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The Value of Critical Thinking in Nursing

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Gayle Morris

Contributing Writer

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Updated October 3, 2023

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

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

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

How Do Nurses Use Critical Thinking?

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

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

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

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

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

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

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Top 5 ways nurses can improve critical thinking skills.

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

Case-Based Approach

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

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

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

Practice Self-Reflection

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

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

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

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

Develop a Questioning Mind

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

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

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

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

Practice Self-Awareness in the Moment

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

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

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

Use a Process

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

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

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

Common Critical Thinking Pitfalls in Nursing

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

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

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

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

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

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

An Essential Skill for All Nurses

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

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

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

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

How does nursing school develop critical thinking skills?

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

Do only nurse managers use critical thinking?

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

Meet Our Contributors

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

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

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

Portrait of Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads, Ph.D., RN

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

Portrait of Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan, BSN, RN, CCRN

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

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  • Research article
  • Open access
  • Published: 07 October 2020

Impact of social problem-solving training on critical thinking and decision making of nursing students

  • Soleiman Ahmady 1 &
  • Sara Shahbazi   ORCID: orcid.org/0000-0001-8397-6233 2 , 3  

BMC Nursing volume  19 , Article number:  94 ( 2020 ) Cite this article

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The complex health system and challenging patient care environment require experienced nurses, especially those with high cognitive skills such as problem-solving, decision- making and critical thinking. Therefore, this study investigated the impact of social problem-solving training on nursing students’ critical thinking and decision-making.

This study was quasi-experimental research and pre-test and post-test design and performed on 40 undergraduate/four-year students of nursing in Borujen Nursing School/Iran that was randomly divided into 2 groups; experimental ( n  = 20) and control (n = 20). Then, a social problem-solving course was held for the experimental group. A demographic questionnaire, social problem-solving inventory-revised, California critical thinking test, and decision-making questionnaire was used to collect the information. The reliability and validity of all of them were confirmed. Data analysis was performed using SPSS software and independent sampled T-test, paired T-test, square chi, and Pearson correlation coefficient.

The finding indicated that the social problem-solving course positively affected the student’ social problem-solving and decision-making and critical thinking skills after the instructional course in the experimental group ( P  < 0.05), but this result was not observed in the control group ( P  > 0.05).

Conclusions

The results showed that structured social problem-solving training could improve cognitive problem-solving, critical thinking, and decision-making skills. Considering this result, nursing education should be presented using new strategies and creative and different ways from traditional education methods. Cognitive skills training should be integrated in the nursing curriculum. Therefore, training cognitive skills such as problem- solving to nursing students is recommended.

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Continuous monitoring and providing high-quality care to patients is one of the main tasks of nurses. Nurses’ roles are diverse and include care, educational, supportive, and interventional roles when dealing with patients’ clinical problems [ 1 , 2 ].

Providing professional nursing services requires the cognitive skills such as problem-solving, decision-making and critical thinking, and information synthesis [ 3 ].

Problem-solving is an essential skill in nursing. Improving this skill is very important for nurses because it is an intellectual process which requires the reflection and creative thinking [ 4 ].

Problem-solving skill means acquiring knowledge to reach a solution, and a person’s ability to use this knowledge to find a solution requires critical thinking. The promotion of these skills is considered a necessary condition for nurses’ performance in the nursing profession [ 5 , 6 ].

Managing the complexities and challenges of health systems requires competent nurses with high levels of critical thinking skills. A nurse’s critical thinking skills can affect patient safety because it enables nurses to correctly diagnose the patient’s initial problem and take the right action for the right reason [ 4 , 7 , 8 ].

Problem-solving and decision-making are complex and difficult processes for nurses, because they have to care for multiple patients with different problems in complex and unpredictable treatment environments [ 9 , 10 ].

Clinical decision making is an important element of professional nursing care; nurses’ ability to form effective clinical decisions is the most significant issue affecting the care standard. Nurses build 2 kinds of choices associated with the practice: patient care decisions that affect direct patient care and occupational decisions that affect the work context or teams [ 11 , 12 , 13 , 14 , 15 , 16 ].

The utilization of nursing process guarantees the provision of professional and effective care. The nursing process provides nurses with the chance to learn problem-solving skills through teamwork, health management, and patient care. Problem-solving is at the heart of nursing process which is why this skill underlies all nursing practices. Therefore, proper training of this skill in an undergraduate nursing program is essential [ 17 ].

Nursing students face unique problems which are specific to the clinical and therapeutic environment, causing a lot of stresses during clinical education. This stress can affect their problem- solving skills [ 18 , 19 , 20 , 21 ]. They need to promote their problem-solving and critical thinking skills to meet the complex needs of current healthcare settings and should be able to respond to changing circumstances and apply knowledge and skills in different clinical situations [ 22 ]. Institutions should provide this important opportunity for them.

Despite, the results of studies in nursing students show the weakness of their problem-solving skills, while in complex health environments and exposure to emerging diseases, nurses need to diagnose problems and solve them rapidly accurately. The teaching of these skills should begin in college and continue in health care environments [ 5 , 23 , 24 ].

It should not be forgotten that in addition to the problems caused by the patients’ disease, a large proportion of the problems facing nurses are related to the procedures of the natural life of their patients and their families, the majority of nurses with the rest of health team and the various roles defined for nurses [ 25 ].

Therefore, in addition to above- mentioned issues, other ability is required to deal with common problems in the working environment for nurses, the skill is “social problem solving”, because the term social problem-solving includes a method of problem-solving in the “natural context” or the “real world” [ 26 , 27 ]. In reviewing the existing research literature on the competencies and skills required by nursing students, what attracts a lot of attention is the weakness of basic skills and the lack of formal and systematic training of these skills in the nursing curriculum, it indicates a gap in this area [ 5 , 24 , 25 ]. In this regard, the researchers tried to reduce this significant gap by holding a formal problem-solving skills training course, emphasizing the common social issues in the real world of work. Therefore, this study was conducted to investigate the impact of social problem-solving skills training on nursing students’ critical thinking and decision-making.

Setting and sample

This quasi-experimental study with pretest and post-test design was performed on 40 undergraduate/four-year nursing students in Borujen nursing school in Shahrekord University of Medical Sciences. The periods of data collection were 4 months.

According to the fact that senior students of nursing have passed clinical training and internship programs, they have more familiarity with wards and treatment areas, patients and issues in treatment areas and also they have faced the problems which the nurses have with other health team personnel and patients and their families, they have been chosen for this study. Therefore, this study’s sampling method was based on the purpose, and the sample size was equal to the total population. The whole of four-year nursing students participated in this study and the sample size was 40 members. Participants was randomly divided in 2 groups; experimental ( n  = 20) and control (n = 20).

The inclusion criteria to take part in the present research were students’ willingness to take part, studying in the four-year nursing, not having the record of psychological sickness or using the related drugs (all based on their self-utterance).

Intervention

At the beginning of study, all students completed the demographic information’ questionnaire. The study’s intervening variables were controlled between the two groups [such as age, marital status, work experience, training courses, psychological illness, psychiatric medication use and improving cognitive skills courses (critical thinking, problem- solving, and decision making in the last 6 months)]. Both groups were homogeneous in terms of demographic variables ( P  > 0.05). Decision making and critical thinking skills and social problem solving of participants in 2 groups was evaluated before and 1 month after the intervention.

All questionnaires were anonymous and had an identification code which carefully distributed by the researcher.

To control the transfer of information among the students of two groups, the classification list of students for internships, provided by the head of nursing department at the beginning of semester, was used.

Furthermore, the groups with the odd number of experimental group and the groups with the even number formed the control group and thus were less in contact with each other.

The importance of not transferring information among groups was fully described to the experimental group. They were asked not to provide any information about the course to the students of the control group.

Then, training a course of social problem-solving skills for the experimental group, given in a separate course and the period from the nursing curriculum and was held in 8 sessions during 2 months, using small group discussion, brainstorming, case-based discussion, and reaching the solution in small 4 member groups, taking results of the social problem-solving model as mentioned by D-zurilla and gold fried [ 26 ]. The instructor was an assistant professor of university and had a history of teaching problem-solving courses. This model’ stages are explained in Table  1 .

All training sessions were performed due to the model, and one step of the model was implemented in each session. In each session, the teacher stated the educational objectives and asked the students to share their experiences in dealing to various workplace problems, home and community due to the topic of session. Besides, in each session, a case-based scenario was presented and thoroughly analyzed, and students discussed it.

Instruments

In this study, the data were collected using demographic variables questionnaire and social problem- solving inventory – revised (SPSI-R) developed by D’zurilla and Nezu (2002) [ 26 ], California critical thinking skills test- form B (CCTST; 1994) [ 27 , 28 ] and decision-making questionnaire.

SPSI-R is a self - reporting tool with 52 questions ranging from a Likert scale (1: Absolutely not – 5: very much).

The minimum score maybe 25 and at a maximum of 125, therefore:

The score 25 and 50: weak social problem-solving skills.

The score 50–75: moderate social problem-solving skills.

The score higher of 75: strong social problem-solving skills.

The reliability assessed by repeated tests is between 0.68 and 0.91, and its alpha coefficient between 0.69 and 0.95 was reported [ 26 ]. The structural validity of questionnaire has also been confirmed. All validity analyses have confirmed SPSI as a social problem - solving scale.

In Iran, the alpha coefficient of 0.85 is measured for five factors, and the retest reliability coefficient was obtained 0.88. All of the narratives analyzes confirmed SPSI as a social problem- solving scale [ 29 ].

California critical thinking skills test- form B(CCTST; 1994): This test is a standard tool for assessing the basic skills of critical thinking at the high school and higher education levels (Facione & Facione, 1992, 1998) [ 27 ].

This tool has 34 multiple-choice questions which assessed analysis, inference, and argument evaluation. Facione and Facione (1993) reported that a KR-20 range of 0.65 to 0.75 for this tool is acceptable [ 27 ].

In Iran, the KR-20 for the total scale was 0.62. This coefficient is acceptable for questionnaires that measure the level of thinking ability of individuals.

After changing the English names of this questionnaire to Persian, its content validity was approved by the Board of Experts.

The subscale analysis of Persian version of CCTST showed a positive high level of correlation between total test score and the components (analysis, r = 0.61; evaluation, r = 0.71; inference, r = 0.88; inductive reasoning, r = 0.73; and deductive reasoning, r = 0.74) [ 28 ].

A decision-making questionnaire with 20 questions was used to measure decision-making skills. This questionnaire was made by a researcher and was prepared under the supervision of a professor with psychometric expertise. Five professors confirmed the face and content validity of this questionnaire. The reliability was obtained at 0.87 which confirmed for 30 students using the test-retest method at a time interval of 2 weeks. Each question had four levels and a score from 0.25 to 1. The minimum score of this questionnaire was 5, and the maximum score was 20 [ 30 ].

Statistical analysis

For analyzing the applied data, the SPSS Version 16, and descriptive statistics tests, independent sample T-test, paired T-test, Pearson correlation coefficient, and square chi were used. The significant level was taken P  < 0.05.

The average age of students was 21.7 ± 1.34, and the academic average total score was 16.32 ± 2.83. Other demographic characteristics are presented in Table  2 .

None of the students had a history of psychiatric illness or psychiatric drug use. Findings obtained from the chi-square test showed that there is not any significant difference between the two groups statistically in terms of demographic variables.

The mean scores in social decision making, critical thinking, and decision-making in whole samples before intervention showed no significant difference between the two groups statistically ( P  > 0.05), but showed a significant difference after the intervention ( P  < 0.05) (Table  3 ).

Scores in Table  4 showed a significant positive difference before and after intervention in the “experimental” group ( P  < 0.05), but this difference was not seen in the control group ( P  > 0.05).

Among the demographic variables, only a positive relationship was seen between marital status and decision-making skills (r = 0.72, P  < 0.05).

Also, the scores of critical thinking skill’ subgroups and social problem solving’ subgroups are presented in Tables  5 and 6 which showed a significant positive difference before and after intervention in the “experimental” group (P < 0.05), but this difference was not seen in the control group ( P  > 0.05).

In the present study conducted by some studies, problem-solving and critical thinking and decision-making scores of nursing students are moderate [ 5 , 24 , 31 ].

The results showed that problem-solving skills, critical thinking, and decision-making in nursing students were promoted through a social problem-solving training course. Unfortunately, no study has examined the effect of teaching social problem-solving skills on nursing students’ critical thinking and decision-making skills.

Altun (2018) believes that if the values of truth and human dignity are promoted in students, it will help them acquire problem-solving skills. Free discussion between students and faculty on value topics can lead to the development of students’ information processing in values. Developing self-awareness increases students’ impartiality and problem-solving ability [ 5 ]. The results of this study are consistent to the results of present study.

Erozkan (2017), in his study, reported there is a significant relationship between social problem solving and social self-efficacy and the sub-dimensions of social problem solving [ 32 ]. In the present study, social problem -solving skills training has improved problem -solving skills and its subdivisions.

The results of study by Moshirabadi (2015) showed that the mean score of total problem-solving skills was 89.52 ± 21.58 and this average was lower in fourth-year students than other students. He explained that education should improve students’ problem-solving skills. Because nursing students with advanced problem-solving skills are vital to today’s evolving society [ 22 ]. In the present study, the results showed students’ weakness in the skills in question, and holding a social problem-solving skills training course could increase the level of these skills.

Çinar (2010) reported midwives and nurses are expected to use problem-solving strategies and effective decision-making in their work, using rich basic knowledge.

These skills should be developed throughout one’s profession. The results of this study showed that academic education could increase problem-solving skills of nursing and midwifery students, and final year students have higher skill levels [ 23 ].

Bayani (2012) reported that the ability to solve social problems has a determining role in mental health. Problem-solving training can lead to a level upgrade of mental health and quality of life [ 33 ]; These results agree with the results obtained in our study.

Conducted by this study, Kocoglu (2016) reported nurses’ understanding of their problem-solving skills is moderate. Receiving advice and support from qualified nursing managers and educators can enhance this skill and positively impact their behavior [ 31 ].

Kashaninia (2015), in her study, reported teaching critical thinking skills can promote critical thinking and the application of rational decision-making styles by nurses.

One of the main components of sound performance in nursing is nurses’ ability to process information and make good decisions; these abilities themselves require critical thinking. Therefore, universities should envisage educational and supportive programs emphasizing critical thinking to cultivate their students’ professional competencies, decision-making, problem-solving, and self-efficacy [ 34 ].

The study results of Kirmizi (2015) also showed a moderate positive relationship between critical thinking and problem-solving skills [ 35 ].

Hong (2015) reported that using continuing PBL training promotes reflection and critical thinking in clinical nurses. Applying brainstorming in PBL increases the motivation to participate collaboratively and encourages teamwork. Learners become familiar with different perspectives on patients’ problems and gain a more comprehensive understanding. Achieving these competencies is the basis of clinical decision-making in nursing. The dynamic and ongoing involvement of clinical staff can bridge the gap between theory and practice [ 36 ].

Ancel (2016) emphasizes that structured and managed problem-solving training can increase students’ confidence in applying problem-solving skills and help them achieve self-confidence. He reported that nursing students want to be taught in more innovative ways than traditional teaching methods which cognitive skills training should be included in their curriculum. To this end, university faculties and lecturers should believe in the importance of strategies used in teaching and the richness of educational content offered to students [ 17 ].

The results of these recent studies are adjusted with the finding of recent research and emphasize the importance of structured teaching cognitive skills to nurses and nursing students.

Based on the results of this study on improving critical thinking and decision-making skills in the intervention group, researchers guess the reasons to achieve the results of study in the following cases:

In nursing internationally, problem-solving skills (PS) have been introduced as a key strategy for better patient care [ 17 ]. Problem-solving can be defined as a self-oriented cognitive-behavioral process used to identify or discover effective solutions to a special problem in everyday life. In particular, the application of this cognitive-behavioral methodology identifies a wide range of possible effective solutions to a particular problem and enhancement the likelihood of selecting the most effective solution from among the various options [ 27 ].

In social problem-solving theory, there is a difference among the concepts of problem-solving and solution implementation, because the concepts of these two processes are different, and in practice, they require different skills.

In the problem-solving process, we seek to find solutions to specific problems, while in the implementation of solution, the process of implementing those solutions in the real problematic situation is considered [ 25 , 26 ].

The use of D’zurilla and Goldfride’s social problem-solving model was effective in achieving the study results because of its theoretical foundations and the usage of the principles of cognitive reinforcement skills. Social problem solving is considered an intellectual, logical, effort-based, and deliberate activity [ 26 , 32 ]; therefore, using this model can also affect other skills that need recognition.

In this study, problem-solving training from case studies and group discussion methods, brainstorming, and activity in small groups, was used.

There are significant educational achievements in using small- group learning strategies. The limited number of learners in each group increases the interaction between learners, instructors, and content. In this way, the teacher will be able to predict activities and apply techniques that will lead students to achieve high cognitive taxonomy levels. That is, confront students with assignments and activities that force them to use cognitive processes such as analysis, reasoning, evaluation, and criticism.

In small groups, students are given the opportunity to the enquiry, discuss differences of opinion, and come up with solutions. This method creates a comprehensive understanding of the subject for the student [ 36 ].

According to the results, social problem solving increases the nurses’ decision-making ability and critical thinking regarding identifying the patient’s needs and choosing the best nursing procedures. According to what was discussed, the implementation of this intervention in larger groups and in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students, in the future, is recommended.

Social problem- solving training by affecting critical thinking skills and decision-making of nursing students increases patient safety. It improves the quality of care because patients’ needs are better identified and analyzed, and the best solutions are adopted to solve the problem.

In the end, the implementation of this intervention in larger groups in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students in the future is recommended.

Study limitations

This study was performed on fourth-year nursing students, but the students of other levels should be studied during a cohort from the beginning to the end of course to monitor the cognitive skills improvement.

The promotion of high-level cognitive skills is one of the main goals of higher education. It is very necessary to adopt appropriate approaches to improve the level of thinking. According to this study results, the teachers and planners are expected to use effective approaches and models such as D’zurilla and Goldfride social problem solving to improve problem-solving, critical thinking, and decision-making skills. What has been confirmed in this study is that the routine training in the control group should, as it should, has not been able to improve the students’ critical thinking skills, and the traditional educational system needs to be transformed and reviewed to achieve this goal.

Availability of data and materials

The datasets used and analyzed during the present study are available from the corresponding author on reasonable request.

Abbreviations

California critical thinking skills test

Social problem-solving inventory – revised

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Acknowledgments

This article results from research project No. 980 approved by the Research and Technology Department of Shahrekord University of Medical Sciences. We would like to appreciate to all personnel and students of the Borujen Nursing School. The efforts of all those who assisted us throughout this research.

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Critical Thinking in Nursing

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

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Critical thinking in nursing.

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

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

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4.2 Basic Concepts

Open Resources for Nursing (Open RN)

Before learning how to use the nursing process, it is important to understand some basic concepts related to critical thinking and nursing practice. Let’s take a deeper look at how nurses think.

Critical Thinking and Clinical Reasoning

Nurses make decisions while providing patient care by using critical thinking and clinical reasoning. Critical thinking is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” [1]   Using critical thinking means that nurses take extra steps to maintain patient safety and don’t just “follow orders.” It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research.

“Critical thinkers” possess certain attitudes that foster rational thinking. These attitudes are as follows:

  • Independence of thought: Thinking on your own
  • Fair-mindedness: Treating every viewpoint in an unbiased, unprejudiced way
  • Insight into egocentricity and sociocentricity: Thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
  • Intellectual humility: Recognizing your intellectual limitations and abilities
  • Nonjudgmental: Using professional ethical standards and not basing your judgments on your own personal or moral standards
  • Integrity: Being honest and demonstrating strong moral principles
  • Perseverance: Persisting in doing something despite it being difficult
  • Confidence: Believing in yourself to complete a task or activity
  • Interest in exploring thoughts and feelings: Wanting to explore different ways of knowing
  • Curiosity: Asking “why” and wanting to know more

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] To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. [3]

Inductive and Deductive Reasoning and Clinical Judgment

Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process.

Inductive reasoning involves noticing cues, making generalizations, and creating hypotheses. Cues are data that  fall outside of expected findings that give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A generalization is a judgment formed from a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes more clear. Based on generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. A hypothesis is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored.

No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. A nurse is similar to the detective looking for cues in Figure 4.1. [4] Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to take action quickly, especially in emergency situations. They can see how certain objects or events form a pattern (i.e., generalization) that indicates a common problem (i.e., hypothesis).

Example: A nurse assesses a patient and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.

Photo showing person looking at camera through a magnifying glass

Deductive reasoning is another type of critical thinking that is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.

Example: Based on research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. (See Figure 4.2). [5]  The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking because the intervention is applied to all patients regardless if they have difficulty sleeping or not.

Photo showing sign that says Quiet Zone

Clinical judgment is the result of critical thinking and clinical reasoning using inductive and deductive reasoning. Clinical judgment is defined by the National Council of State Boards of Nursing (NCSBN) as, “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.” [6] The NCSBN administers the national licensure exam (NCLEX) that measures nursing clinical judgment and decision-making ability of prospective entry-level nurses to assure safe and competent nursing care by licensed nurses.

Evidence-based practice (EBP) is defined by the American Nurses Association (ANA) as, “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.” [7]

Nursing Process

The nursing process is a critical thinking model based on a systematic approach to patient-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently. [8] The mnemonic ADOPIE is an easy way to remember the ANA Standards and the nursing process. Each letter refers to the six components of the nursing process: A ssessment, D iagnosis, O utcomes Identification, P lanning, I mplementation, and E valuation.

The nursing process is a continuous, cyclic process that is constantly adapting to the patient’s current health status. See Figure 4.3 [9] for an illustration of the nursing process.

Image showing workflow of nursing process, with labels

Review Scenario A in the following box for an example of a nurse using the nursing process while providing patient care.

Patient Scenario A : Using the Nursing Process [10]

Photo of simulated patient facing camera

A hospitalized patient has a prescription to receive Lasix 80mg IV every morning for a medical diagnosis of heart failure. During the morning assessment, the nurse notes that the patient has a blood pressure of 98/60, heart rate of 100, respirations of 18, and a temperature of 98.7F. The nurse reviews the medical record for the patient’s vital signs baseline and observes the blood pressure trend is around 110/70 and the heart rate in the 80s. The nurse recognizes these cues form a pattern related to fluid imbalance and hypothesizes that the patient may be dehydrated. The nurse gathers additional information and notes the patient’s weight has decreased 4 pounds since yesterday. The nurse talks with the patient and validates the hypothesis when the patient reports that their mouth feels like cotton and they feel light-headed. By using critical thinking and clinical judgment, the nurse diagnoses the patient with the nursing diagnosis Fluid Volume Deficit and establishes outcomes for reestablishing fluid balance. The nurse withholds the administration of IV Lasix and contacts the health care provider to discuss the patient’s current fluid status. After contacting the provider, the nurse initiates additional nursing interventions to promote oral intake and closely monitor hydration status. By the end of the shift, the nurse evaluates the patient status and determines that fluid balance has been restored.

In Scenario A, the nurse is using clinical judgment and not just “following orders” to administer the Lasix as scheduled. The nurse assesses the patient, recognizes cues, creates a generalization and hypothesis regarding the fluid status, plans and implements nursing interventions, and evaluates the outcome. Additionally, the nurse promotes patient safety by contacting the provider before administering a medication that could cause harm to the patient at this time.

The ANA’s Standards of Professional Nursing Practice associated with each component of the nursing process are described below.

The “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” [11] A registered nurse uses a systematic method to collect and analyze patient data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. For example, a nurse’s assessment of a hospitalized patient in pain includes the patient’s response to pain, such as the inability to get out of bed, refusal to eat, withdrawal from family members, or anger directed at hospital staff. [12]

The “Assessment” component of the nursing process is further described in the “ Assessment ” section of this chapter.

The “Diagnosis” Standard of Practice is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.” [13] A nursing diagnosis is the nurse’s clinical judgment about the client's response to actual or potential health conditions or needs. Nursing diagnoses are the bases for the nurse’s care plan and are different than medical diagnoses. [14]

The “Diagnosis” component of the nursing process is further described in the “ Diagnosis ” section of this chapter.

Outcomes Identification

The “Outcomes Identification” Standard of Practice is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” [15] The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the patient based on their assessment data and nursing diagnoses.

The “Outcomes Identification” component of the nursing process is further described in the “ Outcomes Identification ” section of this chapter.

The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” [16] Assessment data, diagnoses, and goals are used to select evidence-based nursing interventions customized to each patient’s needs and concerns. Goals, expected outcomes, and nursing interventions are documented in the patient’s nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care. [17]

The “Planning” component of the nursing process is further described in the “ Planning ” section of this chapter.

Nursing Care Plans

Creating nursing care plans is a part of the “Planning” step of the nursing process. A nursing care plan is a type of documentation that demonstrates the individualized planning and delivery of nursing care for each specific patient using the nursing process. Registered nurses (RNs) create nursing care plans so that the care provided to the patient across shifts is consistent among health care personnel. Some interventions can be delegated to Licensed Practical Nurses (LPNs) or trained Unlicensed Assistive Personnel (UAPs) with the RN’s supervision. Developing nursing care plans and implementing appropriate delegation are further discussed under the “ Planning ” and “ Implementing ” sections of this chapter.

Implementation

The “Implementation” Standard of Practice is defined as, “The nurse implements the identified plan.” [18] Nursing interventions are implemented or delegated with supervision according to the care plan to assure continuity of care across multiple nurses and health professionals caring for the patient. Interventions are also documented in the patient’s electronic medical record as they are completed. [19]

The “Implementation” Standard of Professional Practice also includes the subcategories  “Coordination of Care” and “Health Teaching and Health Promotion” to promote health and a safe environment. [20]

The “Implementation” component of the nursing process is further described in the “ Implementation ” section of this chapter.

The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” [21] During evaluation, nurses assess the patient and compare the findings against the initial assessment to determine the effectiveness of the interventions and overall nursing care plan. Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated and modified as needed. [22]

The “Evaluation” component of the nursing process is further described in the “ Evaluation ” section of this chapter.

Benefits of Using the Nursing Process

Using the nursing process has many benefits for nurses, patients, and other members of the health care team. The benefits of using the nursing process include the following:

  • Promotes quality patient care
  • Decreases omissions and duplications
  • Provides a guide for all staff involved to provide consistent and responsive care
  • Encourages collaborative management of a patient’s health care problems
  • Improves patient safety
  • Improves patient satisfaction
  • Identifies a patient’s goals and strategies to attain them
  • Increases the likelihood of achieving positive patient outcomes
  • Saves time, energy, and frustration by creating a care plan or path to follow

By using these components of the nursing process as a critical thinking model, nurses plan interventions customized to the patient’s needs, plan outcomes and interventions, and determine whether those actions are effective in meeting the patient’s needs. In the remaining sections of this chapter, we will take an in-depth look at each of these components of the nursing process. Using the nursing process and implementing evidence-based practices are referred to as the “science of nursing.” Let’s review concepts related to the “art of nursing” while providing holistic care in a caring manner using the nursing process.

Holistic Nursing Care

The American Nurses Association (ANA) recently updated the definition of nursing as, “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.” [23]

The ANA further describes nursing is a learned profession built on a core body of knowledge that integrates both the art and science of nursing.  The art of nursing  is defined as, “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.” [24]  

Nurses care for individuals holistically, including their emotional, spiritual, psychosocial, cultural, and physical needs. They consider problems, issues, and needs that the person experiences as a part of a family and a community as they use the nursing process. Review a scenario illustrating holistic nursing care provided to a patient and their family in the following box.

Holistic Nursing Care Scenario

A single mother brings her child to the emergency room for ear pain and a fever. The physician diagnoses the child with an ear infection and prescribes an antibiotic. The mother is advised to make a follow-up appointment with their primary provider in two weeks. While providing discharge teaching, the nurse discovers that the family is unable to afford the expensive antibiotic prescribed and cannot find a primary care provider in their community they can reach by a bus route. The nurse asks a social worker to speak with the mother about affordable health insurance options and available providers in her community and follows up with the prescribing physician to obtain a prescription for a less expensive generic antibiotic. In this manner, the nurse provides holistic care and advocates for improved health for the child and their family.

Caring and the Nursing Process

The American Nurses Association (ANA) states, “The act of caring is foundational to the practice of nursing.” [25] Successful use of the nursing process requires the development of a care relationship with the patient. A care relationship is a mutual relationship that requires the development of trust between both parties. This trust is often referred to as the development of rapport and underlies the art of nursing. While establishing a caring relationship, the whole person is assessed, including the individual’s beliefs, values, and attitudes, while also acknowledging the vulnerability and dignity of the patient and family. Assessing and caring for the whole person takes into account the physical, mental, emotional, and spiritual aspects of being a human being. [26]   Caring interventions can be demonstrated in simple gestures such as active listening, making eye contact, touching, and verbal reassurances while also respecting and being sensitive to the care recipient’s cultural beliefs and meanings associated with caring behaviors. [27] See Figure 4.4 [28] for an image of a nurse using touch as a therapeutic communication technique to communicate caring.

Dr. Jean Watson is a nurse theorist who has published many works on the art and science of caring in the nursing profession. Her theory of human caring sought to balance the cure orientation of medicine, giving nursing its unique disciplinary, scientific, and professional standing with itself and the public. Dr. Watson’s caring philosophy encourages nurses to be authentically present with their patients while creating a healing environment. [29]

Photo showing closeup of a younger hand holding an elderly one

Now that we have discussed basic concepts related to the nursing process, let’s look more deeply at each component of the nursing process in the following sections.

  • Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41 (4), 215-221. ↵
  • Powers, L., Pagel, J., & Herron, E. (2020). Nurse preceptors and new graduate success. American Nurse Journal, 15 (7), 37-39. ↵
  • “ The Detective ” by paurian is licensed under CC BY 2.0 ↵
  • “ In the Quiet Zone… ” by C.O.D. Library is licensed under CC BY-NC-SA 2.0 ↵
  • NCSBN. (n.d.). NCSBN clinical judgment model . https://www.ncsbn.org/14798.htm ↵
  • American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  • “ The Nursing Process ” by Kim Ernstmeyer at Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
  • “Patient Image in LTC.JPG” by ARISE project is licensed under CC BY 4.0 ↵
  • American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/ ↵
  • American Nurses Association. (n.d.). The nursing process . https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/ ↵
  • American Nurses Association. (2021). Nursing: Scope and standards of practice (3rd ed.). American Nurses Association. ↵
  • American Nurses Association. (n.d.) The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process / ↵
  • American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process / ↵
  • Walivaara, B., Savenstedt, S., & Axelsson, K. (2013). Caring relationships in home-based nursing care - registered nurses’ experiences. The Open Journal of Nursing, 7 , 89-95. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722540/pdf/TONURSJ-7-89.pdf ↵
  • “ hospice-1793998_1280.jpg ” by truthseeker08 is licensed under CC0 ↵
  • Watson Caring Science Institute. (n.d.). Watson Caring Science Institute. Jean Watson, PHD, RN, AHN-BC, FAAN, (LL-AAN) . https://www.watsoncaringscience.org/jean-bio/ ↵

Reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.

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.

A type of reasoning that involves forming generalizations based on specific incidents.

Subjective or objective data that gives the nurse a hint or indication of a potential problem, process, or disorder.

A judgment formed from a set of facts, cues, and observations.

A proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring.

“Top-down thinking” or moving from the general to the specific. Deductive reasoning relies on a general statement or hypothesis—sometimes called a premise or standard—that is held to be true. The premise is used to reach a specific, logical conclusion.

The observed outcome of critical thinking and decision-making. It is an iterative process that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care.

A lifelong problem-solving approach that integrates the best evidence from well-designed research studies, theories, clinical expertise, health care resources, and patient preferences and values.

An easy way to remember the ANA Standards and the nursing process. Each letter refers to the six components of the nursing process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.

Individual, family, or group which includes significant others and populations.

Specific documentation of the planning and delivery of nursing care that is required by the Joint Commission.

Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.

A relationship described as one in which the whole person is assessed while balancing the vulnerability and dignity of the patient and family.

Developing a relationship of mutual trust and understanding.

Nursing Fundamentals Copyright © by Open Resources for Nursing (Open RN) is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Effective decision-making: applying the theories to nursing practice.

Samantha Watkins

Emergency Department Staff Nurse, Frimley Health NHS Foundation Trust, Frimley

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Many theories have been proposed for the decision-making conducted by nurses across all practices and disciplines. These theories are fundamental to consider when reflecting on our decision-making processes to inform future practice. In this article three of these theories are juxtaposed with a case study of a patient presenting with an ST-segment elevation myocardial infarction (STEMI). These theories are descriptive, normative and prescriptive, and will be used to analyse and interpret the process of decision-making within the context of patient assessment.

Decision-making is a fundamental concept of nursing practice that conforms to a systematic trajectory involving the assessment, interpretation, evaluation and management of patient-specific situations ( Dougherty et al, 2015 ). Shared decision-making is vital to consider in terms of patient autonomy and professional duty of care as set out in the Nursing and Midwifery Council (NMC) (2018) Code, which underpins nursing practice. Consequently, the following assessment and decision-making processes were conducted within the remits of practice as a student nurse. Decision-making is a dynamic process in nursing practice, and the theories emphasise the importance of adaptability and reflective practice to identify factors that impact on patient care ( Pearson, 2013 ). Three decision-making theories will be explored within the context of a decision made in practice. To abide by confidentiality requirements, the pseudonym ‘Linda’ will be used throughout. Patient consent was obtained prior to writing.

Linda was a 71-year-old who had been admitted to the cardiac ward following an episode of unstable angina. She was on continuous cardiac monitoring as recommended by the National Institute for Health and Care Excellence (NICE) (2016) guideline for chest pain of recent onset. During her stay on the ward, the tracing on the cardiac monitor indicated possible ST-segment elevation ( Thygesen et al, 2018 ). It was initially hypothesised that she might be experiencing an ACS ( Box 1 ) and could be haemodynamically unstable.

Box 1. Acute coronary syndrome

  • Acute coronary syndrome is an umbrella term that includes three cardiac conditions that result from a reduction of oxygenated blood through the coronary arteries, causing myocardial ischaemia. An ST-segment elevation myocardial infarction (STEMI) connotes the complete occlusion of one or more of the coronary arteries, which is demonstrated by patient symptoms and ST-segment elevation seen on an electrocardiogram (ECG)
  • A non-ST-segment elevation myocardial infarction (NSTEMI) results from a partial occlusion of a coronary artery. Patient symptoms often present alongside dynamic ST-segment depression, T-wave inversion or a normal ECG
  • Unstable angina is a result of a transient occlusion of the coronary arteries causing symptoms at rest or on minimal exertion, which may be eased/resolved with rest with or without glyceryl trinitrate (GTN)
  • Signs and symptoms of ischaemia experienced by patient include: chest pain with or without radiation to jaw, neck, back, shoulders or arms, which is described as squeezing or crushing. Associated symptoms of lethargy, syncope, pre-syncopal episodes, diaphoresis, dyspnoea, nausea or vomiting, anxiety or a feeling of impending doom often also prevail

Source: Deen, 2018

The possibility that Linda was experiencing ST-segment elevation myocardial infarction (STEMI) meant that she needed rapid assessment of her condition. Stephens (2019) recommended the use of the ABCDE assessment as a timely and effective tool to identify physiological deterioration in patients with chest pain. The student nurse's ABCDE assessment of Linda is shown in Box 2 .

Box 2. ABCDE assessment * of ‘Linda’

  • Airway: patent, no audible sounds of obstruction; however, unable to speak in full sentences due to dyspnoea
  • Breathing: dyspnoeic, respiratory rate of 27, saturations of 85% on room air—with guidance from the senior charge nurse, 80% oxygen via non-rebreathe mask was administered ( O'Driscoll et al, 2017 )
  • Circulation: tachycardia of 112 beats per minute, hypotensive at 92/50 mmHg, oliguric, diaphoretic, and with cool peripherals and a thready radial pulse
  • Disability: She was alert on the AVPU scale, but anxious and feeling lethargic. Blood glucose was 5.7 mmol/litre
  • Exposure: no erythema or wounds noted. She stated she had central chest pain, which was radiating to her jaw and back, described as ‘pressure’, and rated as a seven out of ten

* in line with Resuscitation Council (2015)

NICE (2016) recommends that the first investigation for patients with chest pain is to conduct an ECG as a rapid and non-invasive assessment for a cardiac cause of the pain. This was carried out and 2 mm ST-segment elevation in the precordial leads V1-V3 was noted, indicating a possible anterior STEMI ( Amsterdam et al, 2014 ). The student nurse had had basic ECG interpretation training as part of the nursing degree undertaken, but had also received informal teaching from registered nursing staff in cardiology. The ECG findings were confirmed by the senior charge nurse after they were alerted to Linda's condition, symptoms, and National Early Warning Score 2 (NEWS 2) ( Royal College of Physicians, 2017 ). The senior charge nurse escalated her care to the cardiology team. A diagnosis of STEMI was made by the cardiology team using the ECG findings and her physiological signs of deterioration from their assessment, within the context of her initial presentation to hospital for unstable angina. This diagnosis, coupled with the deterioration in her condition, meant that she required primary percutaneous coronary intervention (PCI). The NICE (2014) quality standard for acute coronary syndromes and the clinical guideline on STEMI ( NICE, 2013a ) recommend that primary PCI is initiated within 120 minutes to reperfuse the myocardium and prevent further myocardial cellular necrosis. This improves long-term patient outcomes ( Thygesen et al, 2018 ).

Decision-making theories

The recognition of an evolving STEMI on the cardiac monitor corresponds with the model of hypothetico-deductive reasoning ( Pearson, 2013 ) within the descriptive and normative theories ( Box 3 ). Thompson and Dowding (2009) highlighted that this model recognises that decision-making comprises four stages, beginning with cue acquisition. The specific pre-counter cues can be identified as the recognition of the abnormal tracing on the cardiac monitor ( Pearson, 2013 ), suggestive of ST-segment elevation, that indicated Linda might be experiencing haemodynamic deterioration with a cardiac cause. Subsequently, the decision to assess Linda formed the hypothesis generation phase of the decision and the recognition of the clinical signs as indicating STEMI ( Nickerson, 1998 ; Johansen and O'Brien, 2016 ). This hypothesis focused the assessment to identify and examine pertinent factors that supported this conjecture ( Pearson, 2013 ). However, the student nurse required more data to formulate a robust hypothesis thereby initiating the cue interpretation phase by conducting an ABCDE systematic assessment, including ECG. Lindsey (2013) argued that during cue interpretation, the health professional uses prescriptive guidelines to direct the assessment process and provide a rationale.

Box 3. Decision-making theories considered

  • Descriptive theory: is concerned with each individuals’ moral beliefs regarding a particular decision
  • Normative theory: connotes what decisions individuals should make logically
  • Prescriptive theory: encompasses the policies that govern the remits of a decision within the evidence base that informs practice

Source: Pearson, 2013

Arguably, however, clinical knowledge of the pathophysiology of ACS is fundamental to effective cue interpretation, not simply the individual's knowledge of the NICE guidance ( NICE, 2013a ; 2013b ; 2014 ; 2016 ). The student nurse's existing knowledge of the symptoms of ACS supported the cue interpretation with assessing Linda's condition and possible diagnosis of ACS. This knowledge enriched the student nurse's understanding of the guidance, which could then effectively be applied as the central aspect of cue interpretation ( Deen, 2018 ).

Elstein and Schwartz (2002) conceded that the prescriptive theory knowledge synthesised for the decision must be accurate and evidence-based for hypothetico-deductive reasoning to be effective. Courtney and McCutcheon (2009) argued that reliance solely on clinical guidelines can limit decision-making and result in erroneous outcomes and should consequently be used in collaboration with the evidence base. By combining normative theory with prescriptive guidance, clinical decisions can be enriched and validated. Stevens (2013) highlighted that it is vital that the guidance used in corroboration with decision-making models is valid and reliable and therefore prescriptive theory must be critically evaluated against the evidence-base. The guidance published by NICE (2013a) is supported by the American College of Cardiology ( O'Gara et al, 2013 ), European Resuscitation Council ( Nikolaou et al, 2015 ), European Society of Cardiology ( Steg et al, 2012 ) and Cardiac Society of Australia and New Zealand ( Chew et al, 2016 ). Accordingly, these guidelines highlight the clinical signs of STEMI and the diagnostic investigations pertinent to this condition. Within the remits of practice as a student nurse, this evidence supported the decision to escalate Linda's condition.

Antithetically, during cue interpretation and the hypothesis generation phases, Pearson (2013) emphasised the importance of considering multiple hypotheses extrapolated from the clinical data, resulting in the selection of the most appropriate hypothesis when more data are obtained. Despite this, during the interpretation of the cues for the hypothesis, the student nurse failed to consider differential diagnoses, such as pneumothorax or pulmonary embolism, which have similar presentations to STEMI ( Deen, 2018 ). Consequently, this hypothesis generation had an element of uncertainty ( Bjørk and Hamilton, 2011 ), which could have impeded Linda's care by erroneously considering only one potential diagnosis and therefore focusing the assessment on that diagnosis. Student nurses can be considered ‘novice’ health professionals, demonstrating limitations in knowledge regarding differential diagnoses and therefore in potential hypotheses. Pearson (2013) argued that this is because student nurses lack the requisite experience to cluster information as effectively as an ‘expert’ health professional. Consequently, the presentation of one hypothesis is permissible within the remits of practice as a student nurse.

Assessment tools such as ABCDE ( Resuscitation Council UK, 2015 ) ensure that all factors indicative of deterioration are recognised. Consequently, by using a systematic assessment, any potential erroneous hypothesis can be precluded. Therefore, as Carayon and Wood (2010) state, the assessment tool was a barrier to active failure to recognise alternative diagnoses thus circumventing any serious consequences, highlighting the importance of comprehensive assessment to avoid error and safeguard the ethical principle of non-maleficence ( Beauchamp and Childress, 2013 ) fundamental to nursing. Antithetically, Benner et al (2008) argued that even the novice nurse should be able to consider multiple hypotheses within a situation, although they may not be able to reflect on these decisions within the moment. However, as Keller (2009) noted, the hypothetico-deductive model is based on presuppositions recognised by the health professional, such as the evolving cardiac tracing and history of pain, indicating that STEMI was the higher probable cause ( Deen, 2018 ). Consequently, a limitation of hypothetico-deductive reasoning is sufficient experience to aid in generating hypotheses.

Thereafter, in the hypothesis generation phase, the decision-making process evolved to include elements of pattern recognition theory ( Croskerry, 2002 ). The clinical decision that focuses on a single hypothesis can be compared to the use of pattern recognition ( Pearson, 2013 ) where existing knowledge is used to establish the hypothesis. Pearson (2013) commented that hypothetico-deductive reasoning is based on the synthesising and analysing of information whereas the formulation of one hypothesis is suggestive of pattern recognition, where the nurse uses previous experience to evaluate the situation. Consequently, the student nurse's previous experience of assessing a patient in acute STEMI may have guided practice to recognise ST-segment elevation on the telemetry, and then subsequently to conduct an ECG, and to recognise the associated clinical signs of STEMI and to gather a history of the pain using NICE (2013b) guidance on unstable angina, in line with Linda's initial presentation. Croskerry (2002) identified that health professionals who rely on pattern recognition initially recognise visual cues that are then supplemented with more in-depth data, often using assessment tools such as NEWS (and now NEWS 2) and ABCDE. Arguably, the recognition of similarities in clinical presentation, past medical history, and cardiac monitoring tracing of Linda's case to the previous case and use of ABCDE and NEWS 2 to further assess her condition and extrapolate data, identifies that previous experience can facilitate decision-making outcomes.

Finally, in the last phase of the decision-making in the hypothetico-deductive model, the student nurse evaluated the hypothesis and by using the merits from the cues ( Banning, 2008 ) established that STEMI was the most probable cause of Linda's deterioration and could escalate her care appropriately using the prescriptive theory tools described above.

Arguably, by using previous experience to guide practice, an element of confirmation bias may have affected the selection of data ( Thompson and Dowding, 2009 ) and consequently the student may have neglected other important data ( Croskerry, 2003 ). For instance, student nurses are inexperienced with chest auscultation and consequently could not have ruled out differential respiratory diagnoses. Stanovich et al (2013) acknowledged that confirmation bias can be circumvented when evidence is assimilated with hypothesis generation. The consideration that Linda may have been at an increased risk of myocardial infarction due to her age, history of smoking and admission to hospital for unstable angina ( Piepoli et al, 2016 ), indicated that the cause of her deterioration would most likely be cardiac. Thus, an evidence-based approach could inform practice and consequently, any limitations as a ‘novice’ would be minimised through rationalisation and critical thinking. Indeed, Stanovich et al (2013) argued that rationalising and critical thinking are markedly more important than existing knowledge. This is because even an ‘expert’ in a specific field does not have completely comprehensive knowledge, and therefore relies on a critical thought process to make rational decisions.

Conclusively, health professionals must be able to rationalise their decisions ( Johansen and O'Brien, 2016 ) and justify these decisions within the context of each presentation as a central concept of nursing ( NMC, 2018 ).

Communication is vital to establishing consent to treatment where the patient is regarded as having capacity under the Mental Capacity Act 2005. This is particularly significant when conducting investigations and escalating care to ensure that the patient's wishes are respected, and that the patient is empowered with knowledge regarding their condition and care ( Coultier and Collins, 2011 ). Linda was informed that her care required escalation to the appropriate clinical team, and then subsequently recommended to have PCI intervention as the most effective treatment for STEMI ( NICE, 2013a ; 2014 ). Presenting a default decision and using choice architecture can be construed as methods of liberal paternalism used to avoid impeded decision-making from choice overload ( Rosenbaum, 2015 ) or irrational decision bias ( Marewski and Gigerenzer, 2012 ). To escalate Linda's care within the recommended timeframe ( NICE, 2013a ; 2014 ), it was important to use elements of liberal paternalism ( Beauchamp and Childress, 2013 ) while preserving Linda's autonomy of choice ( Kemmerer et al, 2017 ). Linda had a right to make a decision against medical advice as per Re B (Adult, refusal of medical treatment) [2002] and these choices were presented to her by the cardiology team. As a health professional, a duty of care was owed to the patient to escalate concerns regarding her condition under the Code ( NMC, 2018 ).

Conclusively, all three theories of decision-making pertained to this patient's effective care. Nurses must be accountable for their decisions and act within the remits of the NMC (2018) Code. Patient care must consequently be effective, evidence-based and patient-centred. Accountability requires the health professional to act within the remits of their role to ensure safe care is delivered to the patient. This is a fundamental aspect of patient-centric care and principal to effective decision making. Demonstrably, the use of descriptive and normative theories can be interchangeable, however, the use of prescriptive theory is pivotal to validate clinical decision-making. The decision-making process can be further facilitated by use of structured assessment tools to reduce margin of error and improve outcome. Collaborative decision making is pivotal to advancing patient autonomy and empowerment but certain decisions require elements of paternalism to improve the process and uphold the ethical principles of beneficence and non-maleficence. Nevertheless, health professionals have a duty of care to adhere to decisions made by patients established to have capacity to give informed consent, irrespective of the personal beliefs of the professional.

  • This article is a reflection on a case scenario where decisions were made in the care of a patient admitted for cardiac monitoring
  • Nursing decision making is complex and involves a multitude of processes based on experience, knowledge and skill.
  • Understanding the importance of decision-making theory and how these theories apply to practice can be effective in reflecting on practice, and the application of theory to practice can inform patient care

CPD reflective questions

  • Consider the three different theories of decision making outlined here—which theory do you deem the most important to your practice? How does this affect your practice?
  • Consider how reflecting on your own decision making can improve practice
  • What can you do to enrich your own knowledge regarding patients with chest pain?

Critical Thinking and the Nursing Process

In today’s health care arena, the nurse is faced with increasingly complex issues and situations resulting from advanced technology, greater acuity of patients in hospital and community settings, an aging population, and complex disease processes, as well as ethical and cultural factors.  Traditionally, nurses have used a problem-solving approach in planning and providing nursing care. Today the decision-making part of problem solving has become increasingly complex and requires critical thinking.

Definition of Critical thinking

Critical thinking is a multidimensional skill, a cognitive or mental process or set of procedures. It involves reasoning and purposeful, systematic, reflective, rational, outcome-directed thinking based on a body of knowledge, as well as examination and analysis of all available information and ideas. Critical thinking leads to the formulation of conclusions and the most appropriate, often creative, decisions, options, or alternatives. Critical thinking includes metacognition, the examination of one’s own reasoning or thought processes while thinking, to help strengthen and refine thinking skills. Independent judgments and decisions evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Nursing practice in today’s society mandates the use of high-level critical thinking skills within the nursing process. Critical thinking enhances clinical decision making, helping to identify patient needs and to determine the best nursing actions that will assist the patient in meeting those needs. Critical thinking and critical thinkers have distinctive characteristics. As indicated in the above definition, critical thinking is a conscious, outcome-oriented activity; it is purposeful and intentional. The critical thinker is an inquisitive, fair-minded truth seeker with an open-mindedness to the alternative solutions that might surface.

Critical thinking Process: Rationality and Insight

Critical thinking is systematic and organized. The skills involved in critical thinking are developed over time through effort, practice, and experience. Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Critical thinking requires background knowledge and knowledge of key concepts as well as standards of good thinking. The critical thinker uses reality-based deliberation to validate the accuracy of data and the reliability of sources, being mindful of and questioning inconsistencies. Interpretation is used to determine the significance of data that are gathered, and analysis is used to identify patient problems indicated by the data. The nurse uses inference to draw conclusions. Explanation is the justification of actions or interventions used to address patient problems and to help a patient move toward desired outcomes. Evaluation is the process of determining whether outcomes have been or are being met, and self-regulation is the process of examining the care provided and adjusting the interventions as needed. Critical thinking is also reflective, involving metacognition, active evaluation, and refinement of the thinking process. The critical thinker considers the possibility of personal bias when interpreting data and determining appropriate actions. The critical thinker must be insightful and have a sense of fairness and integrity, the courage to question personal ethics, and the perseverance to strive continuously to minimize the effects of egocentricity, ethnocentricity, and other biases on the decision making process.

Components of Critical thinking

Certain cognitive or mental activities can be identified as key components of critical thinking. When thinking critically, a person will do the following:

  • Ask questions to determine the reason why certain developments have occurred and to see whether more information is needed to understand the situation accurately.
  • Gather as much relevant information as possible to consider as many factors as possible.
  • Validate the information presented to make sure that it is accurate (not just supposition or opinion), that it makes sense, and that it is based on fact and evidence.
  • Analyze the information to determine what it means and to see whether it forms clusters or patterns that point to certain conclusions.
  • Draw on past clinical experience and knowledge to explain what is happening and to anticipate what might happen next, acknowledging personal bias and cultural influences.
  • Maintain a flexible attitude that allows the facts to guide thinking and takes into account all possibilities.
  • Consider available options and examine each in terms of its advantages and disadvantages.
  • Formulate decisions that reflect creativity and independent decision making.

Critical thinking requires going beyond basic problem solving into a realm of inquisitive exploration, looking for all relevant factors that affect the issue, and being an “out-of-the-box” thinker. It includes questioning all findings until a comprehensive picture emerges that explains the phenomenon, possible solutions, and creative methods for proceeding. Critical thinking in nursing practice results in a comprehensive patient plan of care with maximized potential for success.

Critical thinking In Nursing Practice

Using critical thinking to develop a plan of nursing care requires considering the human factors that might influence the plan. The nurse interacts with the patient, family, and other health care providers in the process of providing appropriate, individualized nursing care. The culture, attitude, and thought processes of the nurse, the patient, and others will affect the critical thinking process from the data-gathering stage through the decision-making stage; therefore, aspects of the nurse-patient interaction must be considered. Nurses must use critical thinking skills in all practice settings—acute care, ambulatory care, extended care, and in the home and community. Regardless of the setting, each patient situation is viewed as unique and dynamic. The unique factors that the patient and nurse bring to the health care situation are considered, studied, analyzed, and interpreted. Interpretation of the information presented then allows the nurse to focus on those factors that are most relevant and mostsignificant to the clinical situation. Decisions about what to do and how to do it are then developed into a plan of action.

Fonteyn (1998) identified 12 predominant thinking strategies used by nurses, regardless of their area of clinical practice:

Recognizing a pattern

  • Setting priorities
  • Searching for information
  • Generating hypotheses
  • Making predictions
  • Forming relationships
  • Stating a proposition (“if–then”)
  • Asserting a practice rule
  • Making choices (alternative actions)
  • Judging the value
  • Drawing conclusions
  • Providing explanations

Fonteyn further identified other, less prominent thinking strategies the nurse might use:

  • Posing a question
  • Making assumptions (supposing)
  • Making generalizations

These thought processes are consistent with the characteristics of critical thinking and cognitive activities discussed earlier. Fonteyn asserted that exploring how these thinking strategies are used in various clinical situations, and practicing using the strategies, might assist the nurse–learner in examining and refining his or her own thinking skills.

Throughout the critical thinking process, a continuous flow of questions evolves in the thinker’s mind. Although the questions will vary according to the particular clinical situation, certain general inquiries can serve as a basis for reaching conclusions and determining a course of action. When faced with a patient situation, it is often helpful to seek answers to some or all of the following questions in an attempt to determine those actions that are most appropriate:

  • What relevant assessment information do I need, and how do I interpret this information? What does this information tell me?
  • To what problems does this information point? Have I identified the most important ones? Does the information point to any other problems that I should consider?
  • Have I gathered all the information I need (signs/symptoms, laboratory values, medication history, emotional factors, mental status)? Is anything missing?
  • Is there anything that needs to be reported immediately? Do I need to seek additional assistance?
  • Does this patient have any special risk factors? Which ones are most significant? What must I do to minimize these risks?
  • What possible complications must I anticipate?
  • What are the most important problems in this situation? Do the patient and the patient’s family recognize the same problems?
  • What are the desired outcomes for this patient? Which have the highest priority? Does the patient see eye to eye with me on these points?
  • What is going to be my first action in this situation? How can I construct a plan of care to achieve the goals?
  • Are there any age-related factors involved, and will they require some special approach? Will I need to make some change in the plan of care to take these factors into account?
  •  How do the family dynamics affect this situation, and will this have an affect on my actions or the plan of care?
  • Are there cultural factors that I must address and consider?
  • Am I dealing with an ethical problem here? If so, how am I going to resolve it?
  • Has any nursing research been conducted on this subject?

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Problem solving in clinical nursing practice

Affiliation.

  • 1 School of Nursing, Deakin University, Victoria, Australia.
  • PMID: 9292367
  • DOI: 10.1046/j.1365-2648.1997.1997026329.x

Problem solving in clinical nursing practice is the essence of good care delivery. This paper gives an overview of a research study which identified the cognitive problem solving process nurses use while delivering care. The study was conducted in the clinical setting and used a qualitative research methodology of observation, followed by in-depth semi-structured interview. The analysis of the study revealed diagnostic reasoning is the process used by clinicians. Information regarding the differences between novices and experts is offered as topics for discussion throughout the paper, and recommendations for changes to educational processes are made.

  • Clinical Competence*
  • Nurse-Patient Relations
  • Nursing Care / methods*
  • Nursing Methodology Research
  • Nursing Process*
  • Nursing Staff, Hospital / psychology*
  • Problem Solving*
  • Socialization
  • Surveys and Questionnaires

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From problem solving to problem definition: scrutinizing the complex nature of clinical practice

Sayra cristancho.

1 Centre for Education Research & Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada

Lorelei Lingard

Glenn regehr.

2 Centre for Health Education Scholarship, Faculty of Medicine, University of British Columbia, Vancouver, Canada

In medical education, we have tended to present problems as being singular, stable, and solvable. Problem solving has, therefore, drawn much of medical education researchers’ attention. This focus has been important but it is limited in terms of preparing clinicians to deal with the complexity of the 21st century healthcare system in which they will provide team-based care for patients with complex medical illness. In this paper, we use the Soft Systems Engineering principles to introduce the idea that in complex, team-based situations, problems usually involve divergent views and evolve with multiple solution iterations. As such we need to shift the conversation from (1) problem solving to problem definition, and (2) from a problem definition derived exclusively at the level of the individual to a definition derived at the level of the situation in which the problem is manifested. Embracing such a focus on problem definition will enable us to advocate for novel educational practices that will equip trainees to effectively manage the problems they will encounter in complex, team-based healthcare.

Problem solving has been one of the central areas of exploration for researchers studying medical expertise. This work has revealed some important insights into how medical experts grapple with addressing relatively stable, well-defined problems. However, in focusing on problems that are singular, stable, and solvable, these insights might have limited value in preparing clinicians to deal with the complexity of the 21st century healthcare system in which they will provide team-based care for patients with complex medical illness [ 1 ]. In the medical education literature, this concern is gaining recent attention as researchers begin to challenge taken-for-granted assumptions about clinical reasoning activities, such as diagnosis [ 2 ]. When activities such as diagnosis or treatment planning are framed as ongoing processes of meaning making, problem solving can no longer be thought of merely as converging on the correct solution. Consider the following example, derived from a research interview with a senior general surgeon:

Dr. Smith was scheduled to operate on a gentleman with a pelvic exoneration that required removing all the organs within the pelvis. Chemotherapy prior to surgery would likely increase the success of surgery. The patient was assessed by the oncologist who decided not to provide chemotherapy before the operation because the oncologist thought the patient was ‘not reliable’ . To determine what to do, Dr. Smith engaged in a series of conversations with the nurse, the social worker, the oncologist and a more senior colleague. Dr. Smith felt very strongly that ‘treating someone with less than the standard of care’ was inappropriate. Yet, the oncologist continued to resist. As the day of the surgery approached, Dr. Smith gathered support from the rest of the team members involved and essentially ‘ tricked the oncologist’ by admitting the patient to the hospital in advance. With this decision, Dr. Smith presented a new situation to the oncologist saying ‘ok, well, now he’s in hospital, he’s very reliable; he’s not going anywhere … now you can treat him’ . The oncologist reframed his concern, remarking back to the surgeon that ‘sometimes what is good for this patient may not necessarily be good for society’ . Notwithstanding this stance, the oncologist acknowledged that since the patient was already in the hospital, he had to fulfil his professional responsibility of providing chemotherapy. As this treatment was taking place, Dr. Smith felt ‘somewhat morally conflicted because I get what the oncologist is worried about …’. He now reported viewing the situation as ‘teetering’ between doing the right thing for one patient and imposing a significant cost on the system. In describing the shifting context that defined his efforts to help this patient, he characterized the situation as being one of making judgments like a rock climber: ‘very, very slow, inching your way … that feels like a solid hand-hold, ok, I’ll take that … or that doesn’t seem like it’s gonna go, so maybe I’ll try a different strategy, and often what you do at a certain moment in time, opens up what you can see at another moment … I think it’s like being in a constant evolution of finding your place.’

What does this story reveal about the nature of problem solving in every day clinical practice? First, there was not a single problem in play here, but rather a constellation of problems defined differently from different perspectives. For example, from the surgeon’s perspective the question of whether the patient should receive chemotherapy was an issue of pursuing optimal care for a successful outcome, whereas from the oncologist‘s perspective, it was an issue of whether the treatment could be successfully enacted given the patient’s unreliability. Second, in the eyes of the surgeon (and the oncologist), the problem was not stable, but rather constantly evolving over time. Dr. Smith started with a procedural problem (operating on a patient that required removing all organs within the pelvis and identifying chemotherapy as needed to maximize success), which shifted into a care access problem (convincing the oncologist that treating the patient with chemotherapy prior to surgery was the most appropriate action), then became a team dynamics problem (convincing others of the need to admit the patient and tricking the oncologist). Finally, it evolved into a moral problem (the dilemma of doing the right thing for the patient vs. the cost imposed on the system), one imposed by the oncologist’s efforts to respond to his own shifting definition of the problem. Thus, what on the surface appears to be a single central problem of care for the patient is in fact a constantly evolving constellation of problems: it looks different depending on whose point of view we take, and on which point in time we emphasize during the process. The complexity in this team interaction is, therefore, not only, or even primarily, one of problem solving – it is also one of problem defining.

This story of everyday, incremental problem solving and iterative problem definition is the sort that occurs regularly in healthcare, and it illustrates the fluidity of problems. In Dr. Smith’s story the issue of reframing problems was made explicit as he told the story during his interview, but in everyday practice most likely it happens largely tacitly as clinicians balance their various priorities [ 3 ]. Whether explicit or tacit, however, team members learn from such experiences. The next time this senior surgeon and oncologist interact regarding pre-surgical chemotherapy, each will make inferences about the other’s definition of the clinical problem based on this experience and adapt their behaviour accordingly. The surgeon might, for example, admit the patient before consulting with the oncologist, both in an attempt to manage the problem definition and its solution. Thus, through experience, clinicians become savvy definers of problems just as they become savvy solvers of problems. Yet such sophisticated considerations are seldom articulated, and when the pre-emptive solution is enacted the problem does not manifest. Thus, the complexity and multifaceted nature of the underlying problem definition is hidden (perhaps, over repeated enactments, even from the physician himself).

Such examples challenge the conventional premise that problems are singular and stable, and that they can be ‘solved’ once and for all. A singular, stable definition and permanent solution of problems may hold in simple healthcare situations (e. g., a child with a minor ear infection brought to the family physician), but in complex, team-based situations like the one above, these premises are regularly challenged. Because different stakeholders may well approach the same issue differently, the major challenge lies not just in agreeing how to solve the problem, but in appreciating exactly what the problem is at any given moment in time.

If we acknowledge that clinical problem definition is not simple and straightforward, but multifaceted, evolving and iterative, then we require a new language for talking about problem solving . A number of other disciplines have grappled with this issue [ 4 ], and one that has developed a useful language is SSE [ 5 – 8 ]. Elsewhere we have discussed the implications of SSE in relation to other domains such as resilience [ 9 ] and learning [ 10 ]. For the purposes of this paper, we are exploring the value of SSE for reconsidering the construction of problem solving in the medical education literature. One of many concepts that Soft Systems Engineering posits [ 11 – 13 ] is the idea that because real-life problems usually involve divergent views and evolve with multiple solution iterations, the focus needs to shift in two ways. First, it needs to shift from problem solving to problem definition . Second, it needs to shift from a problem definition derived exclusively at the level of the individual to a definition derived at the level of the situation or system in which the problem is manifested [ 11 ].

SSE offers a vocabulary for making these shifts possible. First, SSE identifies the perspectives that are involved in a problem situation: who are the stakeholders in the problem and from what orientation does each define it? In the story above, different team members held different and conflicting perspectives on how to treat this particular patient prior to surgery. While the oncologist struggled with the idea of providing chemotherapy prior to the operation, the surgeon struggled with the consequences of admitting the patient earlier to the hospital. Second, SSE moves beyond a consideration of each isolated perspective to examine the interactions among them [ 11 – 13 ]. Although we might potentially interpret these differing perspectives as just a set of individual problems, in fact, these interacting perspectives collectively shape and reshape the situation in which each individual is enacting his or her part [ 14 , 15 ].

In the surgery story, the interactions among the surgeon’s and the oncologist’s perspectives resulted in a series of redefinitions of the problem for the surgeon: from attending to the procedural steps, to attending to the team dynamics, to attending to the moral dilemma. Thus, under the SSE approach, the construction of the situation becomes a cyclical process: the dynamic nature of the various perspectives a single team member holds and the interactions with other team members’ perspectives reshapes the situation, which in turn influences every team member’s understanding. As a research approach, SSE therefore enables us to ask questions such as:

  • What are all the relevant perspectives for the definition of a problem? In the story above these included both the surgeon and the oncologist, but might also have included those of the nurses, social workers, hospital administrators, and patient. As the surgeon told it, these perspectives seemed to align with his, but it would be important to ask as an open question.
  • How do those perspectives interact with one another to iteratively define the problem? The surgery story showed at least three redefinitions of the problem caused by the interactions among perspectives.
  • How do new behaviours emerge as a consequence of those interactions and in response to the constantly changing nature of the problem? The surgeon-oncologist interaction depicted in the story might result in the surgeon implementing workarounds next time he faces a similar situation with the same oncologist.

Daily clinical problems are dynamic challenges defined multiply by individuals distributed across the system. Adopting an SSE lens can help us conceptualize a ‘problem’ not as singular and static, but as an entity that evolves, adapts and emerges across interactions and across time. Consistent with other recent innovations in medical education [ 4 ], we suggest that embracing a focus on the complexities of problem definition can enable novel educational practices that will equip trainees to effectively manage the problems they are likely to encounter in complex, team-based healthcare.

Biographies

is assistant professor at the Department of Surgery and Scientist, Centre for Education Research & Innovation, Western University, Canada. Her research programme investigates the organizational, social and personal factors that determine the evolution of complex clinical situations. Towards this end, she follows Qualitative and Systems Engineering approaches to research.

is the director of CERI. Her research programme investigates the nature of communication on inter-professional healthcare teams, including the operating room, the intensive care unit, and the internal medicine ward. She is particularly interested in how communication patterns influence patient safety and shapes the professional identity of novices.

is professor at the Department of Surgery and associate director of the Centre for Health Education Scholarship, University of British Columbia, Canada. His collaborative research programme utilizes a variety of quantitative and qualitative methodologies to explore the development, maintenance, enactment and assessment of both clinical expertise and professional identity.

Critical thinking definition

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Critical thinking, as described by Oxford Languages, is the objective analysis and evaluation of an issue in order to form a judgement.

Active and skillful approach, evaluation, assessment, synthesis, and/or evaluation of information obtained from, or made by, observation, knowledge, reflection, acumen or conversation, as a guide to belief and action, requires the critical thinking process, which is why it's often used in education and academics.

Some even may view it as a backbone of modern thought.

However, it's a skill, and skills must be trained and encouraged to be used at its full potential.

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Usage of critical thinking comes down not only to the outline of your paper, it also begs the question: How can we use critical thinking solving problems in our writing's topic?

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COMMENTS

  1. Problem Solving in Nursing: Strategies for Your Staff

    Problem solving is in a nurse manager's DNA. As leaders, nurse managers solve problems every day on an individual level and with their teams. Effective leaders find innovative solutions to problems and encourage their staff to nurture their own critical thinking skills and see problems as opportunities rather than obstacles.

  2. Communication Skills, Problem-Solving Ability, Understanding of

    Such findings support the present study's indication that nurses' communication is a basic means of solving nursing problems, with both actions being interrelated. Our finding that nurses' communication skills are structurally related to their nurse's perception of professionalism supports the findings of many previous studies.

  3. The influencing factors of clinical nurses' problem solving dilemma: a

    Problem solving has been defined as "a goal-directed sequence of cognitive and affective operations as well as behavioural responses to adapting to internal or external demands or challenges.

  4. PDF Critical thinking in Nursing: Decision-making and Problem-solving

    Decision-making free flow of ideas is essential to problem-solving and decision-making because it helps prevent preconceived ideas from controlling the process. Many decisions in healthcare are arrived at by group or teams rather than by the individual, and this type of decision-making requires special skills.

  5. Nurse leaders as problem-solvers: Addressing lateral and... : Nursing

    LHV, also called nurse-on-nurse aggression, disruptive behavior, or incivility, undermines a culture of safety and negatively impacts patient care. 2,3 This experience, known to nurses as "eating their young," isn't only intimidating and disruptive, it's also costly and demoralizing to the nursing profession and healthcare organizations. 4,5 Alt...

  6. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and

    The high-performance expectation of nurses is dependent upon the nurses' continual learning, professional accountability, independent and interdependent decisionmaking, and creative problem-solving abilities.

  7. Creativity and Problem-Solving Skills in Nursing

    Nurses who employ problem-solving skills begin with critical thinking. When there are no clear answers or courses of action, nurses can rely on their creativity to come up with new solutions and make decisions. Combined with creativity, critical thinking can help nurses solve specific patient problems as well as system-wide challenges.

  8. The Value of Critical Thinking in Nursing

    He defines critical thinking as "necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation."

  9. Impact of social problem-solving training on critical ...

    Problem-solving skill means acquiring knowledge to reach a solution, and a person's ability to use this knowledge to find a solution requires critical thinking. The promotion of these skills is considered a necessary condition for nurses' performance in the nursing profession [ 5, 6 ].

  10. Critical Thinking in Nursing

    Nursing is responsible for understanding health and disease status from the beginning of life to death and solving problems by planning appropriate interventions. The nursing process, which confers a professional identity in the nursing profession, is a dynamic process that requires scientific thinking and research and is planned, applied, and ...

  11. Problem solving in nursing practice: application, process, skill

    This paper analyses the role of problem solving in nursing practice including the process, acquisition and measurement of problem-solving skills It is argued that while problem-solving ability is acknowledged as critical if today's nurse practitioner is to maintain effective clinical practice, to date it retains a marginal place in nurse education curricula Further, it has attracted limited ...

  12. 4.2 Basic Concepts

    Critical thinking is a broad term used in nursing that includes "reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow." [1] Using critical thinking means that nurses take extra steps to maintain patient safety and don't just "follow orders."

  13. Effective decision-making: applying the theories to nursing practice

    Decision-making is a fundamental concept of nursing practice that conforms to a systematic trajectory involving the assessment, interpretation, evaluation and management of patient-specific situations (Dougherty et al, 2015).Shared decision-making is vital to consider in terms of patient autonomy and professional duty of care as set out in the Nursing and Midwifery Council (NMC) (2018)Code ...

  14. Relationship Between the Problem-Solving Skills and Empathy ...

    Problem solving is a focus of nursing practice and of great importance for raising the quality of patient care. Constructive problem-solving skills affect cognitive empathy skills. Educational level and career length were found to relate negatively and level of self-confidence was found to relate positively with level of cognitive empathy.

  15. Strategies for Problem Solving

    Problem solving is centered on your ability to identify critical issues and create or identify solutions. Well-developed problem solving skills is a characteristic of a successful student. Remember, problems are a part of everyday life and your ability to resolve problems will have a positive influence on your future. 6 Steps of Problem Solving

  16. Critical Thinking: The Development of an Essential Skill for Nursing

    1. INTRODUCTION Critical thinking is applied by nurses in the process of solving problems of patients and decision-making process with creativity to enhance the effect. It is an essential process for a safe, efficient and skillful nursing intervention.

  17. Critical Thinking and the Nursing Process

    Traditionally, nurses have used a problem-solving approach in planning and providing nursing care. Today the decision-making part of problem solving has become increasingly complex and requires critical thinking. Definition of Critical thinking. Critical thinking is a multidimensional skill, a cognitive or mental process or set of procedures.

  18. Problem Identification: The First Step in Evidence-Based Practice

    As such, I offer the following more nursing-centered and practical definition: EBP for nursing is a way of entering the situation with curiosity and engagement that follows the nursing process by responding to the issue or problem using the best available evidence.

  19. Turning New Nurses Into Critical Thinkers

    The term 'critical thinking' is often used interchangeably with problem-solving and clinical decision-making in nursing literature. Problem-solving focuses on identification and resolution, whereas critical thinking goes beyond this and incorporates asking questions and critiquing solutions. The concept of clinical decision-making focuses ...

  20. Problem solving in clinical nursing practice

    Problem solving in clinical nursing practice is the essence of good care delivery. This paper gives an overview of a research study which identified the cognitive problem solving process nurses use while delivering care. The study was conducted in the clinical setting and used a qualitative research …

  21. What is Problem Solving? Steps, Process & Techniques

    Finding a suitable solution for issues can be accomplished by following the basic four-step problem-solving process and methodology outlined below. Step. Characteristics. 1. Define the problem. Differentiate fact from opinion. Specify underlying causes. Consult each faction involved for information. State the problem specifically.

  22. From problem solving to problem definition: scrutinizing the complex

    This story of everyday, incremental problem solving and iterative problem definition is the sort that occurs regularly in healthcare, and it illustrates the fluidity of problems. In Dr. Smith's story the issue of reframing problems was made explicit as he told the story during his interview, but in everyday practice most likely it happens ...

  23. Using Critical Thinking in Essays and other Assignments

    Critical thinking definition. Critical thinking, as described by Oxford Languages, is the objective analysis and evaluation of an issue in order to form a judgement. Active and skillful approach, evaluation, assessment, synthesis, and/or evaluation of information obtained from, or made by, observation, knowledge, reflection, acumen or ...