which critical thinking skill in nursing practice requires the nurse to possess

What is Critical Thinking in Nursing? (With Examples, Importance, & How to Improve)

Successful nursing requires learning several skills used to communicate with patients, families, and healthcare teams. One of the most essential skills nurses must develop is the ability to demonstrate critical thinking. If you are a nurse, perhaps you have asked if there is a way to know how to improve critical thinking in nursing? As you read this article, you will learn what critical thinking in nursing is and why it is important. You will also find 18 simple tips to improve critical thinking in nursing and sample scenarios about how to apply critical thinking in your nursing career.

What Is Critical Thinking In Nursing?

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

• Ask relevant questions • Justify opinions • Address and evaluate multiple points of view • Explain assumptions and reasons related to your choice of patient care options

5. Can I Be a Nurse If I Cannot Think Critically?

The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

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

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

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

How Do Nurses Use Critical Thinking?

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

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

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

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

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

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

Top 5 Ways Nurses Can Improve Critical Thinking Skills

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

Case-Based Approach

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

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

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

Practice Self-Reflection

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

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

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

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

Develop a Questioning Mind

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

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

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

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

Practice Self-Awareness in the Moment

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

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

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

Use a Process

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

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

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

Common Critical Thinking Pitfalls in Nursing

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

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

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

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

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

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

An Essential Skill for All Nurses

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

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

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

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

How does nursing school develop critical thinking skills?

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

Do only nurse managers use critical thinking?

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

Meet Our Contributors

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

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

Jenna Liphart Rhoads, Ph.D., RN

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

Nicholas McGowan, BSN, RN, CCRN

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

Brain, Decision Making and Mental Health pp 179–189 Cite as

Critical Thinking in Nursing

• Şefika Dilek Güven 3  
• First Online: 02 January 2023

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Part of the book series: Integrated Science ((IS,volume 12))

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

Graphical Abstract/Art Performance

Critical thinking in nursing.

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

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

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

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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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Critical Thinking in Nursing Practice

Chapter 15 Critical Thinking in Nursing Practice Objectives •  Describe characteristics of a critical thinker. •  Discuss the nurse’s responsibility in making clinical decisions. •  Discuss how reflection improves clinical decision making. •  Describe the components of a critical thinking model for clinical decision making. •  Discuss critical thinking skills used in nursing practice. •  Explain the relationship between clinical experience and critical thinking. •  Discuss the critical thinking attitudes used in clinical decision making. •  Explain how professional standards influence a nurse’s clinical decisions. •  Discuss the relationship of the nursing process to critical thinking. Key Terms Clinical decision making, p. 196 Concept map, p. 202 Critical thinking, p. 193 Decision making, p. 195 Diagnostic reasoning, p. 196 Evidence-based knowledge, p. 193 Inference, p. 196 Nursing process, p. 197 Problem solving, p. 195 Reflection, p. 202 Scientific method, p. 195 http://evolve.elsevier.com/Potter/fundamentals/ •  Review Questions •  Case Study with Questions •  Audio Glossary •  Interactive Learning Activities •  Key Term Flashcards •  Content Updates Every day you think critically without realizing it. If it’s hot outside, you take off a sweater. If your DVD doesn’t start, you reposition the disc. If you decide to walk the dogs, you change to a pair of walking shoes. These examples involve critical thinking as you face each day and prepare for all possibilities. As a nurse, you will face many clinical situations involving patients, family members, health care staff, and peers. In each situation it is important to try to see the big picture and think smart. To think smart you have to develop critical thinking skills to face each new experience and problem involving a patient’s care with open-mindedness, creativity, confidence, and continual inquiry. When a patient develops a new set of symptoms, asks you to offer comfort, or requires a procedure, it is important to think critically and make sensible judgments so the patient receives the best nursing care possible. Critical thinking is not a simple step-by-step, linear process that you learn overnight. It is a process acquired only through experience, commitment, and an active curiosity toward learning. Clinical Decisions in Nursing Practice Nurses are responsible for making accurate and appropriate clinical decisions. Clinical decision making separates professional nurses from technical personnel. For example, a professional nurse observes for changes in patients, recognizes potential problems, identifies new problems as they arise, and takes immediate action when a patient’s clinical condition worsens. Technical personnel simply follow direction in completing aspects of care that the professional nurse has identified as necessary. A professional nurse relies on knowledge and experience when deciding if a patient is having complications that call for notification of a health care provider or decides if a teaching plan for a patient is ineffective and needs revision. Benner (1984) describes clinical decision making as judgment that includes critical and reflective thinking and action and application of scientific and practical logic. Most patients have health care problems for which there are no clear textbook solutions. Each patient’s problems are unique, a product of the patient’s physical health, lifestyle, culture, relationship with family and friends, living environment, and experiences. Thus as a nurse you do not always have a clear picture of a patient’s needs and the appropriate actions to take when first meeting a patient. Instead you must learn to question, wonder, and explore different perspectives and interpretations to find a solution that benefits the patient. Because no two patients’ health problems are the same, you always apply critical thinking differently. Observe patients closely, gather information about them, examine ideas and inferences about patient problems, recognize the problems, consider scientific principles relating to the problems, and develop an approach to nursing care. With experience you learn to creatively seek new knowledge, act quickly when events change, and make quality decisions for patients’ well-being. You will find nursing to be rewarding and fulfilling through the clinical decisions you make. Critical Thinking Defined Mr. Jacobs is a 58-year-old patient who had a radical prostatectomy for prostate cancer yesterday. His nurse, Tonya, finds the patient lying supine in bed with arms extended along his sides but tensed. When Tonya checks the patient’s surgical wound and drainage device, she notes that the patient winces when she gently places her hands to palpate around the surgical incision. She asks Mr. Jacobs when he last turned onto his side, and he responds, “Not since last night some time.” Tonya asks Mr. Jacobs if he is having incisional pain, and he nods yes, saying, “It hurts too much to move.” Tonya considers the information she has observed and learned from the patient to determine that he is in pain and has reduced mobility because of it. She decides that she needs to take action to relieve Mr. Jacobs’ pain so she can turn him more frequently and begin to get him out of bed for his recovery. In the case example the nurse observes the clinical situation, asks questions, considers what she knows about postoperative pain and risk for immobility, and takes action. The nurse applies critical thinking, a continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant ( Heffner and Rudy, 2008 ). Critical thinking involves recognizing that an issue (e.g., patient problem) exists, analyzing information about the issue (e.g., clinical data about a patient), evaluating information (reviewing assumptions and evidence) and making conclusions ( Settersten and Lauver, 2004 ). A critical thinker considers what is important in each clinical situation, imagines and explores alternatives, considers ethical principles, and makes informed decisions about the care of patients. Critical thinking is a way of thinking about a situation that always asks “Why?”, “What am I missing?”, “What do I really know about this patient’s situation?”, and “What are my options?” ( Heffner and Rudy, 2008 ; Paul and Heaslip, 1995 ). Tonya knew that pain was likely going to be a problem because the patient had extensive surgery. Her review of her observations and the patient’s report of pain confirmed her knowledge that pain was a problem. Her options include giving Mr. Jacobs an analgesic and waiting until it takes effect so she is able to reposition and make him more comfortable. Once he has less acute pain, Tonya offers to teach Mr. Jacobs some relaxation exercises. You begin to learn critical thinking early in your practice. For example, as you learn about administering baths and other hygiene measures, take time to read your textbook and the nursing literature about the concept of comfort. What are the criteria for comfort? How do patients from other cultures perceive comfort? What are the many factors that promote comfort? The use of evidence-based knowledge, or knowledge based on research or clinical expertise, makes you an informed critical thinker. Thinking critically and learning about the concept of comfort prepares you to better anticipate your patients’ needs, identify comfort problems more quickly, and offer appropriate care. Critical thinking requires cognitive skills and the habit of asking questions, remaining well informed, being honest in facing personal biases, and always being willing to reconsider and think clearly about issues ( Facione, 1990 ). When core critical thinking skills are applied to nursing, they show the complex nature of clinical decision making ( Table 15-1 ). Being able to apply all of these skills takes practice. You also need to have a sound knowledge base and thoughtfully consider what you learn when caring for patients. TABLE 15-1 Critical Thinking Skills SKILL NURSING PRACTICE APPLICATIONS Interpretation Be orderly in data collection. Look for patterns to categorize data (e.g., nursing diagnoses [see Chapter 17 ]). Clarify any data you are uncertain about. Analysis Be open-minded as you look at information about a patient. Do not make careless assumptions. Do the data reveal what you believe is true, or are there other options? Inference Look at the meaning and significance of findings. Are there relationships between findings? Do the data about the patient help you see that a problem exists? Evaluation Look at all situations objectively. Use criteria (e.g., expected outcomes, pain characteristics, learning objectives) to determine results of nursing actions. Reflect on your own behavior. Explanation Support your findings and conclusions. Use knowledge and experience to choose strategies to use in the care of patients. Self-regulation Reflect on your experiences. Identify the ways you can improve your own performance. What will make you believe that you have been successful? Modified from Facione P: Critical thinking: a statement of expert consensus for purposes of educational assessment and instruction. The Delphi report: research findings and recommendations prepared for the American Philosophical Association, ERIC Doc No. ED 315, Washington, DC, 1990, ERIC. Nurses who apply critical thinking in their work are able to see the big picture from all possible perspectives. They focus clearly on options for solving problems and making decisions rather than quickly and carelessly forming quick solutions ( Kataoka-Yahiro and Saylor, 1994 ). Nurses who work in crisis situations such as the emergency department often act quickly when patient problems develop. However, even these nurses exercise discipline in decision making to avoid premature and inappropriate decisions. Learning to think critically helps you care for patients as their advocate, or supporter, and make better-informed choices about their care. Facione and Facione (1996) identified concepts for thinking critically ( Table 15-2 ). Critical thinking is more than just problem solving. It is a continuous attempt to improve how to apply yourself when faced with problems in patient care. TABLE 15-2 Concepts for a Critical Thinker CONCEPT CRITICAL THINKING BEHAVIOR Truth seeking Seek the true meaning of a situation. Be courageous, honest, and objective about asking questions. Open-mindedness Be tolerant of different views; be sensitive to the possibility of your own prejudices; respect the right of others to have different opinions. Analyticity Analyze potentially problematic situations; anticipate possible results or consequences; value reason; use evidence-based knowledge. Systematicity Be organized, focused; work hard in any inquiry. Self-confidence Trust in your own reasoning processes. Inquisitiveness Be eager to acquire knowledge and learn explanations even when applications of the knowledge are not immediately clear. Value learning for learning’s sake. Maturity Multiple solutions are acceptable. Reflect on your own judgments; have cognitive maturity. Modified from Facione N, Facione P: Externalizing the critical thinking in knowledge development and clinical judgment, Nurs Outlook 44(3):129, 1996. Thinking and Learning Learning is a lifelong process. Your intellectual and emotional growth involves learning new knowledge and refining your ability to think, problem solve, and make judgments. To learn, you have to be flexible and always open to new information. The science of nursing is growing rapidly, and there will always be new information for you to apply in practice. As you have more clinical experiences and apply the knowledge you learn, you will become better at forming assumptions, presenting ideas, and making valid conclusions. When you care for a patient, always think ahead and ask these questions: What is the patient’s status now? How might it change and why? Which physiological and emotional responses do I anticipate? What do I know to improve the patient’s condition? In which way will specific therapies affect the patient? What should be my first action? Do not let your thinking become routine or standardized. Instead, learn to look beyond the obvious in any clinical situation, explore the patient’s unique responses to health alterations, and recognize which actions are needed to benefit the patient. With experience you are able to recognize patterns of behavior, see commonalities in signs and symptoms, and anticipate reactions to therapies. Thinking about these experiences allows you to better anticipate each new patient’s needs and recognize problems when they develop. Levels of Critical Thinking in Nursing Your ability to think critically grows as you gain new knowledge in nursing practice. Kataoka-Yahiro and Saylor (1994) developed a critical thinking model ( Fig. 15-1 ) that includes three levels: basic, complex, and commitment. An expert nurse thinks critically almost automatically. As a beginning student you make a more conscious effort to apply critical thinking because initially you are more task oriented and trying to learn how to organize nursing care activities. At first you apply the critical thinking model at the basic level. As you advance in practice, you adopt complex critical thinking and commitment. FIG. 15-1 Critical thinking model for nursing judgment. (Redrawn from Kataoka-Yahiro M, Saylor C: A critical thinking model for nursing judgment, J Nurs Educ 33(8):351, 1994. Modified from Glaser E: An experiment in the development of critical thinking, New York, 1941, Bureau of Publications, Teachers College, Columbia University; Miller M, Malcolm N: Critical thinking in the nursing curriculum, Nurs Health Care 11:67, 1990; Paul RW: The art of redesigning instruction. In Willsen J, Blinker AJA, editors: Critical thinking: how to prepare students for a rapidly changing world, Santa Rosa, Calif, 1993, Foundation for Critical Thinking; and Perry W: Forms of intellectual and ethical development in the college years: a scheme , New York, 1979, Holt, Rinehart, & Winston.) Basic Critical Thinking At the basic level of critical thinking a learner trusts that experts have the right answers for every problem. Thinking is concrete and based on a set of rules or principles. For example, as a nursing student you use a hospital procedure manual to confirm how to insert a Foley catheter. You likely follow the procedure step by step without adjusting it to meet a patient’s unique needs (e.g., positioning to minimize the patient’s pain or mobility restrictions). You do not have enough experience to anticipate how to individualize the procedure. At this level answers to complex problems are either right or wrong (e.g., when no urine drains from the catheter, the catheter tip must not be in the bladder), and one right answer usually exists for each problem. Basic critical thinking is an early step in developing reasoning ( Kataoka-Yahiro and Saylor, 1994 ). A basic critical thinker learns to accept the diverse opinions and values of experts (e.g., instructors and staff nurse role models). However, inexperience, weak competencies, and inflexible attitudes can restrict a person’s ability to move to the next level of critical thinking. Complex Critical Thinking Complex critical thinkers begin to separate themselves from experts. They analyze and examine choices more independently. The person’s thinking abilities and initiative to look beyond expert opinion begin to change. A nurse learns that alternative and perhaps conflicting solutions exist. Consider the case of Mr. Rosen, a 36-year-old man who had hip surgery. The patient is having pain but is refusing his ordered analgesic. His health care provider is concerned that the patient will not progress as planned, delaying rehabilitation. While discussing the importance of rehabilitation with Mr. Rosen, the nurse, Edwin, realizes the patient’s reason for not taking pain medication. Edwin learns that the patient practices meditation at home. As a complex critical thinker, Edwin recognizes that Mr. Rosen has options for pain relief. Edwin decides to discuss meditation and other nonpharmacological interventions with the patient as pain control options and how, when combined with analgesics, these interventions can potentially enhance pain relief. In complex critical thinking each solution has benefits and risks that you weigh before making a final decision. There are options. Thinking becomes more creative and innovative. The complex critical thinker is willing to consider different options from routine procedures when complex situations develop. You learn a variety of different approaches for the same therapy. Commitment The third level of critical thinking is commitment ( Kataoka-Yahiro and Saylor, 1994 ). At this level a person anticipates when to make choices without assistance from others and accepts accountability for decisions made. As a nurse you do more than just consider the complex alternatives that a problem poses. At the commitment level you choose an action or belief based on the available alternatives and support it. Sometimes an action is to not act or to delay an action until a later time. You choose to delay as a result of your experience and knowledge. Because you take accountability for the decision, you consider the results of the decision and determine whether it was appropriate. Critical Thinking Competencies Kataoka-Yahiro and Saylor (1994) describe critical thinking competencies as the cognitive processes a nurse uses to make judgments about the clinical care of patients. These include general critical thinking, specific critical thinking in clinical situations, and specific critical thinking in nursing. General critical thinking processes are not unique to nursing. They include the scientific method, problem solving, and decision making. Specific critical thinking competencies in clinical health care situations include diagnostic reasoning, clinical inference, and clinical decision making. The specific critical thinking competency in nursing involves use of the nursing process. Each of the competencies is discussed in the following paragraphs. General Critical Thinking Scientific Method The scientific method is a way to solve problems using reasoning. It is a systematic, ordered approach to gathering data and solving problems used by nurses, physicians, and a variety of other health care professionals. This approach looks for the truth or verifies that a set of facts agrees with reality. Nurse researchers use the scientific method when testing research questions in nursing practice situations (see Chapter 5 ). The scientific method has five steps: 1  Identifying the problem 2  Collecting data 3  Formulating a question or hypothesis 4  Testing the question or hypothesis 5  Evaluating results of the test or study Consider the following example of the scientific method in nursing practice. A nurse caring for patients who receive large doses of chemotherapy for ovarian cancer sees a pattern of patients developing severe inflammation in the mouth (mucositis) (identifies problem). The nurse reads research articles (collects data) about mucositis and learns that there is evidence to show that having patients keep ice in their mouths (cryotherapy) during the chemotherapy infusion reduces severity of mucositis after treatment. He or she asks (forms question), “Do patients with ovarian cancer who receive chemotherapy have less severe mucositis when given cryotherapy versus standard mouth rinse in the oral cavity?” The nurse then collaborates with colleagues to develop a nursing protocol for using ice with certain chemotherapy infusions. The nurses on the oncology unit collect information that allows them to compare the incidence and severity of mucositis for a group of patients who use cryotherapy versus those who use standard-practice mouth rinse (tests the question). They analyze the results of their project and find that the use of cryotherapy reduced the frequency and severity of mucositis in their patients (evaluating the results). They decide to continue the protocol for all patients with ovarian cancer. Problem Solving You face problems every day such as a computer program that doesn’t function properly or a close friend who has lost a favorite pet. When a problem arises, you obtain information and use it, plus what you already know, to find a solution. Patients routinely present problems in practice. For example, a home care nurse learns that a patient has difficulty taking her medications regularly. The patient is unable to describe what medications she has taken for the last 3 days. The medication bottles are labeled and filled. The nurse has to solve the problem of why the patient is not adhering to or following her medication schedule. The nurse knows that the patient was discharged from the hospital and had five medications ordered. The patient tells the nurse that she also takes two over-the-counter medications regularly. When the nurse asks her to show the medications that she takes in the morning, the nurse notices that she has difficulty reading the medication labels. The patient is able to describe the medications that she is to take but is uncertain about the times of administration. The nurse recommends having the patient’s pharmacy relabel the medications in larger lettering. In addition, the nurse shows the patient examples of pill organizers that will help her sort her medications by time of day for a period of 7 days. Effective problem solving also involves evaluating the solution over time to make sure that it is effective. It becomes necessary to try different options if a problem recurs. From the previous example, during a follow-up visit the nurse finds that the patient has organized her medications correctly and is able to read the labels without difficulty. The nurse obtained information that correctly clarified the cause of the patient’s problem and tested a solution that proved successful. Having solved a problem in one situation adds to a nurse’s experience in practice, and this allows the nurse to apply that knowledge in future patient situations. Decision Making When you face a problem or situation and need to choose a course of action from several options, you are making a decision. Decision making is a product of critical thinking that focuses on problem resolution. Following a set of criteria helps to make a thorough and thoughtful decision. The criteria may be personal; based on an organizational policy; or, frequently in the case of nursing, a professional standard. For example, decision making occurs when a person decides on the choice of a health care provider. To make a decision, an individual has to recognize and define the problem or situation (need for a certain type of health care provider to provide medical care) and assess all options (consider recommended health care providers or choose one whose office is close to home). The person has to weigh each option against a set of personal criteria (experience, friendliness, and reputation), test possible options (talk directly with the different health care providers), consider the consequences of the decision (examine pros and cons of selecting one health care provider over another), and make a final decision. Although the set of criteria follows a sequence of steps, decision making involves moving back and forth when considering all criteria. It leads to informed conclusions that are supported by evidence and reason. Examples of decision making in the clinical area include determining which patient care priority requires the first response, choosing a type of dressing for a patient with a surgical wound, or selecting the best teaching approach for a family caregiver who will assist a patient who is returning home after a stroke. Specific Critical Thinking Diagnostic Reasoning and Inference Once you receive information about a patient in a clinical situation, diagnostic reasoning begins. It is the analytical process for determining a patient’s health problems ( Harjai and Tiwari, 2009 ). Accurate recognition of a patient’s problems is necessary before you decide on solutions and implement action. It requires you to assign meaning to the behaviors and physical signs and symptoms presented by a patient. Diagnostic reasoning begins when you interact with a patient or make physical or behavioral observations. An expert nurse sees the context of a patient situation (e.g., a patient who is feeling light-headed with blurred vision and who has a history of diabetes is possibly experiencing a problem with blood glucose levels), observes patterns and themes (e.g., symptoms that include weakness, hunger, and visual disturbances suggest hypoglycemia), and makes decisions quickly (e.g., offers a food source containing glucose). The information a nurse collects and analyzes leads to a diagnosis of a patient’s condition. Nurses do not make medical diagnoses, but they do assess and monitor patients closely and compare the patients’ signs and symptoms with those that are common to a medical diagnosis. This type of diagnostic reasoning helps health care providers pinpoint the nature of a problem more quickly and select proper therapies. Part of diagnostic reasoning is clinical inference, the process of drawing conclusions from related pieces of evidence and previous experience with the evidence. An inference involves forming patterns of information from data before making a diagnosis. Seeing that a patient has lost appetite and experienced weight loss over the last month, the nurse infers that there is a nutritional problem. An example of diagnostic reasoning is forming a nursing diagnosis such as imbalanced nutrition: less than body requirements (see Chapter 17 ). In diagnostic reasoning use patient data that you gather or collect to logically recognize the problem. For example, after turning a patient you see an area of redness on the right hip. You palpate the area and note that it is warm to the touch and the patient complains of tenderness. You press over the area with your finger; after you release pressure, the area does not blanch or turn white. After thinking about what you know about normal skin integrity and the effects of pressure, you form the diagnostic conclusion that the patient has a pressure ulcer. As a student, confirm your judgments with experienced nurses. At times you possibly will be wrong, but consulting with nurse experts gives you feedback to build on future clinical situations. Often you cannot make a precise diagnosis during your first meeting with a patient. Sometimes you sense that a problem exists but do not have enough data to make a specific diagnosis. Some patients’ physical conditions limit their ability to tell you about symptoms. Some choose to not share sensitive and important information during your initial assessment. Some patients’ behaviors and physical responses become observable only under conditions not present during your initial assessment. When uncertain of a diagnosis, continue data collection. You have to critically analyze changing clinical situations until you are able to determine the patient’s unique situation. Diagnostic reasoning is a continuous behavior in nursing practice. Any diagnostic conclusions that you make will help the health care provider identify the nature of a problem more quickly and select appropriate medical therapies. Clinical Decision Making As in the case of general decision making, clinical decision making is a problem-solving activity that focuses on defining a problem and selecting an appropriate action. In clinical decision making a nurse identifies a patient’s problem and selects a nursing intervention. When you approach a clinical problem such as a patient who is less mobile and develops an area of redness over the hip, you make a decision that identifies the problem (impaired skin integrity in the form of a pressure ulcer) and choose the best nursing interventions (skin care and a turning schedule). Nurses make clinical decisions all the time to improve a patient’s health or maintain wellness. This means reducing the severity of the problem or resolving the problem completely. Clinical decision making requires careful reasoning (i.e., choosing the options for the best patient outcomes on the basis of the patient’s condition and the priority of the problem). Improve your clinical decision making by knowing your patients. Nurse researchers found that expert nurses develop a level of knowing that leads to pattern recognition of patient symptoms and responses ( White, 2003 ). For example, an expert nurse who has worked on a general surgery unit for many years is more likely able to detect signs of internal hemorrhage (e.g., fall in blood pressure, rapid pulse, change in consciousness) than a new nurse. Over time a combination of experience, time spent in a specific clinical area, and the quality of relationships formed with patients allow expert nurses to know clinical situations and quickly anticipate and select the right course of action. Spending more time during initial patient assessments to observe patient behavior and measure physical findings is a way to improve knowledge of your patients. In addition, consistently assessing and monitoring patients as problems occur help you to see how clinical changes develop over time. The selection of nursing therapies is built on both clinical knowledge and specific patient data, including: •  The identified status and situation you assessed about the patient, including data collected by actively listening to the patient regarding his or her health care needs. •  Knowledge about the clinical variables (e.g., age, seriousness of the problem, pathology of the problem, patient’s preexisting disease conditions) involved in the situation, and how the variables are linked together. •  A judgment about the likely course of events and outcome of the diagnosed problem, considering any health risks the patient has; includes knowledge about usual patterns of any diagnosed problem or prognosis. •  Any additional relevant data about requirements in the patient’s daily living, functional capacity, and social resources. •  Knowledge about the nursing therapy options available and the way in which specific interventions will predictably affect the patient’s situation.

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Nurses are critical thinkers

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Margaret McCartney: Nurses must be allowed to exercise professional judgment

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

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

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

Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier

The future of nursing: Leading change, advancing health, (2010). https://campaignforaction.org/resource/future-nursing-iom-report

Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today. 30(6), 515-520.

NMC (2010) New Standards for Pre-Registration Nursing. London: Nursing and Midwifery Council.

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

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

Competing interests: No competing interests

Critical thinking in nursing clinical practice, education and research: From attitudes to virtue

Affiliations.

• 1 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, Consolidated Research Group Quantitative Psychology (2017-SGR-269), University of Barcelona, Barcelona, Spain.
• 2 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, Consolidated Research Group on Gender, Identity and Diversity (2017-SGR-1091), University of Barcelona, Barcelona, Spain.
• 3 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, University of Barcelona, Barcelona, Spain.
• 4 Multidisciplinary Nursing Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Hospital, Barcelona, Spain.
• PMID: 33029860
• DOI: 10.1111/nup.12332

Critical thinking is a complex, dynamic process formed by attitudes and strategic skills, with the aim of achieving a specific goal or objective. The attitudes, including the critical thinking attitudes, constitute an important part of the idea of good care, of the good professional. It could be said that they become a virtue of the nursing profession. In this context, the ethics of virtue is a theoretical framework that becomes essential for analyse the critical thinking concept in nursing care and nursing science. Because the ethics of virtue consider how cultivating virtues are necessary to understand and justify the decisions and guide the actions. Based on selective analysis of the descriptive and empirical literature that addresses conceptual review of critical thinking, we conducted an analysis of this topic in the settings of clinical practice, training and research from the virtue ethical framework. Following JBI critical appraisal checklist for text and opinion papers, we argue the need for critical thinking as an essential element for true excellence in care and that it should be encouraged among professionals. The importance of developing critical thinking skills in education is well substantiated; however, greater efforts are required to implement educational strategies directed at developing critical thinking in students and professionals undergoing training, along with measures that demonstrate their success. Lastly, we show that critical thinking constitutes a fundamental component in the research process, and can improve research competencies in nursing. We conclude that future research and actions must go further in the search for new evidence and open new horizons, to ensure a positive effect on clinical practice, patient health, student education and the growth of nursing science.

Keywords: critical thinking; critical thinking attitudes; nurse education; nursing care; nursing research.

© 2020 John Wiley & Sons Ltd.

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Why Critical Thinking Skills in Nursing Matter (And What You Can Do to Develop Them)

By Hannah Meinke on 07/05/2021

The nursing profession tends to attract those who have natural nurturing abilities, a desire to help others, and a knack for science or anatomy. But there is another important skill that successful nurses share, and it's often overlooked: the ability to think critically.

Identifying a problem, determining the best solution and choosing the most effective method to solve the program are all parts of the critical thinking process. After executing the plan, critical thinkers reflect on the situation to figure out if it was effective and if it could have been done better. As you can see, critical thinking is a transferable skill that can be leveraged in several facets of your life.

But why is it so important for nurses to use? We spoke with several experts to learn why critical thinking skills in nursing are so crucial to the field, the patients and the success of a nurse. Keep reading to learn why and to see how you can improve this skill.

Why are critical thinking skills in nursing important?

You learn all sorts of practical skills in nursing school, like flawlessly dressing a wound, taking vitals like a pro or starting an IV without flinching. But without the ability to think clearly and make rational decisions, those skills alone won’t get you very far—you need to think critically as well.

“Nurses are faced with decision-making situations in patient care, and each decision they make impacts patient outcomes. Nursing critical thinking skills drive the decision-making process and impact the quality of care provided,” says Georgia Vest, DNP, RN and senior dean of nursing at the Rasmussen University School of Nursing.

For example, nurses often have to make triage decisions in the emergency room. With an overflow of patients and limited staff, they must evaluate which patients should be treated first. While they rely on their training to measure vital signs and level of consciousness, they must use critical thinking to analyze the consequences of delaying treatment in each case.

No matter which department they work in, nurses use critical thinking in their everyday routines. When you’re faced with decisions that could ultimately mean life or death, the ability to analyze a situation and come to a solution separates the good nurses from the great ones.

How are critical thinking skills acquired in nursing school?

Nursing school offers a multitude of material to master and upholds high expectations for your performance. But in order to learn in a way that will actually equip you to become an excellent nurse, you have to go beyond just memorizing terms. You need to apply an analytical mindset to understanding course material.

One way for students to begin implementing critical thinking is by applying the nursing process to their line of thought, according to Vest. The process includes five steps: assessment, diagnosis, outcomes/planning, implementation and evaluation.

“One of the fundamental principles for developing critical thinking is the nursing process,” Vest says. “It needs to be a lived experience in the learning environment.”

Nursing students often find that there are multiple correct solutions to a problem. The key to nursing is to select the “the most correct” solution—one that will be the most efficient and best fit for that particular situation. Using the nursing process, students can narrow down their options to select the best one.

When answering questions in class or on exams, challenge yourself to go beyond simply selecting an answer. Start to think about why that answer is correct and what the possible consequences might be. Simply memorizing the material won’t translate well into a real-life nursing setting.

How can you develop your critical thinking skills as a nurse?

As you know, learning doesn’t stop with graduation from nursing school. Good nurses continue to soak up knowledge and continually improve throughout their careers. Likewise, they can continue to build their critical thinking skills in the workplace with each shift.

“To improve your critical thinking, pick the brains of the experienced nurses around you to help you get the mindset,” suggests Eileen Sollars, RN ADN, AAS. Understanding how a seasoned nurse came to a conclusion will provide you with insights you may not have considered and help you develop your own approach.

The chain of command can also help nurses develop critical thinking skills in the workplace.

“Another aid in the development of critical thinking I cannot stress enough is the utilization of the chain of command,” Vest says. “In the chain of command, the nurse always reports up to the nurse manager and down to the patient care aide. Peers and fellow healthcare professionals are not in the chain of command. Clear understanding and proper utilization of the chain of command is essential in the workplace.”

How are critical thinking skills applied in nursing?

“Nurses use critical thinking in every single shift,” Sollars says. “Critical thinking in nursing is a paramount skill necessary in the care of your patients. Nowadays there is more emphasis on machines and technical aspects of nursing, but critical thinking plays an important role. You need it to understand and anticipate changes in your patient's condition.”

As a nurse, you will inevitably encounter a situation in which there are multiple solutions or treatments, and you'll be tasked with determining the solution that will provide the best possible outcome for your patient. You must be able to quickly and confidently assess situations and make the best care decision in each unique scenario. It is in situations like these that your critical thinking skills will direct your decision-making.

Do critical thinking skills matter more for nursing leadership and management positions?

While critical thinking skills are essential at every level of nursing, leadership and management positions require a new level of this ability.

When it comes to managing other nurses, working with hospital administration, and dealing with budgets, schedules or policies, critical thinking can make the difference between a smooth-running or struggling department. At the leadership level, nurses need to see the big picture and understand how each part works together.

A nurse manager , for example, might have to deal with being short-staffed. This could require coaching nurses on how to prioritize their workload, organize their tasks and rely on strategies to keep from burning out. A lead nurse with strong critical thinking skills knows how to fully understand the problem and all its implications.

• How will patient care be affected by having fewer staff?
• What kind of strain will be on the nurses?

Their solutions will take into account all their resources and possible roadblocks.

• What work can be delegated to nursing aids?
• Are there any nurses willing to come in on their day off?
• Are nurses from other departments available to provide coverage?

They’ll weigh the pros and cons of each solution and choose those with the greatest potential.

• Will calling in an off-duty nurse contribute to burnout?
• Was this situation a one-off occurrence or something that could require an additional hire in the long term?

Finally, they will look back on the issue and evaluate what worked and what didn’t. With critical thinking skills like this, a lead nurse can affect their entire staff, patient population and department for the better.

Beyond thinking

You’re now well aware of the importance of critical thinking skills in nursing. Even if you already use critical thinking skills every day, you can still work toward strengthening that skill. The more you practice it, the better you will become and the more naturally it will come to you.

If you’re interested in critical thinking because you’d like to move up in your current nursing job, consider how a Bachelor of Science in Nursing (BSN) could help you develop the necessary leadership skills. Learn more about earning your BSN in our article “ How an RN to BSN Program Will Differ from Your ADN Experience .”

EDITOR’S NOTE: This article was originally published in July 2012. It has since been updated to include information relevant to 2021.

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Some articles on critical thinking in nursing practice

• Fero, L. J., et al. (2009). "Critical thinking ability of new graduate and experienced nurses." Journal of Advanced Nursing 65(1): 139-148. This paper is a report of a study to identify critical thinking learning needs of new and experienced nurses. Concern for patient safety has grown worldwide as high rates of error and injury continue to be reported. In order to improve patient safety, nurses must be able to recognize changes in patient condition, perform independent nursing interventions, anticipate orders and prioritize. Conclusion. Patient safety may be compromised if a nurse cannot provide clinically competent care. Assessments such as the Performance Based Development System can provide information about learning needs and facilitate individualized orientation targeted to increase performance level. © 2008 Blackwell Publishing Ltd.
• Jacob, E., et al. (2018). "Development of an Australian nursing critical thinking tool using a Delphi process." Journal of Advanced Nursing. AIM To develop a critical thinking assessment tool for Australian undergraduate nurses. BACKGROUND Critical thinking is an important skill but difficult to assess in nursing practice. There are often many responses a nurse can make to a clinical problem or situation. Some responses are more correct than others and these decisions have an impact on a patient's care and safety. Differences in a response can relate to the depth of knowledge, experience and critical thinking ability of the individual nurse. DESIGN This study used a Delphi process to develop five clinical case studies together with the most appropriate clinical responses to 25 clinical questions. RESULTS Four rounds of Delphi questions were required to reach consensus on the correct wording and answers for the scenarios. Five case studies have been developed with nursing responses to patient management in rank order from most correct to least correct. CONCLUSION Use of the tool should provide confidence that a nurse has met a certain level of critical thinking ability.
• Ludin, S. M. (2017). "Does good critical thinking equal effective decision-making among critical care nurses? A cross-sectional survey."Intensive and Critical Care Nursing. v. 44 https://doi.org/10.1016/j.iccn.2017.06.002 Background: A critical thinker may not necessarily be a good decision-maker, but critical care nurses are expected to utilise outstanding critical thinking skills in making complex clinical judgements. Studies have shown that critical care nurses' decisions focus mainly on doing rather than reflecting. To date, the link between critical care nurses' critical thinking and decision-making has not been examined closely in Malaysia.
• Simpson, E. and M. Courtney (2002). "Critical thinking in nursing education: literature review." International journal of nursing practice 8(2): 89-98. The need for critical thinking in nursing has been accentuated in response to the rapidly changing health-care environment. Nurses must think critically to provide effective care while coping with the expansion in role associated with the complexities of current health-care systems. This literature review will present a history of inquiry into critical thinking and research to support the conclusion that critical thinking is necessary not only in the clinical practice setting, but also as an integral component of nursing-education programmes to promote the development of nurses' critical-thinking abilities. The aims of this paper are to: (i) review the literature on critical thinking; (ii) examine the dimensions of critical thinking; (iii) investigate the various critical thinking strategies for their appropriateness to enhance critical thinking in nurses; and (iv) examine issues relating to the evaluation of critical-thinking skills in nursing.
• Turner, P. (2005) "Critical thinking in nursing education and practice as defined in the literature". Nursing Education Perspectives 26(5): 272-277. Critical thinking is frequently discussed in nursing education and nursing practice literature. This article presents an analysis of the concept of critical thinking as it applies to nursing, differentiating its use in education and practice literature. Three computerized databases (CINAHL, MEDLINE, and EBSCO) were searched for the years 1981 to 2002, using the keywords critical thinking. References were stratified into two 11-year periods (1981-1991, 1992-2002) to identify changes in the concept over time and integration of the concept differentially into nursing education and nursing practice. A random sample of literature from each stratum was coded for definitions, attributes, surrogate terms, referents, antecedents, and consequences of critical thinking. Critical thinking as a nursing concept has matured since its first appearance in the literature. It is well defined and has clear characteristics. However, antecedents and consequences are not well defined, and many consequences are identical to attributes and surrogate terms. Additional work is needed to clarify the boundaries of the concept of critical thinking in nursing.

Books on critical thinking and clinical reasoning

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Nursing Graduates’ Preparedness for Practice: Substantiating the Call for Competency-Evaluated Nursing Education

Tammy mcgarity.

1 College of Nursing, Texas A&M University Corpus Christi, Corpus Christi, TX 78412-5800, USA; [email protected] (T.M.); moc.em@rekcaa4k (K.A.)

Laura Monahan

2 College of Nursing, University of Illinois Chicago, Chicago, IL 60607, USA

Katelijne Acker

Wendi pollock.

3 Department of Social Sciences, Texas A&M University Corpus Christi, Corpus Christi, TX 78412-5800, USA

Associated Data

Not applicable.

Practice readiness continues to be a challenge in healthcare. This was especially evident during the COVID-19 pandemic. This focused descriptive–correlational study examined nurses’ perceived preparedness for practice during the pandemic. One hundred and eighty-four registered nurses (RN) responded to Qualtrics survey questions addressing the competencies they perceived they had and the competencies they felt they needed that would have better prepared them to care for patients during the COVID-19 pandemic. The results demonstrated that although these nurses felt competent in certain areas, they perceived that they needed more education in those same areas to feel better prepared. Bivariate correlations and linear regression analysis indicated that institutional competency development, education, and work experience influenced perceived competency.

1. Introduction

Formal nursing education strives to prepare and graduate nurses who are ready to practice according to employers’ expectations for competent patient care delivery [ 1 , 2 ]. However, readiness for nursing practice is often ill-defined, and this imprecision creates a lack of continuity across the regulatory, academic, and practice sectors, which adds to the incongruencies in expectations for practice readiness [ 3 ]. Nursing competency includes the core abilities that are required to understand the needs of the patient, the ability to provide care, the ability to collaborate, and the ability to support decision making; thus, it is important to clearly define nursing competency to establish a foundation for the nursing curriculum [ 4 ]. Papathanasious et al. [ 5 ] identified critical analysis as a set of questions applied in an event or to a concept for the determination of important information and ideas while discarding the unnecessary ones. Nurses must be prepared with problem solving skills (often interchangeably used with critical thinking skills in the nursing literature) to recognize changes in patient condition, to perform independent nursing interventions, to anticipate orders, and to prioritize. Preparing nursing students who are practice-ready requires an education curriculum focused on core competencies.

AlMekkkawi and Khalil [ 6 ] describe practice readiness as having the necessary knowledge and competencies to care for patients safely and independently, and they note that reflective and problem-based learning can enhance students’ critical thinking and problem solving skills. In healthcare, competency is defined as “an observable ability of a health care professional to integrate knowledge, skills, and attitude” [ 7 ] (p. 1089). However, the reality is that although most nursing graduates may possess basic nursing knowledge, they need to increase in critical thinking competencies, as well as the commitment, confidence, and professionalism [ 8 , 9 ] required to be practice-ready.

This has been studied, and the results have demonstrated this through previous research that utilized del Bueno’s [ 10 ] validated and reliable tool, the Performance-Based Development System (PBDS), which has been used extensively to assess and validate nurses’ potential to meet competency requirements. The PBDS utilizes methods to evaluate critical thinking, interpersonal skills, and technical competencies [ 10 , 11 ]. Del Bueno’s [ 12 ] seminal research report in 2001 indicated that only 35% of newly graduated registered nurses were considered safe or ready for practice. Comparatively, aggregated data from a 2017 study that utilized the PBDS indicated that only 23% of newly graduated registered nurses demonstrated entry-level competencies, even after passing the National Council Licensure Exam for Registered Nurses (NCLEX-RN) [ 13 ].

Competent nursing practice was critically brought to the forefront during the COVID-19 pandemic [ 14 , 15 ]. This rare global pandemic led to the most intense scrutiny of nursing education and preparedness across multiple settings in recent history [ 16 , 17 ]. Nurses’ experiences, knowledge, skills, and competency to handle this novel infectious disease have been important topics of discussion in the relevant literature [ 11 , 18 ]. In a qualitative study, Badowski and colleagues [ 19 ] stated that nurses working in the frontline during the pandemic recommended that key elements, such as teamwork, communication, flexibility, leadership skills, advocacy, and the development of critical thinking, were crucial concepts to be taught and developed in nursing education. One comment made by a nurse in this study was significant and revealing: “I don’t think the technical skills are what’s needed, but the ability to think through the processes” [ 19 ] (p. 670), emphasizing the importance of the development of critical thinking skills. Studying senior nursing students’ experiences during the pandemic, Canet-Vélez et al. [ 20 ] noted that students requested more education on infection control and personal safety measures, indicating a perceived lack of competency in these basic nursing concepts. This sentiment was reflected in the fact that recent PBDS data demonstrated a continued loss in preparedness among new nurses, and that only 9% of the 2020 graduated nurses were in the competency range for novice nurses [ 21 ]. However, education and training after graduation, in addition to increased work experience, further development of critical thinking skills, and an adherence to professionalism, impacted nurses’ development of competency significantly [ 22 ]. During the COVID-19 pandemic, nurses found themselves caring for patients with a novel infection; many workarounds were implemented, and even seasoned nurses found themselves wondering how to deliver safe patient care. In this article, the authors will describe the competency gap nurses experience when transitioning from nursing school to nursing practice, as identified during the COVID-19 pandemic, and offer an evidence-based solution for nursing education to address this gap.

2. Materials and Methods

Nursing competencies include essential abilities that enable nurses to assess various sources of information and data, and to utilize these in nursing practice to provide competent, comprehensive care to meet patients’ diverse and complex needs effectively and efficiently [ 23 ]. Nursing practice proficiency is expressed in the achievement of competencies that go beyond the combination of knowledge and skills; these competencies improve the quality of nursing care, ensure the safety of patients, and reduce the incidence of near misses in the provision of nursing care [ 24 , 25 ]. Imperative to the development of competencies is that nurses are taught critical thinking skills that include analysis, interpretation, inference, and evaluation to make continual enhancements that address ongoing or newly developing patient needs [ 26 ]. Professional confidence in critical thinking abilities affects the application of nursing competencies, which can, in turn, impact the quality of patient care given [ 27 ].

Nurses’ perception of the competencies they had and those they lacked were the subjects of this research. This study aimed to investigate nurses’ perception of their competency to practice during the novel infectious disease pandemic of COVID-19. The following research questions were the basis of this study: which competencies did nurses perceive to have that prepared them for practice during the COVID pandemic, and which competencies did nurses perceive they lacked that would have better prepared them for practice? Additionally, did nurses perceive that their education and/or experience prepared them for practice during the COVID-19 pandemic?

This focused descriptive–correlational study addressed the perceived competency and preparedness of nurses employed during the height of the COVID-19 pandemic during the period of August through October 2020. Invitations to recruit registered nurses to participate were posted on multiple social media sites, including Facebook, Instagram, and LinkedIn. All participants gave informed consent prior to completing the questionnaire. This informed consent was accessed from a link in the invitation and completed prior to completing the Qualtrics questionnaire. An Internal Review Board at a prominent Texas university approved this study.

All registered nurses (RNs) registered in at least one state in the United States were eligible to participate. The invitation was posted on social media sites, and the RNs who responded were from various states across the United States. The sample consisted of one hundred and eighty-four (184) RNs who responded to the invitation, gave informed consent, and completed the survey. Demographic data collected included length of work experience, level of education, current work status, current position held, specialty certification, and institutional type of work setting ( Table 1 ).

Overall frequencies of participants.

The analysis revealed that participants averaged 3.03 years of practice. Most of the respondents (42%) held a Bachelor of Science in Nursing degree, followed by a Master of Science in Nursing degree (35.2%), and lastly, 19% of respondents had an associate degree or diploma in Nursing. The most common positions at work listed were frontline nurses or direct caregivers (55.4%), and 77.7% of the respondents worked full-time at a single facility. Many of the respondents (44.6%) held a specialty certification. Participants practiced in a variety of settings, ranging from teaching hospitals/systems (34.8%) to acute care hospital/medical centers (35.9%) and outpatient clinics (12%).

Because an instrument to measure nurses’ perceived competency was not available, the authors developed an original set of survey questions to investigate how nurses assessed their level of competency in multiple areas during the novel infectious disease pandemic. The survey consisted of multiple choice questions with Likert-type responses (even-point, positive to negative response categories for survey questions) as well as fill-in-the-blank questions, which asked participants for their level of agreement with the statement that their education and competency validations prepared them to care for COVID-19 patients. Participants were asked to list the top five competencies that they felt had prepared them to care for patients during the pandemic, and the top five competencies they perceived that they lacked. The survey also addressed their perceptions of competency preparation, competency validation modes during orientation, and ongoing competency development.

Frequencies were calculated to describe the distributions of the number one competency that nurses perceived had prepared them to care for patients during the pandemic, and the number one competency that nurses perceived that they were lacking that would have better prepared them for practice. Bivariate correlations were completed to examine whether statistically significant relationships existed between the competencies that participants perceived had prepared them, those that would have prepared them better, and the method and timing of the competency validation after graduation. Finally, linear regression was used to examine the impact of multiple variables on respondents’ perception that the competency validation/education they received had prepared them to nurse patients during the COVID-19 pandemic.

How to accurately measure and analyze perceptions and feelings is an ongoing debate in academia because these concepts cannot be measured in a truly continuous (interval or ratio) manner. However, numerous scholars argue that Likert-style measures of concepts are an acceptable way to utilize measurements of perceptions or feelings in higher-level, multivariate, predictive analysis, and that they can be treated as continuous variables with the assumption that there are equal distances between the categories [ 28 , 29 ]. The variable must have at least five answer response categories to be used in this manner [ 30 ]. For the dependent variable in the current analysis, nurses were asked to give their level of agreement with the following statement: “The competency validation/education you received prepared you for nursing during the COVID-19 pandemic.” Their responses ranged from strongly disagree (1) to strongly agree (6), with a total of six response categories. Accordingly, this variable is being treated as continuous in the linear regression model. Previous studies have shown that perceptions and feelings demonstrate a link between actions, and that the feelings-to-action relationship appears replicable and linear; additionally, the use of Likert-style survey responses in the measurement of perceptions and feelings is common in social-science-related fields [ 31 ].

While linear regression was chosen for presentation in this manuscript, it should be noted that additional, unpresented models were run. In one such model, the dependent variable, nurses’ perception of competency, was recoded into a dichotomous variable (1 = any level of agreement that the respondent felt prepared, and 2 = any level of disagreement that the respondent felt prepared), which was used in a logistic regression model that included all the independent variables in the current paper. Logistic regression is appropriate for a dichotomous dependent variable [ 32 ]. All variables that were statistically significant in the linear regression model were also statistically significant in the logistic regression model, and the measures of substantive significance were similar. The lack of divergence in results between these techniques suggests that either is appropriate to use, and linear regression was selected for presentation because it allows for greater detail in the dependent variable.

The independent variables’ nominal data describing participants’ level of experience, education, work status, position, specialty certification, and institutional work setting (see Table 1 ) were dummy coded or dichotomized. This allowed the variables to be used in linear regression without violating any assumptions of the technique [ 32 ].

Overall, more than 50% of participating nurses perceived that their education did not prepare them for nursing during the COVID-19 pandemic. Only 8% of participants strongly agreed, compared to 10.9% who strongly disagreed, that the education and competency validation they had received had prepared them for nursing during the COVID-19 pandemic.

The results revealed that nurses who participated in in-services and attended competency training classes were statistically significantly more likely to respond that emergency management training had better prepared them to care for patients during the pandemic. Similarly, nurses who had competency training delivered through learning management systems with in-service testing, and through direct observation experiences in COVID-19 patient management, were more likely to respond that they were prepared to care for patients during the pandemic. Additionally, experience at a facility that developed core competencies for high-risk skills, the attainment of a higher level of education, and achievement of more extensive work experience were better predictors for being prepared to care for COVID-19 patients.

Ninety-two (92) individuals responded to the prompt to write in the top five competencies they believed would have better prepared them to care for patients during the pandemic. In contrast, eighty-nine (89) listed the top five competencies covered in their training that they considered to have prepared them. The ‘infection prevention’ topic, which included the use of personal protective equipment (PPE), the donning and doffing skills of PPE, and use of the N95 mask, were the top abilities selected in both categories. Likewise, the ranking of the chosen competencies was similar, with more respondents naming infection control as the top competency that they perceived would have better prepared them ( Table 2 ).

Competency preparedness perception.

Bivariate correlations were completed to examine whether statistically significant relationships existed between the competencies that participants felt had prepared them and those that would have helped prepare them better and the method and timing of competency validation after graduation. The strongest relationship ( p = 0.005) indicated that nurses who received no institutional competency development in high-risk skills were more likely to suggest that none of their competencies prepared them to care for COVID-19 patients. Linear regression was used to analyze the effect(s) of the independent variables on nurses’ perceptions of their competency to care for patients during the COVID-19 pandemic. Table 3 illustrates the multivariate model’s statistical ( p = 0.004) and substantive (R 2 = 0.363) significance. This suggests that education, workplace, positions, and other elements combined do in fact influence RNs’ perception of competency.

Linear regression model.

4. Discussion

The onslaught of a novel infectious disease has once again drawn attention to the educational preparation of nurses and has led many to question the current landscape in the preparation of nurses to practice [ 33 , 34 , 35 ]. This study found a perceived lack of academic preparedness in specific, identified concepts. Participants indicated the following elements that influenced their perceptions of competency: working at a facility that developed core competencies for high-risk skills, receiving more education, and having more years of experience. Those nurses in this study who had less experience, worked at facilities with no intense competency orientations, and who cared for COVID-19 patients with only the competencies that they graduated with, stated that they did not feel well-prepared for practice.

COVID-19-related concepts, such as infection control, gas exchange, perfusion, and their related skills, are addressed in every nursing program, yet participants did not feel competent taking care of patients with this novel disease. An example of this is in infection control: although nurses stated that this was the number one competency chosen in multiple categories, the responding nurses in this study indicated a lack of competency in applying infection control standards in the COVID-19 clinical scenarios and applications.

All participants had learned infection control principles during their formal education. Traditional nursing programs teach extensive content, some of which nursing students tend to learn in disease or condition silos. However, basic concepts, such as infection control, gas exchange, perfusion, and their related skills, have been discussed in every nursing school curriculum. However, nursing students and new graduates alike have trouble applying conceptual knowledge, such as those related to infection control, gas exchange, perfusion, etc., across varying disease populations. All or some of these principles could be applied to all infectious patient populations depending on the type of infection or patient, but the basic principles themselves do not intrinsically change. Yet, many participants indicated the need for more instruction in caring for infectious patients, noting that they were unable to apply infection control principles to different patient populations. For example, many reported that they felt competent to perform cardiopulmonary resuscitation (CPR), but that they did not feel competent to apply this skill to a contagious patient. They further expressed that they were comfortable performing basic isolation procedures but that they could not conceptualize and apply the correct applications of PPE in an unknown infectious disease situation.

Analysis of the data indicated that institutional (after graduation) on-the-job instructions and training helped participants feel better prepared. Researchers contend that just-in-time or on-demand education could be an answer to the apparent lack of competencies [ 36 ]. However, basic nursing education that nursing students receive should prepare these future RNs to be competent to practice effectively after graduation. This means that these graduate nurses should possess the knowledge and skills to apply them across disease populations. They should effectively display these abilities and apply those critical nursing skills necessary to do the work of nursing.

These findings reinforce Kavanagh and Sharpnack’s [ 21 ] assertion that there is an ongoing crisis in nursing competency, and that a vast chasm exists between academia and clinical practice. Crucial factors impacting nursing education today include applicability and accountability for success and what clinical preparedness really requires, which includes keeping current with the rapid pace necessitated in the current learning environments, the need for ongoing education transformations to adequately address contemporary healthcare needs, meeting needs in the face of the rise of rapid technologies and innovations, understanding the impact of digital processing in clinical settings, and addressing the ever-widening gap of inequality in education [ 21 ]. Many contend that “warp speed innovation” in healthcare [ 37 ] (p. 3) and education’s delayed response to evolving practice innovations continue to cause difficulties [ 38 , 39 ], thereby causing serious detriments in the practice of nursing. Practice readiness has been declining for decades [ 12 , 21 ], and nursing education has struggled to close the practice gap.

Traditional programs moving toward concept-based programs attempt to close this widening gap between academia and practice. Academic and practice partnerships improve teaching and learning applications in a concept-based curriculum that supports competency development and critical thinking skills [ 40 , 41 ]. For example, competency-based education strives to promote innovative approaches to enhance nursing education by utilizing integrated technologies that incorporate active learning and interactive teaching designs to improve efficiency and enhance student learning experiences [ 21 ]. Although a concept-based curriculum presents numerous challenges to educational entities in terms of time and faculty support, it effectively promotes student-centered teaching, critical thinking, enriched interactive learning, and the streamlining of essential course content [ 42 ].

If competency is expected, then nursing students’ competencies should be continuously and analytically evaluated. The American Association of Colleges of Nursing Baccalaureate Essentials for Nursing Education outlines the expected outcomes of nursing programs [ 43 , 44 ]. The 2021 nursing essentials are formulated as competencies rather than as individual knowledge, skills, and actions (KSAs) [ 23 ]. Thus, the American Association of Colleges of Nursing Baccalaureate Essentials incorporate concepts for professional nursing development that are integrated throughout the 2021 nursing essentials, which include such competencies as clinical judgment, communication, diversity, equity, inclusion, ethics, compassionate care, health policy, evidence-based practice, and the social determinants of health [ 43 ]. This move requires nursing programs to implement strategies that consistently evaluate graduating nursing students’ competencies and, additionally, should consequently enhance curriculum changes that promote the ongoing development of these necessary critical thinking abilities [ 11 , 13 , 45 , 46 ].

The results of this study support the American Association of Colleges of Nursing’s move to nursing essentials that embody the core competencies for nursing education that enhance critical thinking abilities. Likewise, the National Council of State Boards of Nursing demonstrates that critical thinking, problem solving, and critical decision making are interrelated core skills involved in crucial nursing functions that are essential in today’s more complex healthcare environments. The new National Council Licensure Examination for Registered Nurses (NCLEX-RN) format focuses on core competencies related to clinical decision making (by utilizing new types of question formats, such as case studies, that engage students in the decision making process), assessment of developing health assessment cues, prioritization of hypotheses, generation of solutions, and evaluation of outcomes [ 47 ]. The development of these core competencies includes the necessary nursing abilities to understand complex patient needs, provide competent and compassionate care, collaborate with other healthcare providers, and support and facilitate decision making [ 23 ]. These nursing competencies facilitate the necessary knowledge, skills, and attitudes required to fulfill one’s role as a nurse, regardless of the type of patient.

In the future, if faced with another novel disease, graduates educated under the new American Association of Colleges of Nursing’s essentials should be able to apply required knowledge across various patient populations, demonstrate critical thinking, and exhibit enhanced clinical judgment abilities. These newly graduated nurses should be better prepared for professional nursing practice. Although nursing is a profession that requires lifelong learning, as well as ongoing formation and development, graduates whose competencies are evaluated early on and on a continuous basis should not need to catch up with just-in-time education [ 36 ]. They should be ready to acquire new competencies as healthcare continues to change. Various researchers propose that concept-based learning encourages students to synthesize their knowledge more adeptly and globally [ 42 ]. However, conceptual understanding alone is not enough. Preparing competent graduates of nursing schools means that they not only have the knowledge to apply resources across disease populations and types of patients, but they also display the behaviors required to do the work of nursing. This study supports the move to competency-based evaluation and the emphasis on continually developing critical thinking skills.

Because an instrument to measure perception was not readily available, the authors, who are all educators and nursing competency experts, developed the questionnaire used for this investigation. A copy of the questionnaire is available in Figure 1 . Further utilization of this tool is necessary to demonstrate the validity and reliability of the questionnaire, and its ongoing use is encouraged. The sample size, although small at 184 participants, did represent a variety of workplaces and educational preparations, and would be considered acceptable in that the data collection was completed during the height of the COVID-19 pandemic. Similar investigations are recommended and encouraged to allow for the generalization and applicability of the results.

Questionnaire.

5. Conclusions

This study investigated 184 nurses’ perceptions of their competency during the COVID-19 pandemic and sought to determine whether these nurses perceived that their education and/or experience had prepared them for the public health emergency during the COVID-19 pandemic. More than 50% of the participating registered nurses in this study perceived that their education did not prepare them for nursing during this time, thus demonstrating a perceived lack of academic preparedness in core nursing competencies. This lack of competency preparedness and critical thinking left participants without the skills to translate the application of learned skills to care for this novel disease population. These outcomes support previous studies that utilized the Performance-Based Development System to assess nurses’ potential to meet competency requirements, and which repeatedly demonstrated a perceived lack of competency in basic nursing concepts.

It is imperative to note that practice environments, as well as various regulatory bodies, expect nursing education to prepare nurses to competently practice after graduation. For example, the American Association of Colleges of Nursing emphasizes that the four million nurses in the United States are crucial to the maintenance of patient safety and health-sustaining services. As such, it is critical that the preparation of nurses with consistent sets of core competencies intrinsically enhances the essential partnership between employers and practice leaders in the expectations and provisions of nurses’ obligations of care to their patients [ 43 ]. Preparing nurses with a consistent set of identifiable competencies helps employers and the public understand what to expect from nurses, as well as how to distinguish the nursing capabilities in baccalaureate and graduate nursing preparation and their collaborative abilities with other providers of care. Throughout the development of the new 2021 nursing essentials, the American Association of Colleges of Nursing was very intentional in involving both practice leaders and regulatory bodies in the work of infusing innovations and practice expectations into the development of future nursing curriculums and education. The American Association of Colleges of Nursing engaged a variety of practice leaders in this effort to ensure that nursing education remains synchronized with the current and future needs of the healthcare systems, and that it will meet their requisites with the innovations and technologies necessary to meet patient needs effectively [ 43 ]. This means that graduate nurses should possess the critical thinking competencies necessary to be skillful and flexible in applying that knowledge across various disease populations. The expectation is that registered nurses should practice those crucial nursing skills that are necessary to perform the work of nursing efficiently and effectively.

Looking further into the nursing education continuum, curriculum changes that encompass competency preparedness and evaluation can effectively improve nursing workforce readiness to care for any type of patient, including those with unexpected or unknown conditions. Nursing orientations, annual evaluations, competency testing, and continuing education should encompass competency evaluations and the assessment of critical thinking skills, as well as the dissemination of institutional knowledge. Closing the education–practice competency gap will require further research that addresses the effect that the ongoing changing landscape of nursing education has on newly graduated nurses’ competencies.

Funding Statement

This research received no external funding.

Author Contributions

T.M., L.M., K.A. and W.P. contributed equally to this paper. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Institutional Review Board Approval number TAMU-CC-IRB-2020-05-044. This study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Texas A&M University Corpus Christi: 45 CFR 46.104(d)(2) (research involving use of educational tests, survey procedures, interview procedures or observation of public behavior). Therefore, this project has been determined to be exempt from IRB review. Date of approval: 11 June 2020.

Informed Consent Statement

Informed consent was obtained from all subjects involved in this study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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