critical thinking in nursing staff

• Pre-Nursing
• Nursing School
• After Graduation

How to Apply Critical Thinking in Nursing

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

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

What is critical thinking in nursing?

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

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

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

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

Why is critical thinking important in nursing?

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

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

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

Examples of Critical Thinking in Nursing

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

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

Supplement Your Nursing Studies and Boost Your Grades

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

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Critical Thinking and Decision-Making Skills

Chapter 4 Critical Thinking and Decision-Making Skills Betsy Frank http://evolve.elsevier.com/Huber/leadership/ In an era of changing reimbursements, value based purchasing, and expanded roles for nursing in the health care delivery system, critical thinking and decision making are important skills for nurses caring for patients and for nurse leaders and managers. Both the American Nurses Association’s (2009) and American Association of Nurse Executives’ (2005) standards for practice for nurse administrators and executives support the fact that in a fast-paced health care delivery environment, staff nurses, leaders, and managers must be able to analyze and synthesize a large array of information, use critical thinking and decision making skills to deliver effective day to day patient care, and solve complex problems that occur in complex health care delivery systems (see Figure 4-1 ). Furthermore, the Magnet Hospital initiative and the Institute of Medicine’s ( Committee on the Robert Wood Johnson Foundation, 2011 ) Future of Nursing report highlight the need for nurses to be able to be fully involved and even take the lead in decision making from the unit level to the larger health care delivery system. FIGURE 4-1 Differences and interactions among critical thinking, problem solving, and decision making. Nurses are a cadre of knowledge workers within the health care system. As such, they need information, resources, and support from their environment. In fact, the nurse manager’s expertise in critical thinking and shared decision making are essential for creating healthy work environments where quality and effective care can be delivered ( Kramer et al., 2010 ; Zori et al., 2010 ). Critical thinking and decision-making competences include analytical skills as well as intuition. Just as intuition is part of expert clinical practice ( Benner, 1984 ), intuition plays an important role in developing managerial and leadership expertise (Shirey, 2007). DEFINITIONS Critical thinking can be defined as a set of cognitive skills including “interpretation, analysis, evaluation, inference, explanation, and self-regulation” ( Facione, 2007 , p. 1). Using these skills, nurses in direct patient care and leaders and managers can reflect analytically, reconceptualize events, and avoid the tendency to make decisions and problem solve hastily or on the basis of inadequate information. Facione also pointed out that critical thinking is not only a skill but also a disposition that is grounded in a strong ethical component. Critical thinking in nursing can be defined as “purposeful, informed, outcomes focused thinking…[that] applies logic, intuition, creativity and is grounded in specific knowledge, skills, and experience” ( Alfaro-LeFevre, 2009 , p. 7). Alfaro-LeFevre noted that outcomes-focused thinking helps to prevent, control, and solve problems. Tanner (2000) noted that critical thinking is much more than just the five steps of the nursing process. Problem solving involves moving from an undesirable to a desirable state ( Chambers, 2009 ). Problem solving occurs in a variety of nursing contexts, including direct client care, team-level leadership, and systems-level leadership. Nurses and nurse managers are challenged to move from step-by-step problem-solving techniques to incorporating creative thinking, which involves considering the context when meeting current and future challenges in health care delivery ( Chambers, 2009 ; Rubenfeld & Scheffer, 2006 ). Decision making is the process of making choices that will provide maximum benefit ( Drummond, 2001 ). Decision making can also be defined as a behavior exhibited in selecting and implementing a course of action from alternative courses of action for dealing with a situation or problem. It may or may not be the result of an immediate problem. Critical thinking and effective decision making are the foundation of effective problem solving. If problems require urgent action, then decisions must be made rapidly; if solutions do not need to be identified immediately, decision making can occur in a more deliberative way. Because problems change over time, decisions made at one point in time may need to be changed ( Choo, 2006 ). For example, decisions about how to staff a unit when a nurse calls in sick have to be made immediately. However, if a unit is chronically short-staffed, a decision regarding long-term solutions will have to be made. The process of selecting one course of action from alternatives forms the basic core of the definition of decision making. Choo (2006) noted that all decisions are bounded by cognitive and mental limits, how much information is processed, and values and assumptions. In other words, no matter the decision-making process, all decisions are limited by a variety of known and unknown factors. In a chaotic health care delivery environment, where regulations and standards of care are always changing, any decision may cause an unanticipated future problem. BACKGROUND Critical Thinking Critical thinking is both an attitude toward handling issues and a reasoning process. Critical thinking is not synonymous with problem solving and decision making ( Figure 4-1 ), but it is the foundation for effective decision making that helps to solve problems ( Fioratou et al., 2011 ). Figure 4-2 illustrates the way obstacles such as poor judgment or biased thinking create detours to good judgment and effective decision making. Critical thinking helps overcome these obstacles. Critical thinking skills may not come naturally. The nurse who is a critical thinker has to be open-minded and have the ability to reflect on present and past actions and to analyze complex information. Nurses who are critical thinkers also have a keen awareness of their surroundings ( Fioratou et al., 2011 ). FIGURE 4-2 Decision-making maze. Critical thinking is a skill that is developed for clarity of thought and improvement in decision-making effectiveness. The roots of the concept of critical thinking can be traced to Socrates, who developed a method of questioning as a way of thinking more clearly and with greater logical consistency. He demonstrated that people often cannot rationally justify confident claims to knowledge. Confused meanings, inadequate evidence, or self-contradictory beliefs may lie below the surface of rhetoric. Therefore it is important to ask deep questions and probe into thinking sequences, seek evidence, closely examine reasoning and assumptions, analyze basic concepts, and trace out implications. Other thinkers, such as Plato, Aristotle, Thomas Aquinas, Francis Bacon, and Descartes, emphasized the importance of systematic critical thinking and the need for a systematic disciplining of the mind to guide it in clarity and precision of thinking. In the early 1900s, Dewey equated critical thinking with reflective thought ( The Critical Thinking Community, 2008 ). Critical thinking, then, is characterized by thinking that has a purpose, is systematic, considers alternative viewpoints, occurs within a frame of reference, and is grounded in information ( The Critical Thinking Community, 2008 ). Questioning is implicit in the critical thinking process. The following are some of the questions to be asked when thinking critically about a problem or issue ( Elder & Paul, n.d. ): •  What is the question being asked? •  Is this the right question? •  Is there another question that must be answered first? •  What information is needed? •  Given the information, what conclusions are justified? •  Are there alternative viewpoints? No matter what questions are asked, critical thinkers need to know the “why” of the thinking, the mode of reasoning (inductive or deductive), what the source and accuracy of the information is, what the underlying assumptions and concepts are, and what might be the outcome of the thinking ( The Critical Thinking Community, 2008 ). Critical Thinking in Nursing Nurses in clinical practice continually make judgments and decisions based on the assessment and diagnosis of client needs and practice problems or situations. Clinical judgment is a complex skill grounded in critical thinking. Clinical judgment results in nursing actions directed toward achieving health outcomes ( Alfaro-LeFevre, 2009 ). Scheffer and Rubenfeld (2000) have stated that habits of the mind that are characteristic of critical thinking by nurses include confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, open-mindedness, perseverance, and reflection. Emphasizing the value of expert experience and holistic judgment ability, Benner (2003) cautioned that clinical judgments must not rely too heavily on technology and that the economic incentives to use technology must not come at the expense of human critical thinking and reasoning in individual cases. Critical thinkers have been distinguished from traditional thinkers in nursing. A traditional thinker, thought to be the norm in nursing, preserves status quo. Critical thinkers go beyond the step-by-step processes outlined in the nursing process and traditional problem solving. A critical thinker challenges and questions the norm and considers in the context of decision making potential unintended consequences. Unlike traditional thinkers, critical thinkers are creative in their thinking and anticipate the consequences of their thinking ( Rubenfeld & Scheffer, 2006 ). Creativity is necessary to deal with the complex twenty-first century health care delivery environment. Nurse leaders and managers have an obligation to create care delivery climates that promote critical thinking, which leads to innovative solutions to problems within the system of care ( Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine; Institute of Medicine, 2011 ; Porter-O’Grady, 2011 ). Such a climate encourages deep reflection, especially so that nurses feel safe to learn from mistakes, and encourages nurses to ask questions and consider a variety of viewpoints and alternative solutions to problems. What specific strategies can be used to promote a climate in which critical thinking is fostered? First and foremost, the nurse manager/leader, in the role of mentor, coach, or preceptor, should encourage questions such as “Is what you are doing or proposing based on sound evidence?” ( Ignatavicius, 2008 ). However, Snowden and Boone (2007) cautioned that “best practice, by definition is past practice” (p. 71). Therefore use of best practices needs to be examined carefully in order to use them appropriately. Staff nurses and managers must use critical thinking skills in order to determine the appropriateness of implementing recommended practice protocols. As managers, allowing staff and self “think time” is essential for reflection and is a key component of critical thinking ( Zori & Morrison, 2009 ). Nurse managers’ critical thinking abilities promotes a positive practice environment which can lead to better patient outcomes ( Zori, Nosek, & Musil, 2010 ). Coaching new and experienced nurses to develop expertise in clinical judgment is critically important. Many new nurses, in particular, need to further develop their critical thinking skills ( Fero et al., 2008 ; Forneris & Peden-McAlpine, 2009 ). In addition to having preceptors and others ask questions of new nurses, nurse managers and leaders can use other strategies to enhance critical thinking in nursing staff. Developing concept maps is another useful strategy to promote critical thinking. Although typically used in prelicensure programs ( Ellermann et al., 2006 ), nurse managers can encourage their preceptors to use concept maps with orientees ( Toofany, 2008 ). Developing concept maps in concert with others further develops a nurse’s critical thinking through the process of dialogue. Simulations also promote critical thinking or “thinking like a nurse” ( Tanner, 2006 ). According to Tanner, simulations can promote clinical reasoning, which leads to making conclusions in the form of clinical judgments and, thus, effective problem solving. The use of human patient simulators is well known in educational settings. Simulators may also be useful in orienting new graduates to the acute care setting ( Leigh, 2011 ). Pulman and colleagues (2009) have reported on the use of simulators to promote critical thinking role development in inter-professional environments. Decision Making Decision making is the essence of leadership and management. It is what leaders and managers are expected to do ( Keynes, 2008 ). Thus decisions are visible outcomes of the leadership and management process. The effectiveness of decision making is one criterion for evaluating a leader or manager. Yet staff nurses and nurse managers and leaders must make decisions in uncertain and complex environments ( Clancy & Delaney, 2005 ). Within a climate of uncertainty and complexity, nurse managers and leaders must also understand that all decision making involves high-stakes risk taking ( Clancy & Delaney, 2005 ; Keynes, 2008 ). If poor decisions are made, progress can be impeded, resources wasted, harm caused, and a career adversely affected. The results of poor decisions may be subtle and not appear until years later. Take, for instance, a decision to reduce expenses by decreasing the ratio of registered nurses to nurses’ aides. There may be a short-term cost savings, but if not implemented appropriately, this tactic may result in the gradual erosion of patient care over time (Kane et al., 2007). Unintended effects may include higher turnover of experienced nurses, increased adverse events such as medication errors, decreased staff morale, and lower patient satisfaction scores. The long-term outcome of this decision may actually result in increased expenses not reduced expenses. Thus it is vital for nurses to understand decision making and explore styles and strategies to enhance decision-making skills. Decision making, like traditional problem solving, has been traditionally thought of as a process with identifiable steps yet influenced by the context and by whether there is an intuitive grasp of the situation. However, Effken and colleagues (2010) stated that decision making is much more. Expert decision making is a constructive process in which the outcomes are not preplanned or simply pulled out of a memory bank. Instead, expert decision-making activities are creative, innovative, and adapted to uncertainty and the context of the current problem, using learning from prior experience (p. 189). Nurses make decisions in personal, clinical, and organizational situations and under conditions of certainty, uncertainty, and risk. Various decision-making models and strategies exist. Nurses’ control over decision making may vary as to amount of control and where in the process they can influence decisions. Although decision-making is more than a step-by-step process as noted by Effken and colleagues (2010) , awareness of the components, process, and strategies of decision making contributes to effectiveness in nursing leadership and management decision making. The basic elements of decision making, which enhances day to day activities, contributes to strategic planning and solves problems can be summarized into the following two parts: (1) identifying the goal for decision-making, and (2) making the decision. According to Guo (2008, p. 120) , the steps of the decision-making process can be illustrated as follows, using DECIDE: •  D efine the problem and determine why anything should be done about it and explore what could be happening. •  E stablish desirable criteria for what you want to accomplish. What should stay the same and what can be done to avoid future problems? •  C onsider all possible alternative choices that will accomplish the desired goal or criteria for problem solution. •  I dentify the best choice or alternative based on experience, intuition, experimentation. •  D evelop and implement an action plan for problem solution. •  E valuate decision through monitoring, troubleshooting, and feedback. Notice how these steps are analogous to the traditional problem-solving process or nursing process well-known by nurses and nurse managers. Thus decision making is used to solve problems. However, decision making is more than just problem solving. Decision making may also be the result of opportunities, challenges, or more long-term leadership initiatives as opposed to being triggered by an immediate problem. In any case, the processes are virtually the same, but their purposes may be slightly different. Nurse managers use decision making in managing resources and the environment of care delivery. Decision making involves an evaluation of the effectiveness of the outcomes that result from the decision-making process itself. Whether nurse managers are the sole decision makers or facilitate group decision making, all the factors that influence the problem-solving process also impact how decisions are made: who owns the problem that will result in a decision, what is the context of the decision to be made, and what lenses or perspectives influence the decision to be made? For example, the chief executive officer may frame issues as a competitive struggle not unlike a sports event. The marketing staff may interpret problems as military battles that need to be won. Nurse executives may view concerns from a care or family frame that emphasizes collaboration and working together. Learning and understanding which analogies and perspectives offer the best view of a problem or issue are vital to effective decision making. It may be necessary for nurse managers to expand their frame of reference and be willing to consider even the most outlandish ideas. Obviously, it is important to begin the goal definition phase with staff members who are closest to the issue. That includes staff nurses in concert with their managers. Often, decisions can originate within the confines of the shared governance system that may be in place within an organization ( Dunbar et al., 2007 ). It is wise, also, to consider adding individuals who have no connection with the issue whatsoever. Often it is these “unconnected” staff members who bring new decision frames to the meeting and have the most unbiased view of the problem. One of the core competencies for all health professionals is working in interprofessional teams ( Interprofessional Education Collaborative Expert Panel, 2011 ). Therefore using interprofessional teams for problem solving and decision making can be assumed to be more effective than working in disciplinary silos. No matter who is involved in the decision-making process, the basic steps to arrive at a decision to resolve problems remain the same. One critical aspect to note, however, is that in making decisions, nurse managers must have situational awareness ( Sharma & Ivancevic, 2010 ). That is, decision makers must always consider the context in which the outcome of the decision is to occur. A decision that leads to a desired outcome on one patient care unit may lead to undesirable outcomes on another unit because the patient care environment and personnel are different. DECISION OUTCOMES When looking at outcomes, one critical aspect of decision making is to determine the desired outcome. The desired outcome may vary, according to Guo (2008) , from an ideal or short-term resolution to covering up a situation. What is desired may be (1) for a problem to go away forever, (2) to make sure that all involved in this problem are satisfied with the solution and gain some benefit from it, or (3) to obtain an ideal solution. Sometimes a quick decision is desired, and researching different aspects of the problem or allowing for participation in decision making is not appropriate. For example, in disaster management, the nurse leader will use predetermined procedures for determining roles of the various personnel involved (Coyle et al., 2007). Desired decisions can be categorized into two end points: minimal and optimal. A minimal decision results in an outcome that is sufficient, satisfies basic requirements, and minimally meets desired objectives. This is sometimes called a “satisficing” decision . An optimizing decision includes comparing all possible solutions with desired objectives and then selecting the optimal solution that best meets objectives ( Choo, 2006 ; Guo, 2008 ). In addition to these two strategies, Layman (2011) drawing from Etzioni (1986) , discussed two other strategies: mixed scanning and incrementalism. Incrementalism is slow progress toward an optimal course of action. Mixed scanning combines the stringent rationalism of optimizing with the “muddling through” approach of incrementalism to form substrategies. Optimizing has the goal of selecting the course of action with the highest payoff (maximization). Limitations of time, money, or people may prevent the decision maker from selecting the more deliberative and slower process of optimizing. Still, the decision maker needs to focus on techniques that will enhance effectiveness in decision-making situations. Barriers to effective decision making exist and, once identified, can lead to going back through the decision-making process. Flaws in thinking can create hidden traps in decision making. These are common psychological tendencies that create barriers or biases in cognitive reflection and appraisal. Six common distortions are as follows ( Hammond et al., 1998 ; 2006 ): 1.  Anchoring trap: When a decision is being considered, the mind gives a disproportionate weight to the first information it receives. Past events, trends, and numbers outweigh current and future realities. All individuals have preconceived notions and biases that influence decisions in a variety of ways. For instance the Institute of Medicine (IOM, 2001) endorsed the use of c omputerized p hysician o rder e ntry (CPOE) as one solution to reduce medication errors. Furthermore, The Centers for Medicare and Medicaid Services has set forth meaningful use criteria for implementation of CPOE as well as electronic health records (EHR). Despite incentive payments for implementing EHR ( HFMA P & P Board, 2012 ), the financial costs involved, human-factor errors and work-flow issues can hamper successful implementation ( Campbell et al., 2006 ). 2.  Status-quo trap: Decision makers display a strong bias toward alternatives that perpetuate the status quo. In the face or rapid change in the environment, past practices that exhibit any sense of permanence provide managers with a feeling of security. 3.  Sunk-cost trap: Past decisions become sunk costs, and new choices are often made in a way that justifies past choices. This may result in becoming trapped by an escalation of commitment. Because of rapid, ongoing advances in medical technology, managers are frequently pressured to replace existing equipment before it is fully depreciated. If the new equipment provides a higher level of quality at a lower cost, the sunk cost of the existing equipment is irrelevant to the decision-making process. However, managers may delay purchasing new equipment and forgo subsequent savings because the equipment has yet to reach the end of its useful life. 4.  Confirming-evidence trap: Kahneman and colleagues (2011) noted that decision makers also fall into the trap of confirmation bias where contradictory data are ignored. This bias leads people to seek out information that supports an existing instinct or point of view while avoiding contradictory evidence. A typical example is favoring new technology over less glamorous alternatives. A decision maker may become so enamored by technological solutions (and slick vendor demonstrations) that he or she may unconsciously decide in favor of these systems even though strong evidence supports implementing less costly solutions first. 5.  Framing trap: The way a problem is initially framed profoundly influences the choices made. Different framing of the same problem can lead to different decision responses. A decision frame can be viewed as a window into the varied reasons a problem exists. As implied by the word frame , individuals may perceive problems only within the boundaries of their own frame. The human resources director may perceive a staffing shortage as a compensation problem, the chief financial officer as an insurance reimbursement issue, the director of education as a training issue, and the chief nursing officer as a work environment problem. Obviously all these issues may contribute, in part, to the problem; however, each person, in looking through his or her individual frame, sees only that portion with which he or she is most familiar ( Layman, 2011 ). 6.  Estimating and forecasting traps: People make estimates or forecasts about uncertain events, but their minds are not calibrated for making estimates in the face of uncertainty. The notion that experience is the parent of wisdom suggests that mature managers, over the course of their careers, learn from their mistakes. It is reasonable to assume that the knowledge gained from a manager’s failed projects would be applied to future decisions. Whether right or wrong, humans tend to take credit for successful projects and find ways to blame external factors on failed ones. Unfortunately, this form of overconfidence often results in overly optimistic projections in project planning. This optimism is usually buried in the analysis done before ranking alternatives and recommendations. Conversely, excessive cautiousness or prudence may also result in faulty decisions. This is called aversion bias ( Kahneman et al., 2011 ). Dramatic events may overly influence decisions because of recall and memory, exaggerating the probability of rare but catastrophic occurrences. It is important that managers objectively examine project planning assumptions in the decision-making process to ensure accurate projections. Because misperceptions, biases, and flaws in thinking can influence choices, actions related to awareness, testing, and mental discipline can be employed to ferret out errors in thinking before the stage of decision making ( Hammond et al., 1998 ). Data-driven decision making is important ( Dexter et al., 2011 ; Lamont, 2010 ; Mick, 2011 ). The electronic health record can be mined for valuable data, upon which fiscal, human resource, and patient care decisions can be made. However, the data derived can be overwhelming and cause decision makers to make less than optimal decisions. Shared decision making can help ameliorate decision traps ( Kahneman et al., 2011 ) because dissent within the group may help those accountable for the decision to prevent errors that are “motivated by self-interest” (p. 54). More alternatives can be generated by a group and more data can be gathered upon which to base the decision, rather than just using data that is more readily apparent. DECISION-MAKING SITUATIONS The situations in which decisions are made may be personal, clinical, or organizational ( Figure 4-3 ). Personal decision making is a familiar part of everyday life. Personal decisions range from multiple small daily choices to time management and career or life choices. FIGURE 4-3 Decision-making situations. Clinical decision making in nursing relates to quality of care and competency issues. According to Tanner (2006) , decision making in the clinical arena is called clinical judgment . In nursing, as with all health professions, clinical judgments should be patient-centered, use available evidence from research and other sources, and use available informatics tools (IOM, 2003). These crucial judgments should take place within the context of interprofessional collaboration. Within a hospital or other health care agency, a social network forms that is interprofessional ( Tan et al., 2005 ). This social network has to collaborate for positive change within the organization and to make clinical decisions of the highest quality. Nurses manage care and make decisions under conditions of certainty, uncertainty, and risk. For example, if research has shown that, under prescribed conditions, the selection of a specific nursing intervention is highly likely to produce a certain outcome, then the nurse in that situation faces a condition of relative certainty. An example would be the prevention of decubitus ulcers by frequent repositioning. If little knowledge is available or if the specific situation is more complex or variant from the usual, then the nurse faces uncertainty. Risk situations occur when a threat of harm to patients exists. Conditions of risk occur commonly relative to the administration of medications, crisis events, infection control, invasive procedures, and the use of technology in nursing practice. Furthermore, these conditions also apply to the administration of nursing care delivery, in which decision making is a critical function. Conditions of uncertainty and complexity are common in nursing care management. Over time, the complexity of health care processes has increased as a natural outgrowth of innovation and new technology. With computerized integration of billing, physician ordering, results of diagnostic tests, information about medications and their actions and side effects, and critical pathways and computerized charting, complexity increases more. Trying to integrate so many data points in care delivery can overwhelm the care provider who is making clinical judgments. As a result, subtle failures in any part of the information system can go unnoticed and have catastrophic outcomes. For example, if the computer system in the emergency room cannot “talk” to the system in the operating room, then errors in care management, such as giving cephalexin to patient who has an allergy can occur. If a provider fails to input critical information, such as a medication that a patient is taking, a fatal drug interaction could occur when another provider prescribes a new medication. Ready access to the Internet and online library sources can further create complexity in the decision-making process as care providers have access to more information upon which to make decisions. Readily accessible information related to evidence-based practice and information gleaned from human resources records and clinical systems can overwhelm nurse managers and leaders. Nurse leaders are coming to understand that innovation and new technology are the driving forces behind the discovery of new knowledge and improvements in patient care. Overlapping, unclear, and changing roles for nurses as a result of new technology and services create complex decision-making situations and impact the quality of care delivered (IOM, 2003). In addition, workflow interruptions can inhibit critical thinking, particularly in a chaotic environment ( Cornell et al., 2011 ; Sitterding et al., 2012 ). ADMINISTRATIVE AND ORGANIZATIONAL DECISION MAKING According to Choo (2006) , organizations use information to “make decisions that commit resources and capabilities to purposeful action” (p. 1). Nurse managers, for example, make staffing decisions and thus commit financial resources for the purpose of delivering patient care. Hospital administrators may decide to add additional services to keep up with external forces. These decisions subsequently have financial implications related to reimbursement, staffing, and the like. Etzioni (1989) noted that the traditional model for business decisions was rationalism. However, he further asserted that as information flow became more complex and faster-paced, a new decision-making model based on the use of partial information that has not been fully analyzed had begun to evolve. He called this model “humble decision making.” This approach arises in response to the need to make a decision when the amount of data exceeds the time available to analyze it. For instance, predicting the outcome of clinical and administrative decisions in health care is problematic because such processes are collectively defined as c omplex a daptive s ystems (CASs). A CAS is characterized by groups of individuals who act in unpredictable, nonlinear (not cause and effect) ways, such that one person’s actions affect all the others ( Holden, 2005 ). In CASs, humans do behave in unpredictable ways ( Tan et al., 2005 ). Critical thinking can help all health care personnel to examine these complex systems, wherein groups solve problems through complex, continually altering interactions between the environment and all involved in the decision making ( Fioratou et al., 2011 ). Situations within the environment constantly change and decision makers need to reframe their thinking as they broaden their awareness of the context of their decisions ( Sharma & Ivancevic, 2010 ). Having situation awareness is a must ( Fioratou et al., 2011 ; Sitterding et al., 2012 ). Decision makers need to make every effort to forecast unanticipated consequences of their decisions. For example if staffing is cut, what adverse events might occur (Kane et al., 2007)? Decision making is also influenced by the manager’s leadership style. A democratic/collaborative style of leadership and decision making works best in a complex adaptive system, such as a hospital, which is characterized by a large array of social relationships that can have an economic impact on an organization. Staff nurses who are not engaged in shared decision making may experience less job satisfaction and subsequently may leave an organization, leading to loss of expertise in patient care ( Gromley, 2011 ). However, the full array of leadership styles may at some time be used in the decision-making process. Vroom and Yetton (1973) proposed a classic managerial decision-making model that identified five managerial decision styles on a continuum from minimal subordinate involvement to delegation. Their model uses a contingency approach, which assumes that situational variables and personal attributes of the leader influence leader behavior and thus can affect organizational effectiveness. To diagnose the situation, the decision maker examines the following seven problem attributes: 1.  The importance of the quality of the decision 2.  Whether there is sufficient information/expertise 3.  The amount of structure to the problem 4.  The extent to which acceptance/commitment of followers is critical to implementation 5.  The probability that an autocratic decision will be accepted 6.  The motivation of followers to achieve organizational goals 7.  The extent to which conflict over preferred solutions is likely

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Six exercises for nurses to foster critical thinking

• Publish Date: Posted almost 5 years ago
• Author: by Kate Andrews

As a nurse, no matter what organization you work within, the ability to resolve issues before they turn into problems is crucial to ensure success in your role.  

To prepare for your next nursing position, we detail some fundamental critical thinking exercises that can help develop those all-important problem-solving skills.

What is critical thinking?

During your nursing studies, you will have undoubtedly come across the term ‘critical thinking’. It is the process of applying intentional higher-level thinking to describe a patient’s problem and examining the evidence-based practice in caring for them to make the right choices on the type of care that they require.

Fostering the right attributes and attitude that encourages critical thinking will help you excel in your nursing role and develop your career long into the future. These include:

The confidence to challenge convention

By nature, the nursing profession is driven by process and best practice, but sometimes the opportunity arises for individuals to enrich and change the way that things are done. This does not mean you have to upset the system, but simply that you should be confident enough to speak up and be afforded the opportunity to improve upon existing workplace practices.

Working independently

When you embark upon your career in nursing, you are likely to work under close supervision; however, certain situations may arise where there is an opportunity for you to work independently. If you have a particular skill-set or interest in a niche area, why not ask to take ownership? Not only will this demonstrate initiative and your willingness to develop in your profession, but it also improves your critical thinking skills too.

Practical experience

Practical, hands-on experience is crucial to excelling in any nursing role. Developing critical-thinking skills starts at the beginning of your career, not just in your first position but also the experience you obtain while studying. Anyone will tell you that gaining essential and varied work experience will help you secure the role that you deserve.

Working alongside leaders

There is a lot to be said about great leadership. Learning from senior nurses, not only on the job but also enquiring about their past experiences, mistakes, and learnings will help you to develop your critical thinking skills in any role.

Situational analysis

Continued professional development is a vital part of career success. It is not uncommon to be tested on what you have learned in your job. Commonly senior staff nurses may create hypothetical situations to test your critical thinking and development since starting your position. If this is not a common practice in your place of work, it is always worth asking for more training to ensure your nursing aptitude and critical thinking skills continue to evolve.

Existing case studies

Any nurse should brush up on their skills by reading case studies. These can be found in academic books or learning from a vast breadth of academic papers from established educational institutions, which are often accessible online.

Our experienced team helps to place the very best international nurses and US-based overseas graduates that have the desire to work in the US. We partner with leading healthcare organizations across 25 states who are committed to ethical, best practice long-term care nursing through practical training and development. At Conexus Medstaff, we’re passionate about building healthcare careers in the US. We’re keen to help graduates (and experienced nurses) from overseas embark on a career in nursing in America. To help you recognize what to expect from a career in long-term care nursing, download our free Conexus MedStaff Guide to Long-Term Care Nursing Careers today.

The Value of Critical Thinking in Nursing (And How to Develop It)

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In the pediatric intensive care unit, Nurse Emily faced a critical situation as eight-year-old Lily arrived with a high fever, rapid breathing, and confusion. Recognizing the signs of sepsis, Emily swiftly initiated treatment, including fluids and antibiotics. 

She ordered diagnostic tests that confirmed the diagnosis. Emily's quick thinking, timely actions, and effective communication with the medical team played a crucial role in stabilizing Lily's condition and saving her life. This fictional scenario underscores the importance of critical thinking in nursing, especially when dealing with life-threatening conditions like sepsis .

Critical thinking is an important aspect of successful nursing. We’re going to focus on why it’s important, tips for nurses to think critically, and how immersive virtual reality can help nurses develop this skill. 

What is critical thinking in nursing?

Critical thinking in nursing is the skill of analyzing information, making sound decisions, and solving healthcare problems effectively, ensuring better patient care and outcomes. 

In the above scenario, nurse Emily’s critical thinking skills could have saved 8-year-old Lily's life. 

Critical thinking, coupled with appropriate decision-making, leads to clinical judgment. Let’s explore what this means.  

Clinical judgment refers to the process by which nurses make decisions based on nursing knowledge (evidence, theories, ways/patterns of knowing), other disciplinary knowledge, critical thinking, and clinical reasoning, according to the AACN . 

There are six steps to the NCSBN Clinical Judgment Model

• 1: Recognize cues.
• 2: Analyze cues.
• 3: Prioritize hypothesis.
• 4: Generate solutions.
• 5: Take action.
• 6: Evaluate outcomes.

Strong clinical judgment skills are crucial for patient safety. In fact, studies have shown that up to 65% of adverse events in hospitals result from poor clinical decision-making and could have been prevented.

Check out our article on how UbiSim supports the six steps of clinical judgment . 

Why is critical thinking in nursing important?

In the realm of nursing, critical thinking is not merely a skill; it's the guiding light that nurses rely on to navigate the complex and ever-evolving landscape of healthcare. 

• Impacts patient care: Imagine every patient as a unique puzzle. Critical thinking is nursing’s toolkit for solving these puzzles. It enables them to analyze all the pieces of information, consider various treatment options, and make decisions that are tailor-made for each patient, leading to patient outcomes that can be life-changing.
• Helps nurses anticipate and understand patient condition changes: Sometimes, situations can evolve in the blink of an eye. Critical thinking doesn't just help nurses react; it empowers them to anticipate these changes, learning to pick up on subtle cues and signs that might signal potential issues, allowing them to act swiftly. 
• Ensures patient safety: Patient safety is a nurse’s utmost priority, and critical thinking is the compass for ensuring it. It helps them assess risks, spot potential dangers, and take preventive measures. With critical thinking, they can identify and address errors before they have a chance to escalate.
• Leads to better professional development for the nurse: A nurse’s ability to be a critical thinker doesn't just benefit patients; it also paves the way for their own growth. When they consistently demonstrate strong critical thinking skills, they earn the trust and respect of colleagues and supervisors. This opens doors to career progress and leadership roles within the healthcare system.

What are tips for nurses to improve critical thinking?

• Utilize your resources and mentors: Tap into the wealth of knowledge and experience that surrounds you. Seek guidance and advice from seasoned colleagues and mentors. They can provide valuable insights, share their experiences, and offer different perspectives on patient care. It may even be an opportunity to feel relief and validation from their experiences!
• Confront personal bias & assumptions: Bias can go undetected and can take many forms, such as size, culture, race, religion, age, sexuality, ability, socioeconomic status, gender, and more. Just being aware of these potential biases enables you to treat your patients on a level playing field. 
• Practice reflection: After a long day, the last thing a nurse wants to do is reflect, but taking a few minutes at the end of a week to consider what you did right and what could have used a different choice can contribute to better critical thinking. 
• Build confidence : Confidence plays a significant role in critical thinking. Nurses should trust in their knowledge, experience, and abilities, enabling them to approach challenges with a proactive and solution-oriented mindset. Building confidence through ongoing education, skill development, and positive reinforcement enhances critical thinking abilities in nursing practice.

Critical Thinking Using Virtual Reality

Thinking back to our situation with Nurse Emily and the eight-year-old with sepsis - imagine new nurse trainees starting on the job who have never dealt with sepsis. Do you want to wait until they experience it to have them implement what they learned in class? Or do you want to train them by enabling them to step into virtual reality and practice what it’s like to respond to a patient with sepsis? 

This is what Boston Children’s Hospital is doing - training their new nurses on how to effectively recognize and deal with sepsis using UbiSim’s immersive virtual reality platform. Read their case study to learn more!

As an integral center of UbiSim's content team, Ginelle pens stories on the rapidly changing landscape of VR in nursing simulation. Ginelle is committed to elevating the voices of practicing nurses, nurse educators, and program leaders who are making a difference.

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Chapter 2 - Prioritization

2.1. prioritization introduction, learning objectives.

• Prioritize nursing care based on patient acuity

• Use principles of time management to organize work

• Analyze effectiveness of time management strategies

• Use critical thinking to prioritize nursing care for patients

• Apply a framework for prioritization (e.g., Maslow, ABCs)

“So much to do, so little time.” This is a common mantra of today’s practicing nurse in various health care settings. Whether practicing in acute inpatient care, long-term care, clinics, home care, or other agencies, nurses may feel there is “not enough of them to go around.”

The health care system faces a significant challenge in balancing the ever-expanding task of meeting patient care needs with scarce nursing resources that has even worsened as a result of the COVID-19 pandemic. With a limited supply of registered nurses, nurse managers are often challenged to implement creative staffing practices such as sending staff to units where they do not normally work (i.e., floating), implementing mandatory staffing and/or overtime, utilizing travel nurses, or using other practices to meet patient care demands.[ 1 ] Staffing strategies can result in nurses experiencing increased patient assignments and workloads, extended shifts, or temporary suspension of paid time off. Nurses may receive a barrage of calls and text messages offering “extra shifts” and bonus pay, and although the extra pay may be welcomed, they often eventually feel burnt out trying to meet the ever-expanding demands of the patient-care environment.

A novice nurse who is still learning how to navigate the complex health care environment and provide optimal patient care may feel overwhelmed by these conditions. Novice nurses frequently report increased levels of stress and disillusionment as they transition to the reality of the nursing role.[ 2 ] How can we address this professional dilemma and enhance the novice nurse’s successful role transition to practice? The novice nurse must enter the profession with purposeful tools and strategies to help prioritize tasks and manage time so they can confidently address patient care needs, balance role demands, and manage day-to-day nursing activities.

Let’s take a closer look at the foundational concepts related to prioritization and time management in the nursing profession.

2.2. TENETS OF PRIORITIZATION

Prioritization.

As new nurses begin their career, they look forward to caring for others, promoting health, and saving lives. However, when entering the health care environment, they often discover there are numerous and competing demands for their time and attention. Patient care is often interrupted by call lights, rounding physicians, and phone calls from the laboratory department or other interprofessional team members. Even individuals who are strategic and energized in their planning can feel frustrated as their task lists and planned patient-care activities build into a long collection of “to dos.”

Without utilization of appropriate prioritization strategies, nurses can experience  time scarcity , a feeling of racing against a clock that is continually working against them. Functioning under the burden of time scarcity can cause feelings of frustration, inadequacy, and eventually burnout. Time scarcity can also impact patient safety, resulting in adverse events and increased mortality.[ 1 ] Additionally, missed or rushed nursing activities can negatively impact patient satisfaction scores that ultimately affect an institution’s reimbursement levels.

It is vital for nurses to plan patient care and implement their task lists while ensuring that critical interventions are safely implemented first. Identifying priority patient problems and implementing priority interventions are skills that require ongoing cultivation as one gains experience in the practice environment.[ 2 ] To develop these skills, students must develop an understanding of organizing frameworks and prioritization processes for delineating care needs. These frameworks provide structure and guidance for meeting the multiple and ever-changing demands in the complex health care environment.

Let’s consider a clinical scenario in the following box to better understand the implications of prioritization and outcomes.

Imagine you are beginning your shift on a busy medical-surgical unit. You receive a handoff report on four medical-surgical patients from the night shift nurse:

• Patient A is a 34-year-old total knee replacement patient, post-op Day 1, who had an uneventful night. It is anticipated that she will be discharged today and needs patient education for self-care at home.

• Patient B is a 67-year-old male admitted with weakness, confusion, and a suspected urinary tract infection. He has been restless and attempting to get out of bed throughout the night. He has a bed alarm in place.

• Patient C is a 49-year-old male, post-op Day 1 for a total hip replacement. He has been frequently using his patient-controlled analgesia (PCA) pump and last rated his pain as a “6.”

• Patient D is a 73-year-old male admitted for pneumonia. He has been hospitalized for three days and receiving intravenous (IV) antibiotics. His next dose is due in an hour. His oxygen requirements have decreased from 4 L/minute of oxygen by nasal cannula to 2 L/minute by nasal cannula.

Based on the handoff report you received, you ask the nursing assistant to check on Patient B while you do an initial assessment on Patient D. As you are assessing Patient D’s oxygenation status, you receive a phone call from the laboratory department relating a critical lab value on Patient C, indicating his hemoglobin is low. The provider calls and orders a STAT blood transfusion for Patient C. Patient A rings the call light and states she and her husband have questions about her discharge and are ready to go home. The nursing assistant finds you and reports that Patient B got out of bed and experienced a fall during the handoff reports.

It is common for nurses to manage multiple and ever-changing tasks and activities like this scenario, illustrating the importance of self-organization and priority setting. This chapter will further discuss the tools nurses can use for prioritization.

2.3. TOOLS FOR PRIORITIZING

Prioritization of care for multiple patients while also performing daily nursing tasks can feel overwhelming in today’s fast-paced health care system. Because of the rapid and ever-changing conditions of patients and the structure of one’s workday, nurses must use organizational frameworks to prioritize actions and interventions. These frameworks can help ease anxiety, enhance personal organization and confidence, and ensure patient safety.

Acuity and intensity are foundational concepts for prioritizing nursing care and interventions.  Acuity  refers to the level of patient care that is required based on the severity of a patient’s illness or condition. For example, acuity may include characteristics such as unstable vital signs, oxygenation therapy, high-risk IV medications, multiple drainage devices, or uncontrolled pain. A “high-acuity” patient requires several nursing interventions and frequent nursing assessments.

Intensity addresses the time needed to complete nursing care and interventions such as providing assistance with activities of daily living (ADLs), performing wound care, or administering several medication passes. For example, a “high-intensity” patient generally requires frequent or long periods of psychosocial, educational, or hygiene care from nursing staff members. High-intensity patients may also have increased needs for safety monitoring, familial support, or other needs.[ 1 ]

Many health care organizations structure their staffing assignments based on acuity and intensity ratings to help provide equity in staff assignments. Acuity helps to ensure that nursing care is strategically divided among nursing staff. An equitable assignment of patients benefits both the nurse and patient by helping to ensure that patient care needs do not overwhelm individual staff and safe care is provided.

Organizations use a variety of systems when determining patient acuity with rating scales based on nursing care delivery, patient stability, and care needs. See an example of a patient acuity tool published in the  American Nurse  in Table 2.3 .[ 2 ] In this example, ratings range from 1 to 4, with a rating of 1 indicating a relatively stable patient requiring minimal individualized nursing care and intervention. A rating of 2 reflects a patient with a moderate risk who may require more frequent intervention or assessment. A rating of 3 is attributed to a complex patient who requires frequent intervention and assessment. This patient might also be a new admission or someone who is confused and requires more direct observation. A rating of 4 reflects a high-risk patient. For example, this individual may be experiencing frequent changes in vital signs, may require complex interventions such as the administration of blood transfusions, or may be experiencing significant uncontrolled pain. An individual with a rating of 4 requires more direct nursing care and intervention than a patient with a rating of 1 or 2. [3]

Example of a Patient Acuity Tool [ 4 ]

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Read more about using a  patient acuity tool on a medical-surgical unit.

Rating scales may vary among institutions, but the principles of the rating system remain the same. Organizations include various patient care elements when constructing their staffing plans for each unit. Read more information about staffing models and acuity in the following box.

Staffing Models and Acuity

Organizations that base staffing on acuity systems attempt to evenly staff patient assignments according to their acuity ratings. This means that when comparing patient assignments across nurses on a unit, similar acuity team scores should be seen with the goal of achieving equitable and safe division of workload across the nursing team. For example, one nurse should not have a total acuity score of 6 for their patient assignments while another nurse has a score of 15. If this situation occurred, the variation in scoring reflects a discrepancy in workload balance and would likely be perceived by nursing peers as unfair. Using  acuity-rating staffing models  is helpful to reflect the individualized nursing care required by different patients.

Alternatively, nurse staffing models may be determined by staffing ratio.  Ratio-based staffing models  are more straightforward in nature, where each nurse is assigned care for a set number of patients during their shift. Ratio-based staffing models may be useful for administrators creating budget requests based on the number of staff required for patient care, but can lead to an inequitable division of work across the nursing team when patient acuity is not considered. Increasingly complex patients require more time and interventions than others, so a blend of both ratio and acuity-based staffing is helpful when determining staffing assignments.[ 5 ]

As a practicing nurse, you will be oriented to the elements of acuity ratings within your health care organization, but it is also important to understand how you can use these acuity ratings for your own prioritization and task delineation. Let’s consider the Scenario B in the following box to better understand how acuity ratings can be useful for prioritizing nursing care.

You report to work at 6 a.m. for your nursing shift on a busy medical-surgical unit. Prior to receiving the handoff report from your night shift nursing colleagues, you review the unit staffing grid and see that you have been assigned to four patients to start your day. The patients have the following acuity ratings:

Patient A: 45-year-old patient with paraplegia admitted for an infected sacral wound, with an acuity rating of 4.

Patient B: 87-year-old patient with pneumonia with a low grade fever of 99.7 F and receiving oxygen at 2 L/minute via nasal cannula, with an acuity rating of 2.

Patient C: 63-year-old patient who is postoperative Day 1 from a right total hip replacement and is receiving pain management via a PCA pump, with an acuity rating of 2.

Patient D: 83-year-old patient admitted with a UTI who is finishing an IV antibiotic cycle and will be discharged home today, with an acuity rating of 1.

Based on the acuity rating system, your patient assignment load receives an overall acuity score of 9. Consider how you might use their acuity ratings to help you prioritize your care. Based on what is known about the patients related to their acuity rating, whom might you identify as your care priority? Although this can feel like a challenging question to answer because of the many unknown elements in the situation using acuity numbers alone, Patient A with an acuity rating of 4 would be identified as the care priority requiring assessment early in your shift.

Although acuity can a useful tool for determining care priorities, it is important to recognize the limitations of this tool and consider how other patient needs impact prioritization.

Maslow’s Hierarchy of Needs

When thinking back to your first nursing or psychology course, you may recall a historical theory of human motivation based on various levels of human needs called Maslow’s Hierarchy of Needs.  Maslow’s Hierarchy of Needs  reflects foundational human needs with progressive steps moving towards higher levels of achievement. This hierarchy of needs is traditionally represented as a pyramid with the base of the pyramid serving as essential needs that must be addressed before one can progress to another area of need.[ 6 ] See Figure 2.1  [ 7 ] for an illustration of Maslow’s Hierarchy of Needs.

Maslow’s Hierarchy of Needs places physiological needs as the foundational base of the pyramid.[ 8 ] Physiological needs include oxygen, food, water, sex, sleep, homeostasis, and excretion. The second level of Maslow’s hierarchy reflects safety needs. Safety needs include elements that keep individuals safe from harm. Examples of safety needs in health care include fall precautions. The third level of Maslow’s hierarchy reflects emotional needs such as love and a sense of belonging. These needs are often reflected in an individual’s relationships with family members and friends. The top two levels of Maslow’s hierarchy include esteem and self-actualization. An example of addressing these needs in a health care setting is helping an individual build self-confidence in performing blood glucose checks that leads to improved self-management of their diabetes.

So how does Maslow’s theory impact prioritization? To better understand the application of Maslow’s theory to prioritization, consider Scenario C in the following box.

You are an emergency response nurse working at a local shelter in a community that has suffered a devastating hurricane. Many individuals have relocated to the shelter for safety in the aftermath of the hurricane. Much of the community is still without electricity and clean water, and many homes have been destroyed. You approach a young woman who has a laceration on her scalp that is bleeding through her gauze dressing. The woman is weeping as she describes the loss of her home stating, “I have lost everything! I just don’t know what I am going to do now. It has been a day since I have had water or anything to drink. I don’t know where my sister is, and I can’t reach any of my family to find out if they are okay!”

Despite this relatively brief interaction, this woman has shared with you a variety of needs. She has demonstrated a need for food, water, shelter, homeostasis, and family. As the nurse caring for her, it might be challenging to think about where to begin her care. These thoughts could be racing through your mind:

Should I begin to make phone calls to try and find her family? Maybe then she would be able to calm down.

Should I get her on the list for the homeless shelter so she wouldn’t have to worry about where she will sleep tonight?

She hasn’t eaten in awhile; I should probably find her something to eat.

All of these needs are important and should be addressed at some point, but Maslow’s hierarchy provides guidance on what needs must be addressed first. Use the foundational level of Maslow’s pyramid of physiological needs as the top priority for care. The woman is bleeding heavily from a head wound and has had limited fluid intake. As the nurse caring for this patient, it is important to immediately intervene to stop the bleeding and restore fluid volume. Stabilizing the patient by addressing her physiological needs is required before undertaking additional measures such as contacting her family. Imagine if instead you made phone calls to find the patient’s family and didn’t address the bleeding or dehydration – you might return to a severely hypovolemic patient who has deteriorated and may be near death. In this example, prioritizing emotional needs above physiological needs can lead to significant harm to the patient.

Although this is a relatively straightforward example, the principles behind the application of Maslow’s hierarchy are essential. Addressing physiological needs before progressing toward additional need categories concentrates efforts on the most vital elements to enhance patient well-being. Maslow’s hierarchy provides the nurse with a helpful framework for identifying and prioritizing critical patient care needs.

Airway, breathing, and circulation, otherwise known by the mnemonic “ABCs,” are another foundational element to assist the nurse in prioritization. Like Maslow’s hierarchy, using the ABCs to guide decision-making concentrates on the most critical needs for preserving human life. If a patient does not have a patent airway, is unable to breathe, or has inadequate circulation, very little of what else we do matters. The patient’s  ABCs  are reflected in Maslow’s foundational level of physiological needs and direct critical nursing actions and timely interventions. Let’s consider Scenario D in the following box regarding prioritization using the ABCs and the physiological base of Maslow’s hierarchy.

You are a nurse on a busy cardiac floor charting your morning assessments on a computer at the nurses’ station. Down the hall from where you are charting, two of your assigned patients are resting comfortably in Room 504 and Room 506. Suddenly, both call lights ring from the rooms, and you answer them via the intercom at the nurses’ station.

Room 504 has an 87-year-old male who has been admitted with heart failure, weakness, and confusion. He has a bed alarm for safety and has been ringing his call bell for assistance appropriately throughout the shift. He requires assistance to get out of bed to use the bathroom. He received his morning medications, which included a diuretic about 30 minutes previously, and now reports significant urge to void and needs assistance to the bathroom.

Room 506 has a 47-year-old woman who was hospitalized with new onset atrial fibrillation with rapid ventricular response. The patient underwent a cardioversion procedure yesterday that resulted in successful conversion of her heart back into normal sinus rhythm. She is reporting via the intercom that her “heart feels like it is doing that fluttering thing again” and she is having chest pain with breathlessness.

Based upon these two patient scenarios, it might be difficult to determine whom you should see first. Both patients are demonstrating needs in the foundational physiological level of Maslow’s hierarchy and require assistance. To prioritize between these patients’ physiological needs, the nurse can apply the principles of the ABCs to determine intervention. The patient in Room 506 reports both breathing and circulation issues, warning indicators that action is needed immediately. Although the patient in Room 504 also has an urgent physiological elimination need, it does not overtake the critical one experienced by the patient in Room 506. The nurse should immediately assess the patient in Room 506 while also calling for assistance from a team member to assist the patient in Room 504.

Prioritizing what should be done and when it can be done can be a challenging task when several patients all have physiological needs. Recently, there has been professional acknowledgement of the cognitive challenge for novice nurses in differentiating physiological needs. To expand on the principles of prioritizing using the ABCs, the CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to guide prioritization based on identifying the differences among Critical needs, Urgent needs, Routine needs, and Extras.[ 9 ]

“Critical” patient needs require immediate action. Examples of critical needs align with the ABCs and Maslow’s physiological needs, such as symptoms of respiratory distress, chest pain, and airway compromise. No matter the complexity of their shift, nurses can be assured that addressing patients’ critical needs is the correct prioritization of their time and energies.

After critical patient care needs have been addressed, nurses can then address “urgent” needs. Urgent needs are characterized as needs that cause patient discomfort or place the patient at a significant safety risk.[ 10 ]

The third part of the CURE hierarchy reflects “routine” patient needs. Routine patient needs can also be characterized as “typical daily nursing care” because the majority of a standard nursing shift is spent addressing routine patient needs. Examples of routine daily nursing care include actions such as administering medication and performing physical assessments.[ 11 ] Although a nurse’s typical shift in a hospital setting includes these routine patient needs, they do not supersede critical or urgent patient needs.

The final component of the CURE hierarchy is known as “extras.” Extras refer to activities performed in the care setting to facilitate patient comfort but are not essential.[ 12 ] Examples of extra activities include providing a massage for comfort or washing a patient’s hair. If a nurse has sufficient time to perform extra activities, they contribute to a patient’s feeling of satisfaction regarding their care, but these activities are not essential to achieve patient outcomes.

Let’s apply the CURE mnemonic to patient care in the following box.

If we return to Scenario D regarding patients in Room 504 and 506, we can see the patient in Room 504 is having urgent needs. He is experiencing a physiological need to urgently use the restroom and may also have safety concerns if he does not receive assistance and attempts to get up on his own because of weakness. He is on a bed alarm, which reflects safety considerations related to his potential to get out of bed without assistance. Despite these urgent indicators, the patient in Room 506 is experiencing a critical need and takes priority. Recall that critical needs require immediate nursing action to prevent patient deterioration. The patient in Room 506 with a rapid, fluttering heartbeat and shortness of breath has a critical need because without prompt assessment and intervention, their condition could rapidly decline and become fatal.

In addition to using the identified frameworks and tools to assist with priority setting, nurses must also look at their patients’ data cues to help them identify care priorities.  Data cues  are pieces of significant clinical information that direct the nurse toward a potential clinical concern or a change in condition. For example, have the patient’s vital signs worsened over the last few hours? Is there a new laboratory result that is concerning? Data cues are used in conjunction with prioritization frameworks to help the nurse holistically understand the patient’s current status and where nursing interventions should be directed. Common categories of data clues include acute versus chronic conditions, actual versus potential problems, unexpected versus expected conditions, information obtained from the review of a patient’s chart, and diagnostic information.

Acute Versus Chronic Conditions

A common data cue that nurses use to prioritize care is considering if a condition or symptom is acute or chronic.  Acute conditions  have a sudden and severe onset. These conditions occur due to a sudden illness or injury, and the body often has a significant response as it attempts to adapt.  Chronic conditions  have a slow onset and may gradually worsen over time. The difference between an acute versus a chronic condition relates to the body’s adaptation response. Individuals with chronic conditions often experience less symptom exacerbation because their body has had time to adjust to the illness or injury. Let’s consider an example of two patients admitted to the medical-surgical unit complaining of pain in Scenario E in the following box.

As part of your patient assignment on a medical-surgical unit, you are caring for two patients who both ring the call light and report pain at the start of the shift. Patient A was recently admitted with acute appendicitis, and Patient B was admitted for observation due to weakness. Not knowing any additional details about the patients’ conditions or current symptoms, which patient would receive priority in your assessment? Based on using the data cue of acute versus chronic conditions, Patient A with a diagnosis of acute appendicitis would receive top priority for assessment over a patient with chronic pain due to osteoarthritis. Patients experiencing acute pain require immediate nursing assessment and intervention because it can indicate a change in condition. Acute pain also elicits physiological effects related to the stress response, such as elevated heart rate, blood pressure, and respiratory rate, and should be addressed quickly.

Actual Versus Potential Problems

Nursing diagnoses and the nursing care plan have significant roles in directing prioritization when interpreting assessment data cues.  Actual problems  refer to a clinical problem that is actively occurring with the patient. A  risk problem  indicates the patient may potentially experience a problem but they do not have current signs or symptoms of the problem actively occurring.

Consider an example of prioritizing actual and potential problems in Scenario F in the following box.

A 74-year-old woman with a previous history of chronic obstructive pulmonary disease (COPD) is admitted to the hospital for pneumonia. She has generalized weakness, a weak cough, and crackles in the bases of her lungs. She is receiving IV antibiotics, fluids, and oxygen therapy. The patient can sit at the side of the bed and ambulate with the assistance of staff, although she requires significant encouragement to ambulate.

Nursing diagnoses are established for this patient as part of the care planning process. One nursing diagnosis for this patient is  Ineffective Airway Clearance . This nursing diagnosis is an actual problem because the patient is currently exhibiting signs of poor airway clearance with an ineffective cough and crackles in the lungs. Nursing interventions related to this diagnosis include coughing and deep breathing, administering nebulizer treatment, and evaluating the effectiveness of oxygen therapy. The patient also has the nursing diagnosis  Risk for   Skin Breakdown  based on her weakness and lack of motivation to ambulate. Nursing interventions related to this diagnosis include repositioning every two hours and assisting with ambulation twice daily.

The established nursing diagnoses provide cues for prioritizing care. For example, if the nurse enters the patient’s room and discovers the patient is experiencing increased shortness of breath, nursing interventions to improve the patient’s respiratory status receive top priority before attempting to get the patient to ambulate.

Although there may be times when risk problems may supersede actual problems, looking to the “actual” nursing problems can provide clues to assist with prioritization.

Unexpected Versus Expected Conditions

In a similar manner to using acute versus chronic conditions as a cue for prioritization, it is also important to consider if a client’s signs and symptoms are “expected” or “unexpected” based on their overall condition.  Unexpected conditions  are findings that are not likely to occur in the normal progression of an illness, disease, or injury.  Expected conditions  are findings that are likely to occur or are anticipated in the course of an illness, disease, or injury. Unexpected findings often require immediate action by the nurse.

Let’s apply this tool to the two patients previously discussed in Scenario E. As you recall, both Patient A (with acute appendicitis) and Patient B (with weakness and diagnosed with osteoarthritis) are reporting pain. Acute pain typically receives priority over chronic pain. But what if both patients are also reporting nausea and have an elevated temperature? Although these symptoms must be addressed in both patients, they are “expected” symptoms with acute appendicitis (and typically addressed in the treatment plan) but are “unexpected” for the patient with osteoarthritis. Critical thinking alerts you to the unexpected nature of these symptoms in Patient B, so they receive priority for assessment and nursing interventions.

Handoff Report/Chart Review

Additional data cues that are helpful in guiding prioritization come from information obtained during a handoff nursing report and review of the patient chart. These data cues can be used to establish a patient’s baseline status and prioritize new clinical concerns based on abnormal assessment findings. Let’s consider Scenario G in the following box based on cues from a handoff report and how it might be used to help prioritize nursing care.

Imagine you are receiving the following handoff report from the night shift nurse for a patient admitted to the medical-surgical unit with pneumonia:

At the beginning of my shift, the patient was on room air with an oxygen saturation of 93%. She had slight crackles in both bases of her posterior lungs. At 0530, the patient rang the call light to go to the bathroom. As I escorted her to the bathroom, she appeared slightly short of breath. Upon returning the patient to bed, I rechecked her vital signs and found her oxygen saturation at 88% on room air and respiratory rate of 20. I listened to her lung sounds and noticed more persistent crackles and coarseness than at bedtime. I placed the patient on 2 L/minute of oxygen via nasal cannula. Within 5 minutes, her oxygen saturation increased to 92%, and she reported increased ease in respiration.

Based on the handoff report, the night shift nurse provided substantial clinical evidence that the patient may be experiencing a change in condition. Although these changes could be attributed to lack of lung expansion that occurred while the patient was sleeping, there is enough information to indicate to the oncoming nurse that follow-up assessment and interventions should be prioritized for this patient because of potentially worsening respiratory status. In this manner, identifying data cues from a handoff report can assist with prioritization.

Now imagine the night shift nurse had not reported this information during the handoff report. Is there another method for identifying potential changes in patient condition? Many nurses develop a habit of reviewing their patients’ charts at the start of every shift to identify trends and “baselines” in patient condition. For example, a chart review reveals a patient’s heart rate on admission was 105 beats per minute. If the patient continues to have a heart rate in the low 100s, the nurse is not likely to be concerned if today’s vital signs reveal a heart rate in the low 100s. Conversely, if a patient’s heart rate on admission was in the 60s and has remained in the 60s throughout their hospitalization, but it is now in the 100s, this finding is an important cue requiring prioritized assessment and intervention.

Diagnostic Information

Diagnostic results are also important when prioritizing care. In fact, the National Patient Safety Goals from The Joint Commission include prompt reporting of important test results. New abnormal laboratory results are typically flagged in a patient’s chart or are reported directly by phone to the nurse by the laboratory as they become available. Newly reported abnormal results, such as elevated blood levels or changes on a chest X-ray, may indicate a patient’s change in condition and require additional interventions. For example, consider Scenario H in which you are the nurse providing care for five medical-surgical patients.

You completed morning assessments on your assigned five patients. Patient A previously underwent a total right knee replacement and will be discharged home today. You are about to enter Patient A’s room to begin discharge teaching when you receive a phone call from the laboratory department, reporting a critical hemoglobin of 6.9 gm/dL on Patient B. Rather than enter Patient A’s room to perform discharge teaching, you immediately reprioritize your care. You call the primary provider to report Patient B’s critical hemoglobin level and determine if additional intervention, such as a blood transfusion, is required.

2.4. CRITICAL THINKING AND CLINICAL REASONING

Prioritization of patient care should be grounded in critical thinking rather than just a checklist of items to be done.  Critical thinking  is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[ 1 ] Certainly, there are many actions that nurses must complete during their shift, but nursing requires adaptation and flexibility to meet emerging patient needs. It can be challenging for a novice nurse to change their mindset regarding their established “plan” for the day, but the sooner a nurse recognizes prioritization is dictated by their patients’ needs, the less frustration the nurse might experience. Prioritization strategies include collection of information and utilization of clinical reasoning to determine the best course of action.  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.” [2]

When nurses use critical thinking and clinical reasoning skills, they set forth on a purposeful course of intervention to best meet patient-care needs. Rather than focusing on one’s own priorities, nurses utilizing critical thinking and reasoning skills recognize their actions must be responsive to their patients. For example, a nurse using critical thinking skills understands that scheduled morning medications for their patients may be late if one of the patients on their care team suddenly develops chest pain. Many actions may be added or removed from planned activities throughout the shift based on what is occurring holistically on the patient-care team.

Additionally, in today’s complex health care environment, it is important for the novice nurse to recognize the realities of the current health care environment. Patients have become increasingly complex in their health care needs, and organizations are often challenged to meet these care needs with limited staffing resources. It can become easy to slip into the mindset of disenchantment with the nursing profession when first assuming the reality of patient-care assignments as a novice nurse. The workload of a nurse in practice often looks and feels quite different than that experienced as a nursing student. As a nursing student, there may have been time for lengthy conversations with patients and their family members, ample time to chart, and opportunities to offer personal cares, such as a massage or hair wash. Unfortunately, in the time-constrained realities of today’s health care environment, novice nurses should recognize that even though these “extra” tasks are not always possible, they can still provide quality, safe patient care using the “CURE” prioritization framework. Rather than feeling frustrated about “extras” that cannot be accomplished in time-constrained environments, it is vital to use prioritization strategies to ensure appropriate actions are taken to complete what must be done. With increased clinical experience, a novice nurse typically becomes more comfortable with prioritizing and reprioritizing care.

Prioritization of patient care should be grounded in critical thinking rather than just a checklist of items to be done.  Critical thinking  is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[ 1 ] Certainly, there are many actions that nurses must complete during their shift, but nursing requires adaptation and flexibility to meet emerging patient needs. It can be challenging for a novice nurse to change their mindset regarding their established “plan” for the day, but the sooner a nurse recognizes prioritization is dictated by their patients’ needs, the less frustration the nurse might experience. Prioritization strategies include collection of information and utilization of clinical reasoning to determine the best course of action.  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.”[ 2 ]

2.7. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activities are provided as immediate feedback.)

The CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to help guide prioritization based on identifying the differences among  C ritical needs,  U rgent needs,  R outine needs, and  E xtras.

You are the nurse caring for the patients in the following table. For each patient, indicate if this is a “critical,” “urgent,” “routine,” or “extra” need.

II. GLOSSARY

Airway, breathing, and circulation.

Nursing problems currently occurring with the patient.

The level of patient care that is required based on the severity of a patient’s illness or condition.

A staffing model used to make patient assignments that reflects the individualized nursing care required for different types of patients.

Conditions having a sudden onset.

Conditions that have a slow onset and may gradually worsen over time.

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.”[ 1 ]

A broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[ 2 ]

A strategy for prioritization based on identifying “critical” needs, “urgent” needs, “routine” needs, and “extras.”

Pieces of significant clinical information that direct the nurse toward a potential clinical concern or a change in condition.

Conditions that are likely to occur or anticipated in the course of an illness, disease, or injury.

Prioritization strategies often reflect the foundational elements of physiological needs and safety and progr ess toward higher levels.

A staffing model used to make patient assignments in terms of one nurse caring for a set number of patients.

A nursing problem that reflects that a patient may experience a problem but does not currently have signs reflecting the problem is actively occurring.

A prioritization strategy including the review of planned tasks and allocation of time believed to be required to complete each task.

A feeling of racing against a clock that is continually working against you.

Conditions that are not likely to occur in the normal progression of an illness, disease, or injury.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 2 - Prioritization.
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• PRIORITIZATION INTRODUCTION
• TENETS OF PRIORITIZATION
• TOOLS FOR PRIORITIZING
• CRITICAL THINKING AND CLINICAL REASONING
• LEARNING ACTIVITIES

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International Journal of Nursing Science

p-ISSN: 2167-7441    e-ISSN: 2167-745X

2018;  8(4): 73-76

doi:10.5923/j.nursing.20180804.03

Critical Thinking and Decision Making in Nursing Administration: A Philosophical Analysis

Lilian G. Tumapang

College of Advanced Education, Ifugao State University, Nayon, Lamut, Ifugao, Philippines

Copyright © 2018 The Author(s). Published by Scientific & Academic Publishing.

Nurse administrators are compelled to manage the dynamic health care system and advance excellence at every level of the organization. A challenge that besets nursing management points at developing the capacity of nurse executives to apply critical thinking in making decisions and establishing priorities in the clinical setting. To this direction, the theory titled “Critical thinking and decision making in nursing administration” aims to elucidate the association of critical thinking to the decision-making process in the context of nursing management. As for the philosophical standpoint, the author advocates for the “no-one-philosophical view-fits-all” approach or perspective. The key point of analysis would lie in the employment of the concepts, ideas, beliefs, and notions derived a given phenomenon.

Keywords: Critical thinking, Decision-making, Nursing administration, Philosophical perspective

Cite this paper: Lilian G. Tumapang, Critical Thinking and Decision Making in Nursing Administration: A Philosophical Analysis, International Journal of Nursing Science , Vol. 8 No. 4, 2018, pp. 73-76. doi: 10.5923/j.nursing.20180804.03.

Article Outline

1. introduction, 2. philosophical underpinnings, 3. the theory of critical thinking and decision-making in nursing administration, 3.1. theoretical assumptions, 3.2. propositions, 3.3. key concepts, 3.4. metaparadigm of nursing according to the author’s constructivist perspective, 3.5. application to nursing, 4. testing of the theory, 5. conclusions, acknowledgements.

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Critical Thinking of Nurse Managers Related to Staff RNs’ Perceptions of the Practice Environment

2010, Journal of Nursing Scholarship

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Sana Ibrahim

Client – centered Nursing Care Journal

Background: One of the main goals of nursing education is training them to provide proper medical services to patients as well as healthy people in the community and health centers using their knowledge and specific skills. This service requires nurses’ critical thinking and effective learning. The purpose of this study was to determine the impact of critical thinking skills on decision making styles of nursing management. Methods: This interventional study is of semi-experimental kind and conducted on 60 nursing managers (30 in each group of the samples). In the beginning of the study, California questionnaire of critical thinking scale was completed by the participants. The intervention group received critical thinking skills training for 8 sessions (4 theoretical sessions and 4 practical sessions). A week after the end of the last training session, the same questionnaires were completed by the participants. Results: Prior to conducting the study, 2 groups were not significantly different regarding demographic variables. The mean score of critical thinking and decision making style of the control group was the same before and after intervention, but in the intervention group, the mean score increased. Conclusion: Teaching critical thinking skills increases the level of critical thinking and the use of rational decision making style by nurses. Nurses’ cognitive ability, especially their ability to process information and make decisions, is a major component of their performance and requires possession of critical thinking. Thus, universities of medical sciences are suggested to provide necessary support to allow the development of professional competencies, decision making, problem-solving, and selfsufficiency skills, which are influenced by the ability for critical thinking.

ijbhtnet.com

Mehmet Mazı

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Susan Wesmiller

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Fusun Terzioglu

Study rationale The development of a problem-solving approach to nursing has been one of the more important changes in nursing during the last decade. Nurse Managers need to have effective problem-solving and management skills to be able to decrease the cost of the health care and to increase the quality of care.Study aim This descriptive study was conducted to determine the perceived problem-solving ability of nurse managers.Method From a population of 87 nurse managers, 71 were selected using the stratified random sampling method, 62 nurse managers agreed to participate. Data were collected through a questionnaire including demographic information and a problem-solving inventory. The problem-solving inventory was developed by Heppner and Petersen in 1982, and validity and readability studies were done. It was adapted to Turkish by Şahin et al (1993). The acquired data have been evaluated on the software spss 10.0 programme, using percentages, mean values, one-way anova and t-test (independent samples t-test).Results Most of the nurses had 11 or more years of working experience (71%) and work as charge nurses in the clinics. It was determined that 69.4% of the nurse managers did not have any educational training in administration. The most encountered problems stated were issues related to managerial (30.6%) and professional staff (25.8%). It was identified that nurse managers who had received education about management, following scientific publication and scientific meeting and had followed management models, perceived their problem-resolving skills as more adequate than the others (P > 0.05).Conclusion In this study, it was determined that nurses do not perceive that they have problem-solving skills at a desired level. In this context, it is extremely important that this subject be given an important place in both nursing education curriculum and continuing education programmes.

JONA: The Journal of Nursing Administration

Jennifer Bradley

Strides in Development of Medical Education Journal

Background The lack of clinical competence in nurses leads to problems in providing nursing services. Studies indicate that nurses lacking the required skills can endanger the public health in medical centers. Critical thinking is a factor that can affect nurses' clinical competence. Objectives The current study aimed at investigating the relationship between critical thinking and clinical competence in nurses. Methods The current descriptive-analytical and cross sectional study was conducted on 120 nurses selected by random sampling method. Data collection tools included the California Critical Thinking Disposition Inventory (CCTDI), as well as clinical competence and demographic information questionnaires. Data were analyzed with SPSS using Pearson correlation coefficient, linear regression, and -test. Results Pearson correlation test showed a positive correlation between the total scores of critical thinking and clinical competence. Based on the results of the linear regression analysis, the tendency toward critical thinking could predict 28.4% of the clinical competence. The nurses mean CCTDI scores were at the positive level and their mean clinical competence scores were at the average level. Conclusions According to the obtained results, nursing authorities can organize practical workshops on the development of critical thinking of clinical nurses as one of the most important and operational strategies to improve nursing clinical competence and, ultimately, move towards optimal care.

Zenodo (CERN European Organization for Nuclear Research)

dr.fawzia badran

Journal of Excellence in Nursing and Healthcare Practice

Diane Whitehead

Clinical nurses play an important role in the healthcare team. The practice question for this Doctor of Nursing Practice project explored the perceptions of RNs about their clinical leadership knowledge and competencies at a 160-bed rehabilitation hospital in a metropolitan city in the southeast United States. Thirty RNs completed the following three surveys: an 8-question clinical leadership knowledge assessment, a 17-question leadership competency assessment, and a 6-question emotional intelligence self-assessment. Fifty percent or more of clinical nurses believed that they were knowledgeable in identified components of clinical leadership. The leadership competency skills assessment revealed a wide range: from 3–6% of participants who indicated that they were not at all competent to 33–57% of participants who indicated that they felt very competent. Seventy-six percent of the participants felt positive about their emotional intelligence abilities. Recommendations to nursing leade...

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Miaofen Yen , Mei-chih Huang , Shiow-y Hwang

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Critical thinking, critical practice

Affiliation.

• 1 College of Nursing, Wayne State University, Detroit, Mich., USA.
• PMID: 10373884

Nursing leaders in critical care can use strategies such as questioning, clinical scenarios, conferences, and context-dependent test items to assess and improve their staff's critical thinking skills.

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Why is critical thinking important?

What do lawyers, accountants, teachers, and doctors all have in common?

What is critical thinking?

The Oxford English Dictionary defines critical thinking as “The objective, systematic, and rational analysis and evaluation of factual evidence in order to form a judgment on a subject, issue, etc.” Critical thinking involves the use of logic and reasoning to evaluate available facts and/or evidence to come to a conclusion about a certain subject or topic. We use critical thinking every day, from decision-making to problem-solving, in addition to thinking critically in an academic context!

Why is critical thinking important for academic success?

You may be asking “why is critical thinking important for students?” Critical thinking appears in a diverse set of disciplines and impacts students’ learning every day, regardless of major.

Critical thinking skills are often associated with the value of studying the humanities. In majors such as English, students will be presented with a certain text—whether it’s a novel, short story, essay, or even film—and will have to use textual evidence to make an argument and then defend their argument about what they’ve read. However, the importance of critical thinking does not only apply to the humanities. In the social sciences, an economics major , for example, will use what they’ve learned to figure out solutions to issues as varied as land and other natural resource use, to how much people should work, to how to develop human capital through education. Problem-solving and critical thinking go hand in hand. Biology is a popular major within LAS, and graduates of the biology program often pursue careers in the medical sciences. Doctors use critical thinking every day, tapping into the knowledge they acquired from studying the biological sciences to diagnose and treat different diseases and ailments.

Students in the College of LAS take many courses that require critical thinking before they graduate. You may be asked in an Economics class to use statistical data analysis to evaluate the impact on home improvement spending when the Fed increases interest rates (read more about real-world experience with Datathon ). If you’ve ever been asked “How often do you think about the Roman Empire?”, you may find yourself thinking about the Roman Empire more than you thought—maybe in an English course, where you’ll use text from Shakespeare’s Antony and Cleopatra to make an argument about Roman imperial desire.  No matter what the context is, critical thinking will be involved in your academic life and can take form in many different ways.

The benefits of critical thinking in everyday life

Building better communication.

One of the most important life skills that students learn as early as elementary school is how to give a presentation. Many classes require students to give presentations, because being well-spoken is a key skill in effective communication. This is where critical thinking benefits come into play: using the skills you’ve learned, you’ll be able to gather the information needed for your presentation, narrow down what information is most relevant, and communicate it in an engaging way. 

Typically, the first step in creating a presentation is choosing a topic. For example, your professor might assign a presentation on the Gilded Age and provide a list of figures from the 1870s—1890s to choose from. You’ll use your critical thinking skills to narrow down your choices. You may ask yourself:

• What figure am I most familiar with?
• Who am I most interested in? 
• Will I have to do additional research? 

After choosing your topic, your professor will usually ask a guiding question to help you form a thesis: an argument that is backed up with evidence. Critical thinking benefits this process by allowing you to focus on the information that is most relevant in support of your argument. By focusing on the strongest evidence, you will communicate your thesis clearly.

Finally, once you’ve finished gathering information, you will begin putting your presentation together. Creating a presentation requires a balance of text and visuals. Graphs and tables are popular visuals in STEM-based projects, but digital images and graphics are effective as well. Critical thinking benefits this process because the right images and visuals create a more dynamic experience for the audience, giving them the opportunity to engage with the material.

Presentation skills go beyond the classroom. Students at the University of Illinois will often participate in summer internships to get professional experience before graduation. Many summer interns are required to present about their experience and what they learned at the end of the internship. Jobs frequently also require employees to create presentations of some kind—whether it’s an advertising pitch to win an account from a potential client, or quarterly reporting, giving a presentation is a life skill that directly relates to critical thinking. 

Fostering independence and confidence

An important life skill many people start learning as college students and then finessing once they enter the “adult world” is how to budget. There will be many different expenses to keep track of, including rent, bills, car payments, and groceries, just to name a few! After developing your critical thinking skills, you’ll put them to use to consider your salary and budget your expenses accordingly. Here’s an example:

• You earn a salary of $75,000 a year. Assume all amounts are before taxes.
• 1,800 x 12 = 21,600
• 75,000 – 21,600 = 53,400
• This leaves you with $53,400
• 320 x 12 = 3,840 a year
• 53,400-3,840= 49,560
• 726 x 12 = 8,712
• 49,560 – 8,712= 40,848
• You’re left with $40,848 for miscellaneous expenses. You use your critical thinking skills to decide what to do with your $40,848. You think ahead towards your retirement and decide to put $500 a month into a Roth IRA, leaving $34,848. Since you love coffee, you try to figure out if you can afford a daily coffee run. On average, a cup of coffee will cost you $7. 7 x 365 = $2,555 a year for coffee. 34,848 – 2,555 = 32,293
• You have $32,293 left. You will use your critical thinking skills to figure out how much you would want to put into savings, how much you want to save to treat yourself from time to time, and how much you want to put aside for emergency funds. With the benefits of critical thinking, you will be well-equipped to budget your lifestyle once you enter the working world.

Enhancing decision-making skills

Choosing the right university for you.

One of the biggest decisions you’ll make in your life is what college or university to go to. There are many factors to consider when making this decision, and critical thinking importance will come into play when determining these factors.

Many high school seniors apply to colleges with the hope of being accepted into a certain program, whether it’s biology, psychology, political science, English, or something else entirely. Some students apply with certain schools in mind due to overall rankings. Students also consider the campus a school is set in. While some universities such as the University of Illinois are nestled within college towns, New York University is right in Manhattan, in a big city setting. Some students dream of going to large universities, and other students prefer smaller schools. The diversity of a university’s student body is also a key consideration. For many 17- and 18-year-olds, college is a time to meet peers from diverse racial and socio-economic backgrounds and learn about life experiences different than one’s own.

With all these factors in mind, you’ll use critical thinking to decide which are most important to you—and which school is the right fit for you.

Develop your critical thinking skills at the University of Illinois

At the University of Illinois, not only will you learn how to think critically, but you will put critical thinking into practice. In the College of LAS, you can choose from 70+ majors where you will learn the importance and benefits of critical thinking skills. The College of Liberal Arts & Sciences at U of I offers a wide range of undergraduate and graduate programs in life, physical, and mathematical sciences; humanities; and social and behavioral sciences. No matter which program you choose, you will develop critical thinking skills as you go through your courses in the major of your choice. And in those courses, the first question your professors may ask you is, “What is the goal of critical thinking?” You will be able to respond with confidence that the goal of critical thinking is to help shape people into more informed, more thoughtful members of society.

With such a vast representation of disciplines, an education in the College of LAS will prepare you for a career where you will apply critical thinking skills to real life, both in and outside of the classroom, from your undergraduate experience to your professional career. If you’re interested in becoming a part of a diverse set of students and developing skills for lifelong success, apply to LAS today!

Read more first-hand stories from our amazing students at the LAS Insider blog .

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Safe staffing is critical to patient outcomes

Alison Paterson, Eastern member of the Professional Nursing Committee, talks about the RCN’s crucial work on safe staffing.

Welcome to my second blog as your Eastern region representative on the Professional Nursing Committee (PNC). I have been in this role since January 2023 and have just been re-elected to continue for the next four years. Many thanks to those of you who voted for me.

It is an exciting and busy time to be part of the PNC. The RCN's safe staffing summit was held in December. Attending this event, I found it inspiring, but also disappointing. There are so many years of evidence showing how vital safe staffing is to patient outcomes. This has sadly been continually ignored by successive governments and policy-makers. 

The expert speakers included Howard Catton, CEO of the International Council of Nurses, who told us 57% of nurses and doctors perceive their workplace to be unsafe. He said we now talk about “recruitment and retention”, but we should change this to “retention, retention, retention and recruitment”.

Professor Jane Ball, Professor of Nursing Workforce and Policy at Southampton University, confirmed that the right staffing levels are critical. She explained: “When registered nurses are caring for more than eight patients this is a level that should be treated as a red flag, because at that level some care is almost always missed.”

RCN Chief Nurse, Professor Nicola Ranger, said she believed the profession was under threat due to the lack of nursing staff. She appealed to us all to take action to call for safe staffing levels.

If you would like to learn more and get involved please visit the  RCN's campaign for safe staffing .

You can watch the highlights of the  RCN safe staffing summit highlights here .

In March, I joined RCN Eastern’s Regional Director, Teresa Budrey, at a follow-up event. It was great to meet registered nurses from across the region who are the workforce leads for their trusts. 

The PNC are working to update and strengthen the nursing workforce standards, which have already been used successfully by staff in all settings to improve their nursing establishments. 

In addition to my PNC role, I have been selected and appointed as the PNC representative on the new RCN Equality, Diversity and Inclusion Committee.

The purpose of this committee is to provide advice, leadership and oversight to the development, implementation and delivery of the RCN Group’s Equity, Diversity and Inclusion Strategy. This work is so vital to the future of the RCN.

The RCN Congress is taking place in Newport, Wales, in June and I’m looking forward to meet ing many of you there. There is sure to be lively debate and lots of learning opportunities. If you haven't registered already, there is still time to register to attend Congress .

Alison Paterson

RCN Eastern member on the Professional Nursing Committee

Lead Cancer Nurse at East and North Hertfordshire NHS Trust

Page last updated - 22/04/2024

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• Apr 22, 2024

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ST. LOUIS — The Biden administration announced Monday that it has finalized a rule that sets minimum staffing levels for nursing homes that receive Medicare and Medicaid dollars, a controversial move that advocates have long called for, and that industry groups have long opposed.

The rule will be introduced in phases to give nursing homes time to hire, with longer time frames for rural areas, where recruitment is often more difficult. But if it took effect today, 320 of 486 Missouri nursing homes wouldn't meet the standard, according to an analysis by the Long Term Care Community Coalition, a New York-based nonprofit that advocates on behalf of residents.

The rule tracks staff-to-resident ratios, and would also require facilities to have a registered nurse on site 24 hours a day, seven days a week. There will be temporary exemptions for nursing homes in places designated as workforce shortages areas, and which demonstrate good-faith efforts to hire. Residents and families will be notified when a facility uses such an exemption.

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Richard Mollot, executive director of the Long Term Care Community Coalition, applauded the requirement for 24-hour RN staffing.

"Study after study has shown that the RN staffing levels are really the most important indicators of quality and safety," Mollot said. "We and other advocates have pushed for this for decades."

The rule looks at how many hours staff work per day, compared to the number of residents they care for. The federal rule contemplates 3.48 staff hours per resident, per day. Missouri averages 3.2, the lowest in the nation, and Illinois averages 3.24, according to the nonprofit's data. The nonprofit analyzed staffing data that nursing homes submit to the U.S. Centers for Medicare and Medicaid Services, and averaged it against the facilities' reported resident censuses.

Advocates have argued that chronic understaffing in nursing homes erodes the quality of care for residents, who are often in vulnerable situations. And workers at St. Louis-area facilities have said that as more seniors try to "age in place," nursing homes in the region have accepted more younger residents with mental health conditions. Staffing levels and training don't always keep up.

But the movement has been met with steady pushback from industry groups, which argue that Medicaid doesn't pay nursing homes enough to cover these drastic changes.

The head of the American Health Care Association, a federal trade group that lobbies on behalf of nursing homes, on Monday called the new rule "unconscionable." He argued that it sets an impossible task before facilities that are already struggling with labor shortages and an aging U.S. population.

"While it may be well intentioned, the federal staffing mandate is an unreasonable standard that only threatens to shut down more nursing homes, displace hundreds of thousands of residents, and restrict seniors' access to care," AHCA President and CEO Mark Parkinson said in a statement.

Advocates, meanwhile, aren't sure the rule goes far enough.

Mollot said he worried that setting a relatively low bar will give nursing homes the impression that 3.48 hours per day is an acceptable amount of care, which it isn't.

Some facilities that now exceed the requirement may decrease staffing levels after the rule is imposed, he said, and lawsuits filed against facilities for abuse or neglect may be weakened, if nursing homes can claim to have adequate staffing.

"You run the risk of a race to the bottom," Mollot said.

A special committee created by the St. Louis Board of Aldermen to examine the city's long-term care industry has backed the creation of a staffing requirement.

In March, the committee called for the board to pass a resolution in support of the federal rule. The committee  also called on state legislators to raise the Medicaid per diem rate  to match that of Medicare — and to allocate a portion to hiring and retention.

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