total, 420 participants were required for this study. Convenience sampling was conducted to recruit the sample. The inclusion criteria were the nurses' employed full‐time employment in the study hospitals. Participants who participated in step 1 or being absent during the data collection such as sick leave or delivering a baby were excluded. Participants were grouped in each hospital and received an envelope with all questionnaires. Then, researchers explained the research's purpose, benefits and risks to the potential participants and the procedure for ensuring confidentiality, and the voluntary nature of the participation. The informed consent form was signed immediately after they agreed to participate in this study. Then, the participants were required to complete the questionnaires in 20 to 30 min and to return them to the data collector.
3.3.1. sample characteristics.
This instrument collected data about the personal information and occupational variables. The personal information included age, gender, marital status, ethnicity, religion, education level and self‐rated health conditions. The occupational variables were the duration of working as a nurse, the duration of working in the current hospital, the duration of working in the specific position, having heard the term “critical thinking” or not, previous exposure to critical thinking training or education or not, and type of work position.
The N‐CT‐4 Practice (V‐v) was used to measure the critical thinking ability of the professional nurses. The original instrument (N‐CT‐4 Practice) was established and classified based on the four dimensions of the 4‐circle critical thinking model of Alfaro‐LeFevre (Zuriguel‐Pérez et al., 2017 ). These four dimensions were personal; intellectual and cognitive; interpersonal and self‐management; and technical dimensions. The personal dimension has 39 items to assess the individual pattern of intellectual behaviours; the intellectual and cognitive dimension has 44 items to assesses the knowledge of activity comprehension connected to the nursing process and decision‐making. For the interpersonal and self‐management dimension, it has 20 items to analyse interpersonal abilities that allow for therapeutic communication with patients and health teams and to gain information that is associated with the patient in the clinical environment. The final one, the technical dimension, has 6 items to is concerned with knowledge and expertise in the procedures that are part of the discipline of nursing. This scale has 109 items that are rated using a four‐point Likert response format (1 = never or almost never, 2 = occasionally, 3 = often, and 4 = always or almost always), for example: “I recognize my own emotions.” (item 1); “I have the scientific knowledge required to carry out my professional practice.” (item 40); “I adapt information to the needs and capacities of the patient.” (item 84); “I possess skills in the use of information and communication technologies needed to produce optimal professional results.” (item 105). The total score is obtained from the sum of the 109 items. The scores range from 109–436, and they are categorized into a low level (score <329), moderate level (score between 329–395) and high level (score >395). The overall Cronbach's alpha was 0.96, and the intraclass correlation coefficient (ICC) was 0.77 (Zuriguel‐Pérez et al., 2017).
The N‐CT‐4 Practice (V‐v) was translated, and its psychometric properties were tested with 545 Vietnamese nurses. The results showed that the N‐CT‐4 Practice (V‐v) has acceptable reliability (Cronbach's alpha) and validity (content and construct validity). Particularly, the overall Cronbach's alpha was 0.98, with that of the four dimensions ranging from 0.86–0.97. The ICC was 0.81 over two weeks. The item content validity index was 1.0. Moreover, the goodness‐of‐fit indexes in a confirmatory factor analysis showed acceptable values, which were χ 2 / df = 2.87, root mean square error of approximation (RMSEA) = 0.059, standardized root mean square residual (SRMR) = 0.063, comparative fit index (CFI) = 0.73 and Tucker Lewis index (TLI) = 0.72 (T. V. Nguyen & Liu, 2021 ). Therefore, the N‐CT‐4 Practice (V‐v) can be used to measure the critical thinking ability of Vietnamese professional nurses.
This study conformed with the ethical principles of the Declaration of Helsinki (Helsinki Declaration, 2013 ), and it was granted research ethics committee approval by the ethical review board of the first author's institution.
The data were analysed using SPSS for Windows version 23.0 (IBM Corp.), and both descriptive and inferential statistics were calculated. The level of significance for all analyses was set at < 0.05. First, descriptive statistics were employed to summarize the collected data. The continuous variables were described using the mean and standard deviation ( SD ), and the frequency and percentage (%) were used for the categorical variables. Next, independent Student's t tests, analysis of variance (with Scheffe's post hoc comparison) and Pearson's correlation analysis were conducted to explore the association between the critical thinking ability and the personal and occupational factors. Then, a multiple regression analysis using the stepwise method was performed to identify the predictors of critical thinking ability (Pallant, 2010 ).
A total of 420 participants completed the questionnaires; the characteristics of overall participants and subjects in each group are listed in Table 1 . Three groups of subjects were included, which were NMs (24.8%), GNs (49.8%) and AAs (25.4%), respectively. Regarding the personal variables, almost all participants were Vietnamese (96.7%), no religion (73.1%) and had good health condition (60%). Meanwhile, the comparison among each group showed that age ( F = 9.89, p < .001), gender (χ 2 = 6.48, p < .05), marital status (χ 2 = 6.77, p < .05) and education level (χ 2 = 147.38, p < .001) had reached the statistical significance. Further analysis showed that the age of NMs was significantly older than subjects in both the GN and AA group, AA group had a higher ratio of that in the GN group, and the AA group had a higher ratio of married one than the GN group. For educational levels, subjects in the NM group had a higher ratio of bachelor and master degree, whereas the other two groups had a high ratio of diploma and associate degree.
Characteristics of the participants ( n = 420)
Variables | Totals | Comparisons among work position | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
NM ( = 104) | GN ( = 209) | AA ( = 107) | χ | (1) NM | (2) GN | (3) AA | ‐test | Scheffe's post hoc | |||
(%) | Mean ± | (%) | Mean ± | ||||||||
Personal variables | |||||||||||
Age (years) | 32.54 ± 7.32 | 35.22 ± 7.08 | 31.46 ± 7.0 | 32.05 ± 7.56 | 9.89 | (1) > (2), (3) | |||||
Gender | |||||||||||
Male | 105 (25) | 28 (26.9) | 60 (28.7) | 17 (15.9) | 6.48 | ||||||
Female | 315 (75) | 76 (73.1) | 149 (71.3) | 90 (84.1) | |||||||
Marital status | |||||||||||
Single/divorced/widowed | 169 (40.2) | 34 (32.7) | 97 (46.4) | 38 (35.5) | 6.77 | ||||||
Married | 251 (59.8) | 70 (67.3) | 112 (53.6) | 69 (64.5) | |||||||
Ethnicity | |||||||||||
Vietnamese | 406 (96.7) | 101 (97.1) | 205 (98.1) | 100 (93.5) | 4.79 | ||||||
Other | 14 (3.3) | 3 (2.9) | 4 (1.9) | 7 (6.5) | |||||||
Religion | |||||||||||
No | 307 (73.1) | 82 (78.8) | 149 (71.3) | 76 (71) | 2.33 | ||||||
Yes | 113 (26.9) | 22 (21.2) | 60 (28.7) | 31 (29) | |||||||
Education level | |||||||||||
Diploma | 126 (30.0) | 3 (2.9) | 90 (43.1) | 33 (30.8) | 147.38 | ||||||
Associate | 123 (29.3) | 8 (7.7) | 64 (30.6) | 51 (47.7) | |||||||
Bachelor's/graduate | 171 (40.7) | 93 (89.4) | 55 (26.3) | 23 (21.5) | |||||||
Self‐rated health condition | |||||||||||
Very good | 51 (12.1) | 9 (8.7) | 27 (12.9) | 15 (14) | 6.63 | ||||||
Good | 252 (60.0) | 71 (68.3) | 126 (60.3) | 55 (51.4) | |||||||
Fair/bad/very bad | 117 (27.9) | 24 (23.1) | 56 (26.8) | 37 (34.6) | |||||||
Work‐related factors | |||||||||||
Duration of working as a nurse (years) | 9.30 ± 7.05 | 12.30 ± 7.12 | 8.08 ± 6.42 | 8.75 ± 7.20 | 13.08 | (1) > (2), (3) | |||||
Duration of working in the current hospital (years) | 8.81 ± 6.85 | 11.66 ± 7.02 | 7.66 ± 6.33 | 8.29 ± 6.93 | 12.98 | (1) > (2), (3) | |||||
Duration of working in the specific position (years) | 6.10 ± 5.46 | 5.06 ± 4.94 | 7.41 ± 6.21 | 4.05 ± 3.27 | 14.79 | (2) > (1) > (3) | |||||
Heard the term "CT" | |||||||||||
No | 280 (66.7) | 56 (53.8) | 151 (72.2) | 73 (68.2) | 10.74 | ||||||
Yes | 140 (33.7) | 48 (46.2) | 58 (27.8) | 34 (31.8) | |||||||
Previous exposure to CT training/education | |||||||||||
No | 420 (100) | 104 (100) | 209 (100) | 107 (100) |
Abbreviations: AA, Administrator assistant; CT , Critical thinking; GN, General nurse; NM, Nurses manager ; SD , standard deviation.
Chi‐square and one‐way ANOVA test; significant at * p < .05; ** p < .01; *** p < .001.
Regarding work‐related factors, the characters of all participants and subjects in each group are also listed in Table 1 . The comparison of professional experience, such as duration of working as a nurse, duration of working in the current hospital, duration of working in this specific position and heard the terminology of "critical thinking" showed a significant statistical difference among the three groups ( p < .001). They showed that NMs had a longer duration of working as a nurse (mean = 12.30, SD = 7.12) and duration of working in the current hospital (mean = 11.6, SD = 7.02) than the other two groups; GNs had the longest duration of working in the specific position (mean = 7.41, SD = 6.21). More subjects in the NM group heard the terminology of "critical thinking" than subjects in the other two groups. However, none of the subjects had been exposed to critical thinking training or education. Furthermore, there was a positive correlation among age, the duration of working as a nurse, the duration of working in the current hospital and duration of working in a specific position ( r = .78–.975, p < .01).
The mean of the total scores of the N‐CT‐4 Practice (V‐v) for all participants was 333.86 ± 40.22 (with the average score/item = 3.06 ± 0.37), the median score was 331 (interquartile range [IQR] = 311–359), and it ranged from 204–436, which indicates that they generally had a moderate level of critical thinking. Meanwhile, most of the participants reported a low (48.3%) or moderate (45.5%) level of critical thinking. Only 6.2% of the participants had a high level of critical thinking. Regarding the four dimensions of the N‐CT‐4 Practice (V‐v), the average sum score was 119.52 ± 14.19 (with the average score/item = 3.06 ± 0.36) in the personal dimension, 136.38 ± 17.62 (with the average score/item = 3.10 ± 0.40) in the intellectual and cognitive dimension, 68.71 ± 12.65 (with the average score/item = 3.44 ± 0.63) in the interpersonal and self‐management dimension and 18.09 ± 3.01 (with the average score/item = 3.01 ± 0.50) in the technical dimension.
There were statistically significant associations between the critical thinking ability and some work‐related factors, such as work position ( F = 23.30, p < .001), duration of working as a nurse ( r = 0.15, p < .01), duration of working in the current hospital ( r = 0.13, p < .05) and having heard the term "critical thinking" ( t = −2.48, p < .05; Table 2 ). The findings indicated that NMs had higher scores than GNs and AAs. Moreover, nurses who had worked for a longer duration as a nurse or worked longer in the current hospital had a higher critical thinking ability. Meanwhile, those who had not heard the term "critical thinking" had lower scores than participants who had heard this term.
Association between the participants’ characteristics and the critical thinking ability ( n = 420)
Variables | Mean ± | a/b/ ‐value | ‐value | Scheffe's comparison |
---|---|---|---|---|
Personal factors | ||||
Age | 0.12 | . | ||
Gender | ||||
Male | 341.70 ± 37.29 | 2.32 | . | |
Female | 331.24 ± 40.88 | |||
Marital status | ||||
Single/divorced/widowed | 331.24 ± 40.49 | −1.09 | .275 | |
Married | 335.62 ± 40.03 | |||
Ethnicity | ||||
Vietnamese | 334.57 ± 39.57 | 1.97 | . | |
Other | 313.07 ± 53.73 | |||
Religion | ||||
No | 334.63 ± 39.39 | 0.65 | .516 | |
Yes | 331.75 ± 42.51 | |||
Education level | ||||
(1) Diploma | 327.84 ± 38.20 | 7.45 | . | 3 > 1, 2 |
(2) Associate | 327.50 ± 39.25 | |||
(3) Bachelor's/graduate | 342.86 ± 40.80 | |||
Self‐rated health condition | ||||
(1) Very good | 343.94 ± 37.25 | 3.41 | . | 1 > 3 |
(2) Good | 334.97 ± 39.47 | |||
(3) Fair/bad/very bad | 327.06 ± 42.19 | |||
Occupational factors | ||||
Duration of working as a nurse | 0.15 | . | ||
Duration of working in the current hospital | 0.13 | . | ||
Duration of working in the specific position | 0.07 | .184 | ||
Heard the term “critical thinking” | ||||
No | 330.44 ± 39.68 | −2.48 | . | |
Yes | 340.69 ± 40.56 | |||
Work position | ||||
(1) Nurse manager | 355.49 ± 38.53 | 23.30 | 1 > 2, 3 | |
(2) General nurse | 329.11 ± 32.79 | |||
(3) Administrative assistant | 322.11 ± 46.89 |
The bolded values indicate the level of statistical significance (with p < .05; p < .01; or p < .001) between the independent and dependent variables.
Abbreviations: SD , standard deviation.
There were statistically significant associations between the critical thinking ability and some personal‐related factors, such as age ( r = 0.12, p < .05), gender ( t = 2.32, p < .05), ethnicity ( t = 1.97, p < .05), education level ( F = 7.45, p < .01) and health condition ( F = 3.14, p < .05; Table 2 ). The findings indicated that the older nurses reported a higher critical thinking ability, and male nurses had a higher score than female ones. Vietnamese participants had higher scores than participants with other ethnicities. Participants with a bachelor's/graduate degree level of education had higher scores than participants with a diploma and associate degree level of education. Those with very good health had a higher score than participants who rated their health as fair/bad/very bad.
All of the statistically significant variables identified in the univariate analysis were selected as independent variables to determine the predictors of critical thinking ability. For the regression analysis, the categorical variables were first coded as dummy variables. The factors of having never heard of “critical thinking,” being an NM being male, being Vietnamese, having a diploma degree and being in very good health were selected as the standard factors. The results of the stepwise multiple regression method showed that there were only two predictors, namely the variables of work position and gender. Working as an AA or GN or being female can predict the critical thinking ability, and they accounted for 11% of the total variance ( F = 17.12, p < .001). This indicates that the AAs and GNs had a lower level of critical thinking than the NMs. Besides, when compared with male nurses, the female nurses exhibited a lower level of critical thinking (Table 3 ).
Predictors of the critical thinking ability ( n = 420)
Model | Beta | ‐value | square | ‐value | ‐value | |
---|---|---|---|---|---|---|
Constant | 362.11 | 0.11 | 17.12 | |||
Administrative assistant | −32.38 | −0.351 | ||||
General nurse | −26.55 | −0.330 | ||||
Female | −9.05 | −0.098 | . |
This study showed that the critical thinking ability of most professional nurses was at a low or moderate level. This finding is consistent with previous studies (Chang et al., 2011 ; Lang et al., 2013 ; Zuriguel‐Pérez et al., 2018 ). Using the same tool, Zuriguel‐Pérez et al. ( 2018 ) found that the median score of the N‐CT‐4 Practice was 363 (IQR = 340–386) for clinical nurses in Spain. Our study found a slightly lower median score (331; IQR = 311–359) but it was still in a moderate level (range of score: 329–395). Although critical thinking is a relatively new issue in Vietnamese professional nurses, it is not a brand new concept. Certain elements have been included in the nursing curriculum and clinical practice (e.g. the nursing process, problem‐based learning, evidence‐based practice). Therefore, up to 66.7% of participants had never heard the term "critical thinking," but 45.5% still reported a moderate level when measured using the N‐CT‐4 Practice (V‐v).
In Vietnam, clinical professional nurses are categorized into NMs, GNs and AAs with different job descriptions. Critical thinking ability has been identified as an important component for the high quality of care around the world, except in Vietnam. In order to identify this ability, we collected data from 3 hospitals in one region and grouped these data for analysis. Based on the comparison among NMs, GNs and AAs, it was found that NMs had a higher level of critical thinking than GNs and AAs. This can be explained by the fact that NMs have a higher age, work experience and high educational qualification than the other two groups. This result partially supports the finding that NMs report a slightly higher level of critical thinking than RNs (Zuriguel‐Pérez et al., 2018 ). Critical thinking is a necessary skill for effective and efficient management. Evidently, at present, NMs with a high level of critical thinking create positive practice environments that can help the staff nurses to deliver high quality and safe patient care (Zori et al., 2010 ). Therefore, all healthcare personnel needs to learn and apply critical thinking in order to conduct their work effectively and efficiently.
For clinical nurses, continuous in‐service education is very important to update their knowledge and skill of care. Literature found various factors associated with curriculum design and learning of critical thinking ability. Therefore, grouping subjects in the present study together in order to identify the related factors could help the development of further in‐service education of critical thinking ability effectively and efficiently. In this study, a statistically significant positive correlation was found between the critical thinking ability and age, the duration of working as a nurse and the duration of working in the current hospital. These findings are consistent with previous studies. For example, older nurses have a higher level of critical thinking than younger ones (Chang et al., 2011 ; Chen et al., 2019 ; Feng et al., 2010 ; Ludin, 2018 ; Wangensteen et al., 2010 ; Yurdanur, 2016 ; Zuriguel‐Pérez et al., 2018 ), and nurses with more experience report a better critical thinking ability than those with less experience (Chang et al., 2011 ; Chen et al., 2019 ; Feng et al., 2010 ; Ludin, 2018 ). Older and experienced nurses are more mature in their way of thinking (Chen et al., 2019 ; Ludin, 2018 ). Because there were statistically significant positive correlations among age, the duration of working as a nurse and the duration of working in the current hospital. This indicates that older nurses have a longer duration of working as a nurse or working in the current hospital so they have better critical thinking. However, the correlation between these factors and critical thinking in the current study is small; further explorations are suggested.
This study showed that there is a significant association between critical thinking ability and gender and ethnicity, which is also supported by the literature. Ludin ( 2018 ) found that female nurses reported a lower critical thinking ability than male nurses. Traditionally, females have generally had fewer opportunities to receive education and more difficulty asserting their rights during decision‐making than males in Vietnam (L. T. Nguyen et al., 2017 ). Even today, the phenomenon of gender inequality still exists in certain areas in Vietnam. This traditional burden and the limited opportunities to practice in a clinical care setting might lower the levels of the female participants’ critical thinking. Ethnicity has a similar impact, as found in the present study. For example, it has been reported that Caucasian and Hispanic/Latino participants have a significantly higher critical thinking ability than African American participants (Lang et al., 2013 ) and that Malaysian and Indian participants report different levels of critical thinking; nevertheless, only 0.9% of the participants were Indian (Ludin, 2018 ). However, in the present study, as almost all of the participants were Vietnamese (96.7%), the skewed distribution of the ethnicity might limit the generalizability of the results. In future studies, an equal distribution of ethnicity is strongly recommended.
This study also confirmed that those who had a bachelor's/graduate degree had a higher level of critical thinking than those who had a diploma or associate degree, even though the former had never heard the term "critical thinking." A vast amount of studies has found that education has a positive impact on the level of critical thinking (Chang et al., 2011 ; Gloudemans et al., 2013 ; Ludin, 2018 ; Yildirim et al., 2012 ; Zuriguel‐Pérez et al., 2018 ). Meanwhile, this study found that participants who had heard the term "critical thinking" displayed a higher level of critical thinking than those who had not heard this term. Education might be the major reason for this variation. In the present study, only 40.7% of participants had a bachelor's/graduate degree. In order to promote their levels of critical thinking, it is necessary to arrange for them, to encourage them, to attend advanced education or to provide further content in the in‐service education.
In this study, participants with very good health had a higher level of critical thinking than participants who self‐rated their health as fair/bad/very bad. Health status does have an impact on work productivity, job performance, quality of care and extra learning (Letvak et al., 2011 ). Thus, poor health limits their learning and critical thinking ability. This ability is an important predictor of real‐life outcomes (e.g. interpersonal, work, financial, health and education) (Butler et al., 2017 ). Therefore, the causal effects between health and critical thinking ability need further exploration.
In the current study, only the female gender and the type of work position as an AA or GN were identified as predictors, and they explained only 11% of the total variance of critical thinking ability in the regression model. The uneven distribution of gender and work position might be the reason for the low variance. Even though the male was significantly less than the female, NM was fewer than GN and AA. More factors need to be included in further studies.
The limitations of this study include that it used a convenience sample from only three public hospitals located in the Southwestern part of Vietnam. This sample does not represent all professional nurses in Vietnam. The N‐CT‐4 Practice is the instrument with good psychometric properties specific for clinical practice and translated into English (Zuriguel‐Pérez et al., 2017), Persian (FallahNezhad & Ziaeirad, 2018 ) and Turkish (Urhan & Seren, 2019 ). Different points of the Likert response format were selected by tools to measure critical thinking ability. For example, the N‐CT‐4 Practice selected a four‐point Likert response and it was rated in frequency, such as 1 = never or almost never and 4 = always or almost always. However, a seven‐point Likert scale for the Critical Thinking Disposition Assessment (CTDA) was selected and rated in levels of agreement, such as 1 for very strongly disagree and 7 for very strongly agree (Cui et al., 2021 ). Which response format can be more reprinting the characters of critical thinking ability? Further investigation is strongly suggested. Besides, the N‐CT‐4 Practice (V‐v) questionnaire has too many items that may lead to the boredom of the participants to answer and thus affect the accuracy of the results. Moreover, the collapsing of three distinctly separate groups of nurses into one group for most of the analyses lead to not showing differences in critical thinking and influencing factors among the three groups. These factors all limit the generalization of the present results. Based on these limitations, it is suggested that the use of nationwide systematic sampling and an international comparison are strongly suggested in further studies. Regarding the critical thinking questionnaire, it would be better to use the revised versions with fewer questions. Therefore, developmental and psychometric properties are suggested to shorten this questionnaire.
The results demonstrate that most of the professional nurses had a low or moderate critical thinking ability. Certain personal and occupational variables were significantly associated with the level of critical thinking. Being male or working as an NM were statistically significant predictors of critical thinking ability, and they explained only 11% of the total variance.
The findings of this study indicate that it is necessary to develop strategies to improve the critical thinking ability of professional nurses. The critical thinking ability has been confirmed to be an essential factor for high‐quality health care that focuses on the quality of patient care and patient safety. Besides, providing more opportunities to pursue advanced degrees or enhancing the provision of in‐service education in hospitals that involves classroom teaching or web‐based learning is strongly recommended for this specific group of nurses. Consequently, the quality of patient care could be improved.
The authors declare that they have no competing interests.
The authors would like to thank the expert panel, translators, research assistants, the hospitals and all of the clinical nurses who participated in this study. We are indebted to the study participants and would like to dedicate the research findings to improving the critical thinking ability of Vietnamese professional nurses in the future. No specific grant was received from funding agencies in the public, commercial, or not‐for‐profit sectors.
Van Nguyen T, Liu H‐E. Factors associated with the critical thinking ability of professional nurses: A cross‐sectional study . Nurs Open . 2021; 8 :1970–1980. 10.1002/nop2.875 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
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