6 core critical thinking skills nursing

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.

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Thinking Like a Nurse: The Critical Thinking Skills in the Nursing Practice

Thinking how to nurse is thinking like a nurse. Florence Nightingale (1860) wrote on her notes that women who have charge of the other’s health—to which the application of her integrated experiences must teach herself to think how to nurse, a self-learning acquired from “hints”.

Perhaps, Nightingale referred “hints” as the use of critical thinking skills in patient’s care. The ability to think critically was the foundation of nursing practice started from historic times and is becoming one of the key performance indicators for both students and nursing professionals nowadays.

Educational system continues to evolve and progresses heeding to the needs of the society, and parallel to the changing educational structure and methodology. However, Haber (2020) reported that only 75% of employers claim that the students they hire who underwent 12 or more years of formal education lack of critical thinking and problem-solving abilities despite the progress in the educational system.

What is Critical Thinking?

Critical thinking skills, a fundamental skill that plays a pivotal role in our daily survival. In general terms, the skill will not stop in memorization, the process goes beyond connecting the dots from one to concept to another, problem-solving techniques, think creatively, and apply the learned knowledge in new ways (Walden University, 2020). Kaminske (2019), defines critical thinking skills as a domain-specific skill on the ability to solve problems and make effective decisions that require expertise to be applied in a range of situations and scenarios.

In the nursing practice, Critical thinking skill works in assimilation with critical reasoning as a practice-based discipline of decision-making to the health care professionals. Critical thinking is the process of the intentional higher level of thinking to identify patient’s health care needs and appraise evidence-based practice to make choices in the delivery of care.

On the other hand, clinical reasoning as integrated to clinical thinking in application to clinical situation works as a cognitive process to utilized thinking strategies to gather and critically analyze the data concerning the health care needs of the patient, organized the information according to its prioritization, and formulate efficient nursing care plans to improve patient’s outcomes (Berman, et al., 2016).

“Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action”, a precise definition presented by Michael Scriven and Richard Paul at the Eighth Annual International Conference on Critical Thinking and Education Reform during the summer of 1987 (Lakhanigam, 2017).

Lakhanigam added the definition published by the Journal of Nursing Education in 2010 that describes critical thinking as the process involving interpretation and analysis of the problem, reasoning to find a solution, applying, and finally evaluation of the outcomes”. Regis College (2020), emphasized the use of deductive reasoning in observation, analyzing information, formulate conclusions, and performing appropriate actions in a self-directed process.

Theories on the Physiology of Thinking

From the ancient theory of “tabula rasa”, as describes in Wikipedia (2020) that humans are born without built-in mental content, and all knowledge is collected by the brain from experiences and perceptions. In this computer age, a neurologist discovered neurological pathways on how to re-program or reformat our brains like computers by analyzing how the brain appears to process, recognize, remember and transfer information at the level of neural circuits, synapses and neurotransmitters. Willis (2012) discussed the brain’s neuroplastic response to stimulation called neuroplasticity. The information is processed in the reflective and cognitive functions of prefrontal cortex wherein learning incorporated into networks of longterm conceptual memory.

Neuroplasticity is greatly affected by stress, boredom and frustration as seen in the neuroimaging scans of students showed that active metabolic states block the processing in the prefrontal cortex. In response to stress, the amygdala as the switching station became hyperactive resulting to switches of input and output away from the prefrontal cortex down to the control of the lower reactive brain, this response is called fight/flight/freeze (act out/zone out). In this situation, the lower brain’s reactive behaviours are in control. This will result in the loss of information access to the prefrontal cortex and new learning is not retained.

Elseways, Knowles (1984) four principles of andragogy of adult learning included (a.) experiences from mistakes that provide the basis for the learning activities; and (b.) the importance of problems and crisis, as adult learning is problem-centred rather than content-oriented; as well as (c.) involvement in the planning and evaluation of learning; and lastly, (d.) that adults are most interested in a subject that is relevant to their job and personal life.

Learning and thinking as applied in a higher-level context, Ausubel’s assimilation theory may recount the theories on critical thinking. In this theory, Ausubel claimed that learning occurs as a result of the interaction between the acquired learning and the cognitive structure in application to practice (Seel, 2012). Moreover, critical analysis and differentiation of interrelationships between concepts called concept mapping refines the knowledge into a more organized, precise, specific, and integrated learning.

In different circumstances, nursing as a professional working in a toxic environment of the sick, pained, hopeless, weak, and dying patients; bullying, queen bee syndrome, and seniority egoism of colleagues; and backbreaking workloads—have reported cases of work-related boredom and stress. The application of the three theories may improve mentoring-learning strategies in meaningful nursing education and training.

Theories on learning acquisition from the collection of information, physiologic processing on cognitive-reflective functions of the brain, concept mapping, and internal/external utilization of knowledge in application to critical thinking are the frameworks of a skilled critical thinker.

Characteristics of a Skilled Critical-Thinker

Health care system can go a long way, achieving a considerable success having employees that possess the ability to think critically thus decreasing errors in clinical judgments. For this purpose, every nurse is required to obtain the characteristics of an excellent skilled critical thinker.

The study of Scheffer and Rubenfeld revealed the common qualities among internationally diverse expert nurses from nine different countries supporting the idea of critical thinking in nursing that encompasses logic and reasoning (Berman, et. Al., 2016), and that includes:

11 Affective Components of a Skilled Critical-Thinker Nurse:

• Perseverance
• Open-mindedness
• Flexibility
• Inquisitiveness
• Intellectual integrity
• Perspective

7 Cognitive Skills of a Skilled Critical-Thinker Nurse:

• Information seeking
• Discriminating
• Transforming knowledge
• Applying standards
• Logical reasoning

Critical Thinking Beyond Exigency and Expediency

Undeniably, nurses with critical thinking ability diversified with effective problem-solving and efficient decision-making skills are the most in-demand and highly valued in the field of the health care industry and academe.

As a nurse striding in the most complicated, stressful and multi-tasking job, you are responsible for making life-changing decisions under the pressure of time and emotions. These reasons as to why critical thinking skills in nursing practice plays a vital role in the care of the patient. Luna (2020), cited seven importance of critical thinking skills in the practice of nursing, such as:

• Nurses’ Critical Thinking Heavily Impacts Patient Care
• It’s Vital to Recognizing Shifts in Patient Status
• It’s Integral to an Honest and Open Exchange of Ideas
• It Allows You to Ensure Patient Safety
• It Helps Nurses Find Quick Fixes and Troubleshooting
• Critical Thinking can Lead to Innovative Improvements
• It Plays a Role in Rational Decision Making

Critical thinking skill is needed in problems identification and implementation of interventions resulting in improved patients outcomes, as well as development in nursing practice by providing new insights on the learned knowledge. Feedback and reflections provide interconnections between nursing research , critical thinking and the nursing practice (Berman, et. Al., 2016).

Critical Thinking Skills: The Mastery, Update and Upgrade

Critical thinking skill is an ability beyond thinking rationally and clearly. It is a process of thinking independently and working at your own feet in formulating own opinions or new theory by utilizing critical analysis on the interrelationship of two or more ideas and delineating conclusions without external control (Wabisabi Learning, 2020).

Modified Wabisabi Learning’s 12 Solid Strategies for Teaching Critical Thinking Skills, and its Application to Nursing Education, Training and Practice:

1. Practice on Eloquence in Question and Answer (Solution Fluency)

Mastery requires ample amount of practice to become highly skilled in critical thinking. Accustom to deliberate open discussions encouraging brainstorming on issues affecting the practice and daily living by using explicit open-ended questions and comprehensive instructions for problem-solving may provide opportunities to apply knowledge into practice as well as encouraging the transfer of ideas between domains (Haber, 2020). Brainstorming is an excellent learning tool to exercise critical thinking (Walden University, 2020) particularly if applied in a situational crisis or a hospital scenario.

2. Create a Foundation

From the theory of back to basic, mastery of low-level skills is a requirement in preparatory to the application of critical thinking skills (Kaminske, 2019).

Learning experiences from theoretical and experiential knowledge are good foundations to start critical thinking. Moreover, practicing thinking skills obtained from theoretical and experiential undertakings improve intellectual ability (Berman, et. al., 2016). Practical understanding and specialization on a particular focus may excel you more in thinking critically. The competence and skills acquired from clinical experience are the most essential learning in developing clinical judgment.

3. Consult the Classics

Nursing theorists and their work are the best examples of consulting the classics. In critical thinking, nurses identify claims based on facts, conclusions, judgment/opinions and evidence-based practice. Exploring nursing theorists and their works are like exploring great minds, acquiring lessons on character motivation, refuting theories or formulating a new theory from existing theory. Case studies and in-depth objective critiques of nursing theories may not only promote critical thinking but act as a leverage to bridge the gap between theory and practice.

4. Create an Environment for Open Communication

During clinical rounds, nurses and/or students with a clinical instructor are engaged into thinking process by providing the opportunity to communicate assessment data, collaborate ideas, formulate nursing care plan, and discuss the various context of the situation from different perspectives (Di Vito-Thomas, 2005).

5. Use Information Fluency

Information fluency is mastering the proper use of information and to the ability to intuitively analyze and interpret it in unearthing knowledge and appropriate facts useful in solving a problem (Wabisabi Learning, 2020).

Knowledge of medical conditions, procedures and its connections to patient’s care are important in building critical thinking. Learning from available resources like medical journals, surfing the internet, and meaningful dialogue with colleagues can increase your medical know-how (Jillings, 2020).

6. Utilize Peer Groups

Peer groups, particularly well experienced and highly skilled colleagues are an excellent source of information, questions, and problem-solving techniques as it expands thinking and viewpoints. It also develops interpersonal skills like teamwork and resolving conflicts (Berman, et. Al., 2016).

7. Try One Sentence of Reflections at a time

Reflections will teach the learner to apply their knowledge, logic and reasoning by explaining themselves in a low-pressure setting. It provides an opportunity to explore situations with a different approach and better solutions for future use (Jillings, 2020).

The mastery of metacognition helps the learner to use reflection in defining clinical experiences and explore ways on how to improve it. Recollecting facts and events in patient’s care may integrate the learner into different concepts by connecting different ideas from one another (Di Vito-Thomas, 2005).

8. Problem-solving with Reasoning

Understanding rationale, the sets of reasons or logical basis for a course of action assist the learners to gain a broad knowledge of the topic and promotes a higher level of understanding. Problem-solving guided by rationale is a technique to the use of deductive and inductive reasoning in the thinking process (Di Vito-Thomas, 2005).

9. Roleplaying and Return Demonstration

Role-playing is a self-directed activity that encourages analytic and creative thinking. It helps the learner to internalize empathy while compromising in portraying a role or another persona creating a wider chance for memory retention.

Practice and repetition of observed procedures during return demonstration creates an avenue for re-thinking ways on how to do a task properly with ease in your own phase as you implement it by yourself.

10. Thinking and Speaking With Sketch (Concept Mapping)

Incorporating a concept with multiple perspectives and connecting complex ideas in a structured way to search for potential solutions. These processes create an abstract concept that encourages logical arguments used in critical thinking (Kaminske, 2019).

Interactive activities such as case study with a panel discussion, observing clinical dynamics during in-depth arguments, making a multidisciplinary joint care plan for patient promotes an environment for critical thinking thus facilitating the development of clinical judgment (Di Vito-Thomas, 2005).

11. Do Some Prioritizing and Decision-making

Make critical thinking as a culture and not just an activity by encouraging decision-making. Prioritizing through analyzing information, applying knowledge, and evaluating a prospected solution are the cornerstones of decision-making. This will allows the learner to apply learned theories to a different scenario by weighing the advantages and disadvantages of different solutions and option in deciding best practices.

12. Correct Misconceptions and Personal Bias

Personal beliefs greatly influence one’s ability to think critically as people always seek out ideas that conform to their own beliefs (Kaminske (2019). Several factors that act as the pitfalls in critical thinking are misconceptions, personal bias, and assumptions—which can bring a learner into a wrong direction. A discussion with colleagues who have mastery in evidence-based practice and conducting more in-depth investigations can give ideas and extends point of view (Jillings, 2020).

Conclusion and Suggestions:

Analytical skills through keen observation, understanding important data, and identifying a pattern of recognition; problem-solving capacity by connecting relationship of phenomena, data interpretation guided by significance and rationale; and use of reflection and evaluation abilities in formulating conclusion are the important factors in clinical judgment and decision-making.

Critical thinking is a learned skill resulted from a rolled-up innate curiosity in the application of strong theoretical and experiential foundations in solving clinical problems that direct to the best care decision, which produce positive patient outcomes and improve patient care services.

In this era of technological advancement where machine replaces almost of everything, critical thinking still plays an important role in the nursing practice. Nurses who can manipulate complex clinical situations with efficient skills on critical/analytical thinking, problem-solving and decision-making are often in the front line to compete for the position with greater autonomy and higher chances for opportunities.

• Nightingale, F. (1860). Notes on Nursing: What it Is, and what it is Not. London: Harrisons & Sons.
• Haber, J. (2020). It’s Time to Get Serious About Teaching Critical Thinking. Inside Higher Ed. Retrieved on 24 October 2020 from https://www.insidehighered.com/views/2020/03/02/teaching-students-think-critically-opinion
• Walden University. (2020). 7 Ways to Teach Critical Thinking in Elementary Education. Retrieved on 24 October 2020 from https://www.waldenu.edu/online-bachelors-programs/bs-in-elementary-education/resource/seven-ways-to-teach-critical-thinking-in-elementary-education
• Kaminske, A.N. (2019). Can We Teach Critical Thinking?. The Learning Scientists. Retrieved on 24 October 2020 from https://www.learningscientists.org/blog/2019/2/28/can-we-teach-critical-thinking#:~:text=beliefs%20(3).-,Can%20we%20teach%20critical%20thinking%3F,happens%20to%20enjoy%20science%20fiction
• Berman, A., Snyder, S.J. & Frandsen, G. (2016). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, 10 th New Jersey: Pearson Education, Inc.
• Lakhanigam, S. (2017). Critical Thinking: A Vital Trait for Nurses. Minority Nurse. Retrieved on 24 October 2020 from https://minoritynurse.com/critical-thinking-vital-trait-nurses/
• Regis College (2020). How to Leverage Critical Thinking in Nursing Practice. Retrieved on 24 October 2020 from https://online.regiscollege.edu/blog/how-to-leverage-critical-thinking-in-nursing-practice/
• (2020). Tabula Rasa. Retrieved on 24 October 2020 from https://en.wikipedia.org/wiki/Tabula_rasa
• Willis, J. (2012). A Neurologist Makes the Case for Teaching Teachers About the Brain. George Lucas Educational Foundation. Retrieved on 24 October 2020 from https://www.edutopia.org/blog/neuroscience-higher-ed-judy-willis
• Knowles, M. (1984). The Adult Learner: A Neglected Species, 3 rd Houston, TX: Gulf Publishing.
• Seel, N.M. (2012). Assimilation Theory of Learning. In: Seel N.M. (eds) Encyclopedia of the Sciences of Learning. Springer, Boston, MA. https://doi.org/10.1007/978-1-4419-1428-6_358
• Luna, A. (2020). 7 Reasons Critical Thinking In Nursing Is Important. AMN Healthcare Company. Retrieved on 24 October 2002 from https://www.onwardhealthcare.com/nursing-resources/seven-reasons-critical-thinking-in-nursing-is-important/
• Wabisabi Learning. (2020). 12 Solid Strategies for Teaching Critical Thinking Skills. Retrieved on 24 October 2020 from https://wabisabilearning.com/blogs/critical-thinking/teaching-critical-thinking-skills
• Di Vito-Thomas, P. (2005). Nursing Student Stories on Learning How to Think Like a Nurse. Nurse Educator, 30(3), pp. 133-136.
• Jillings, B. (2020). Critical Thinking in Nursing: Why It’s Important and How to Improve. AMN Healthcare Company. Retrieved on 24 October 2020 from https://www.americanmobile.com/mobile/NZArticle/?articleId=3346

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Critical Thinking in Nursing

• First Online: 02 January 2023

Cite this chapter

• Şefika Dilek Güven 3  

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

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

Graphical Abstract/Art Performance

Critical thinking in nursing.

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

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

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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Developing critical thinking skills for delivering optimal care

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

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

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Skin cancer is a risk no matter the skin tone. But it may be overlooked in people with dark skin. August 17, 2022

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Analysis of the interprofessional clinical learning environment for quality improvement and patient safety from perspectives of interprofessional teams. March 16, 2022

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Critical Thinking TACTICS for Nurses: Achieving the IOM Competencies

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Developing Critical-Thinking Skills in Student Nurses

April 8, 2020

View all blog posts under Articles | View all blog posts under Master of Science in Nursing

Critical thinking skills for nurses include problem-solving and the ability to evaluate situations and make recommendations. Done correctly, critical thinking results in positive patient outcomes, Srinidhi Lakhanigam, an RN-BSN, said in a Minority Nurse article.

“Critical thinking is the result of a combination of innate curiosity; a strong foundation of theoretical knowledge of human anatomy and physiology, disease processes, and normal and abnormal lab values; and an orientation for thinking on your feet,” Lakhanigam said in “Critical Thinking: A Vital Trait for Nurses.” “Combining this with a strong passion for patient care will produce positive patient outcomes. The critical thinking nurse has an open mind and draws heavily upon evidence-based research and past clinical experiences to solve patient problems.”

Since the 1980s, critical thinking has become a widely discussed component of nurse education, and a significant factor for National League for Nursing (NLN) nursing school accreditation. Nursing school curriculum is expected to teach students how to analyze situations and develop solutions based on high-order thinking skills. For nurse educators who are responsible for undergraduate and graduate learners , teaching critical thinking skills is crucial to the future of healthcare.

Characteristics of Critical Thinkers

A landmark 1990 study found critical thinkers demonstrate similar characteristics. The Delphi Report by the American Philosophical Association (APA) identified these cognitive skills common to critical thinkers:

Interpretation

Critical thinkers are able to categorize and decode the significance and meaning of experiences, situations, data, events, and rules, among others.

Critical thinkers can examine varying ideas, statements, questions, descriptions and concepts and analyze the reasoning.

Critical thinkers consider relevant information from evidence to draw conclusions.

Explanation

Critical thinkers state the results of their reasoning through sound arguments.

Self-regulation

Critical thinkers monitor their cognitive abilities to reflect on their motivations and correct their mistakes.

In addition, critical thinkers are well-informed and concerned about a wide variety of topics. They are flexible to alternative ideas and opinions and are honest when facing personal biases. They have a willingness to reconsider their views when change is warranted.

In nursing, critical thinking and clinical reasoning are inextricably linked, columnist Margaret McCartney said in the BMJ . While experienced nurses are able to make sound clinical judgements quickly and accurately, novice nurses find the process more difficult, McCartney said in “Nurses must be allowed to exercise professional judgment.”

“Therefore, education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills,” McCartney said. “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 judgments and decisions are reached in complex healthcare environments.”

Teaching Critical Thinking to Nurses

In 2015, a study in the Journal of College Teaching & Learning found a positive correlation between critical thinking skills and success in nursing school. The study said, “It is the responsibility of nurse educators to ensure that nursing graduates have developed the critical thinking abilities necessary to practice the profession of nursing.”

To help new nurses develop critical-thinking skills, the professional development resources provider Lippincott Solutions recommended nurse educators focus on the following in the classroom:

Promoting interactions

Collaboration and learning in group settings help nursing students achieve a greater understanding of the content.

Asking open-ended questions

Open-ended questions encourage students to think about possible answers and respond without fear of giving a “wrong” answer.

Providing time for students to reflect on questions

Student nurses should be encouraged to deliberate and ponder questions and possible responses and understand that perhaps the immediate answer is not always the best answer.

Teaching for skills to transfer

Educators should provide opportunities for student nurses to see how their skills can apply to various situations and experiences.

In the Minority Nurse article, Lakhanigam also said students who thirst for knowledge and understanding make the best critical thinkers. The author said novice nurses who are open to constructive criticism can learn valuable lessons that will translate into successful practice.

At the same time, however, critical thinking skills alone will not ensure success in the profession , Lakhanigam said in the article. Other factors count as well.

“A combination of open-mindedness, a solid foundational knowledge of disease processes, and continuous learning, coupled with a compassionate heart and great clinical preceptors, can ensure that every new nurse will be a critical thinker positively affecting outcomes at the bedside,” Lakhanigam said.

Another element that ensures success as both an educator and student is earning a nursing degree from a school that focuses on student accomplishments. At Duquesne University’s School of Nursing, students learn best practices in healthcare. The online master’s in nursing program prepares educators to train the next generation of nurses.

About Duquesne University’s online Master of Science in Nursing (MSN) Program

Duquesne University’s MSN curriculum for the Nursing Education and Faculty Role program focuses on preparing registered nurses (RNs) for careers as nurse educators. Students enrolled in the online master’s in nursing program learn the skills needed in the classroom and for clinical training. RNs learn how to empower student nurses to work to their fullest potential.

The MSN program is presented entirely online, so RNs can pursue their career goals and continue personal responsibilities simultaneously.  Duquesne University has been recognized for excellence in education as a U.S. News & World Report Best Online Graduate Nursing Program and best among Roman Catholic universities in the nation.

For more information, contact Duquesne University today.

Critical Thinking: A Vital Trait for Nurses: Minority Nurse

Consensus Descriptions of Core CT Skills And Sub-Skills: Delphi

Margaret McCartney: Nurses must be allowed to exercise professional judgment: BMJ

Predicting Success in Nursing Programs: Journal of College Teaching & Learning

Turning New Nurses Into Critical Thinkers: Wolters Kluwer

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Nursing Competency: Definition, Structure and Development

pj.ca.u-irottot.dem@dkfakim

Nursing competency includes core abilities that are required for fulfilling one’s role as a nurse. Therefore, it is important to clearly define nursing competency to establish a foundation for nursing education curriculum. However, while the concepts surrounding nursing competency are important for improving nursing quality, they are still not yet completely developed. Thus, challenges remain in establishing definitions and structures for nursing competency, competency levels necessary for nursing professionals, training methods and so on. In the present study, we reviewed the research on definitions and attributes of nursing competency in Japan as well as competency structure, its elements and evaluation. Furthermore, we investigated training methods to teach nursing competency.

Healthcare has greatly changed due to issues such as disease structure changes and a rapidly aging population with decreasing birthrates. Accordingly, healthcare and care provider systems are changing. For example, when a patient has an acute medical problem, the hospital is expected to provide short-term, intensive care. When the treatment is completed, home care is needed to provide support for treating the patient with dignity and respect until the end of his/her life. Thus, nurses must provide comprehensive care that meets patients’ complex and diverse needs. Regardless of work setting, this is required of all nurses; presently, there is a growing expectation that nurses should be able to combine various sources of information and incorporate these into their decision-making and nursing practice.

Nurses are always challenged on how they can contribute to society as professionals. They are expected to take professional responsibilities for continuously providing direct care, protecting individual lives and supporting activities of daily living.

To accomplish this, it is important for nurses to improve their nursing competency and utilize it in their daily practice. Competence is an ability acquired through experience and learning. The concept of competence is two-fold: 1) potential abilities that may work effectively under certain circumstances and 2) motivation to show one’s usefulness using those abilities. On the other hand, competency is a behavioral characteristic that is based on one’s interests and experiences influenced by his/her motivation and attitude. It is an optimal behavioral trait that likely leads to achievements. Competence (ability) is a premise for developing competency (behavioral characteristics).

Here we reviewed the research on definitions and attributes of nursing competency in Japan as well as its structure, elements and evaluation. We further investigated methods for teaching nursing competency.

DEFINITIONS AND ATTRIBUTES OF NURSING COMPETENCY

According to one concept analysis study, 1 nursing competency can be divided into the following three theories: behaviorism, trait theory, and holism. Behaviorism refers to competency as an ability to perform individual core skills, and is evaluated by demonstration of those skills. Trait theory considers competency as individual traits necessary for effectively performing duties (knowledge, critical thinking skills, etc.). Holism views competency as a cluster of elements, including knowledge, skills, attitudes, thinking ability and values that are required in certain contexts. Nursing competency is generally viewed as a complex integration of knowledge including professional judgment, skills, values and attitude, indicating that holism is widely accepted. In nursing practice, nurses are required to apply their acquired knowledge, skills and innate individual traits to each situation and be able to adapt that knowledge and those skills to different circumstances.

There are two definitions of holistic, integrated nursing competency: 1) By analyzing a) graduation achievement goals as they relate to enhancing the development of nursing competency (the Conference for Nursing Education model), 2 b) the International Competency Standards Framework for general nurses (International Council of Nurses) 3 and c) the Scope and Standards of Nursing Practice (American Nurses Association), 4 Nakayama et al. 5 defined nursing competency as “the ability to take action by combining knowledge, skills, values, beliefs, and experience acquired as a nurse” and explained that competency can be viewed as an integrated performance reflecting the professional nurse’s feelings, thoughts and judgment; and 2) Takase and Teraoka 6 defined nursing competency as a nurse’s ability to effectively demonstrate a set of attributes, such as personal characteristics, professional attitude, values, knowledge and skills and to fulfill his/her professional responsibility through practice. A competent person must possess these attributes, have the motivation and ability to utilize them and must effectively use them to provide safe, effective and professional nursing care to his/her patient.

These definitions were developed by referencing international standards and literature reviews of the concept of nursing competency using domestic and international databases, clearly describing the structure of nursing and also leading to the development of evaluation methods. Therefore, they will play important roles in future research on nursing competency.

On the other hand, in order for more nurses to evaluate and enhance their own nursing competencies in their practice, it is important to develop definitions of nursing competency and competency levels that are simple and easy to understand. The Japanese Nurses Association has been developing a standardized clinical ladder for nurses. As a result, the Association developed nursing competency indices that could be used across all areas of nursing practice. 7 These nationally standardized indices were created to help nurses objectively evaluate their competencies, use them in different practice settings and situations and enhance the quality of nursing care. The Association defines core nursing competency as “the ability to perform clinical nursing care that is based on the nurse’s ethical thinking and accurate nursing skills and that is provided to meet the needs of the cared.” It also developed a rubric showing four core competencies for nurses (the abilities to understand needs, provide care, work collaboratively, and support decision-making) as a clinical ladder, with five levels for each competency as follows: I) following basic nursing care procedures and practicing nursing with needed advice; II) practicing nursing independently based on a standard nursing care plan; III) practicing individual nursing suited to care recipients; IV) practicing nursing using predictive judgment with a broad perspective; and V) in more complex situations, practicing nursing by selecting the best means for care recipients and increasing QOL. Since the rubric shows objectives (including performance objectives) for each level, it helps many nurses evaluate their own skills, thus enhancing their competencies.

As described above, nursing competency is a complex integration of knowledge including professional judgment, skills, values and attitude. It is an intelligent practical skill set that integrates or combines different factors and issues in complex ways, specific to each circumstance. Table 1 shows the components of nursing competency.

Components of nursing competency

Next, we examined the attributes (common traits and characteristics) of nursing competency.

To acquire nursing competency, nurses must possess the skills and personal traits necessary to effectively perform their duties while integrating multiple elements including knowledge, techniques, attitude, thinking ability and values that are required in specific contexts. There are three categories into which these elements can be divided: personal traits necessary for nursing, professional attitudes and behaviors, and the ability to provide care based on professional knowledge and skills. 1 Personal traits include affection, understanding, self-control, critical thinking and problem-solving ability. Professional attitudes and behaviors involve the following performance standards: taking up professional responsibilities, being autonomous, being aware of one’s own limitations, providing explanations, respecting patient rights, promoting continuous learning and maintaining up-to-date knowledge and skills. Providing care based on professional knowledge and skills includes the ability to collaborate with other healthcare professionals, develop intrapersonal relationships, educate and instruct, manage nursing care, ensure safety and quality of nursing and expand the capacity of nursing.

Thus, nursing competency attributes include a wide variety of abilities, and nursing competency can be referred to as performance traits explicitly demonstrated by a competent nurse who possesses these abilities.

COMPONENTS OF NURSING COMPETENCY

In order to make nursing competency measurable, since it is a holistic and integrated concept, many researchers seek to identify its main components. Matsutani et al. 8 analyzed the definitions, attributes, elements and structure of nursing competency by reviewing articles in English about nursing competency. The present review produced a definition of nursing competency that included the ability to integrate knowledge and skills under particular situations or settings and traits that included core abilities necessary for ethical and effective nursing practice. Nursing competency is a holistic and integrated concept, which is constructed from complex activities. It is defined as a performance competency, which meets the standards expected from potential competencies. In addition, Matsutani et al. 8 categorized nursing competency into seven elements subsisting within three major components: i) the ability to understand people [1) applying knowledge and 2) building intrapersonal relationships]; ii) the ability to provide people-centered care [3) providing nursing care, 4) practicing ethically, and 5) collaborating with other professionals]; and iii) the ability to improve nursing quality [6) expanding their professional capacity, and 7) ensuring the delivery of high-quality nursing]. Matsutani et al. 8 presented a diagram showing people-centered, collaborative relationships among the three participants involved in creating healthy living: people who require nursing care, healthcare and welfare professionals, and nurses who play important roles in the fields of healthcare and welfare. This schematization of nursing competency is very useful.

Nakayama et al. 9 studied and organized processes for developing and evaluating nursing competency by collecting longitudinal and cross-sectional data on nursing competency from university graduate nurses who worked in hospital settings to discern the developmental processes that surrounded their competencies. They examined conceptual definitions and nursing competency frameworks through literature review of domestic and foreign articles and subsequently developed a competency structure with four concepts and 13 competencies. Further, Nakayama et al. created a list of questions for evaluating these competencies and developed a tentative measurement system called the Clinical Nursing Competence Self-Assessment Scale (CNCSS). 9 The CNCSS measures the following four competency concepts: basic nursing abilities (basic responsibilities, ethical practice and supportive relationships); the ability to provide care that addresses individual needs (clinical judgment, planned nursing implementation, evaluation of care, and health promotion); the ability to modify care environment and collaboration systems [risk management, care coordination and nursing care management (fulfillment of responsibilities)] and the ability to devote time toward professional development in nursing practice (enhancement of professionalism, improvement of nursing quality, and continuous learning). This scale enabled the assessment of university graduate nurses’ competencies and was initially used for nurses with 1–5 years of experience. However, the scale was later deemed useful for accurately measuring nursing competency in nurses with > 5 years of experience. 10

Takase and Teraoka 6 conducted a concept analysis of nursing competency through a literature review of foreign articles published between 2000 and 2009. They then developed a scale based on the resultant definitions and attributes of nursing competency and presented the components of this scale. The following ten attributes represent the characteristics of nursing competency addressed: personal characteristics; cognitive ability; orientation to ethical/legal practice; engagement in professional development; collaboration with other healthcare professionals; providing teaching or coaching to patients and staff; demonstrating management skills; ensuring quality and safety in care; establishing interpersonal relationships with patients and nursing staff; and managing nursing care. In addition, Takase and Teraoka 6 developed the Holistic Nursing Competence Scale (HNCS) based on the definitions and attributes of nursing competency that are mentioned above, which consisted of 36 items with a five-factor structure that were retained to form the HNCS. These factors illustrate nurses’ general aptitude and their competencies in staff education and management, ethical practice, provision of nursing care and professional development. This scale consists of 36 items and allows for the easy administration of periodic clinical nursing competency evaluations. The attributes of nursing competency identified through concept analysis are reflected onto the scale items without deviation from their original meanings. Therefore, HNCS can be considered as a holistic scale. Since this scale holds high reliability and validity, it is believed to be useful for clinical application.

To train nurses who can function in a wide range of facilities and settings, provide educational support and help maintain stable nursing workforce, the Japanese Nurses Association has been developing a “nursing clinical ladder (Japanese Nurses Association version)” as a nationally standardized index. This index is designed to be used in any nursing practice setting, and thus its use is not limited to the facilities with which individual nurses are affiliated. 7 The nursing clinical ladder i) develops a standardized nursing competency index, applicable for all nurses regardless of practice setting and background and supports their competency development; ii) assures and secures nursing quality by properly evaluating nursing competencies, and iii) provides safe and trusted nursing care to patients and service users. The clinical ladder is a system that shows nursing competency throughout different phases, displays target abilities for each phase and indicates nurses’ abilities according to their achievement levels. It enables nurses to assess their own competency levels for self-improvement and can also be used for staff development.

A core competency of nursing is “the ability to practice nursing that meets the needs of clients cared for using logical thinking and accurate nursing skills.” The nursing competency structure consists of four abilities: the ability to understand needs, the ability to provide care, the ability to collaborate and the ability to support decision-making. These four abilities are closely related and utilized in all types of nursing practice settings.

As shown previously, nursing competency has various definitions, and different components have been indicated. Therefore, future studies are needed to clarify the relationships that exist among the components that support each nursing competency and in what order each element is acquired. Furthermore, it is important to develop nursing competency training methods, evaluate their effectiveness and conduct further research, which contributes to improving nursing quality.

EVALUATION OF NURSING COMPETENCY

To provide seamless training from basic education to post-graduation clinical practice, many studies have focused on evaluating the nursing competency of university graduate nurses with < 5 years of experience. 11 – 15

A study was conducted on the competency characteristics of nurses with 1 year of experience using the CNCSS. 16 The results showed trends that where competency was high in areas of “ethical practice,” “risk management,” and “basic responsibilities” and low in “care coordination,” “professional development,” “improvement of nursing quality,” and “health promotion.” New nurses focus on the duties at hand, which inevitably increase the basic nursing abilities that are associated with ethics and responsibilities. However, it is difficult for them to provide individualized nursing care that supports patients’ lifestyles and engage in professional development while providing care.

According to the study conducted on competencies of nurses with < 5 years of clinical experience, 17 nurses had a considerably high competency in direct, everyday care compared with the nurses with only 1 year of experience. They had acquired an ability to provide care that addressed individual health needs, including making appropriate clinical judgments, implementing planned nursing care, and evaluating outcomes. The ability that displayed the most improvement was care coordination, which involves practicing nursing as part of a team. Although improvements were seen in some of the nursing competency attributes during the fifth year of clinical experience, competencies in other areas were still low and required improvement even after the sixth year of experience.

Tsuji et al. developed a Likert-type nursing competency scale with seven domains and 31 items to evaluate the competencies of mid-level nurses. 18 The results revealed a competency plateau phenomenon among mid-level nurses. In other words, nurses with 5–10 years of clinical experience showed almost no correlation between the years of experience and nursing competency scores. There were considerable differences among competency levels of these mid-level nurses, suggesting that there were nurses who strove for steady improvement of competency and ones who did not.

Many studies use self-administered questionnaires for evaluating nursing competency. However, Kudo et al. evaluated the competencies of average nurses with >10 years of clinical experience using management evaluation. 19 Abilities evaluated highly by management were clinical judgment and planned implementation of nursing care. Abilities reported, but not included in the evaluation scale, involved the ability to respond, adjust, anticipate, and solve problems. That is, management expected these nurses to possess abilities to interpret situations, take action, and produce favorable outcomes.

Many studies on nursing competency evaluation have focused on nurses with 1–5 years of experience, and little is known about competency development in mid-level nurses. On the other hand, the number of studies that focus on components of nursing competency is slowly increasing. Studies involving relationships among nursing competencies include relationships with critical thinking skills, 20 sense of coherence and spirituality, 21 development of social skills,22 and learning behaviors. 22 Also, relationships with learning environments, 23 nursing care quality 24 and current careers 25 have been studied. In all studies, nursing competency is referred to as an ability, which is a complex integration of knowledge including professional judgment, skills, values, and attitudes. These studies also investigated factors related to competency development. Further research should focus on identifying factors that affect nursing competency, which will help achieve insight into methods of training for nursing competency.

TRAINING IN NURSING COMPETENCY

Many studies on nursing competency training methods have focused on basic nursing education, 26 – 28 and little has been studied on clinical nurses. For clinical competency training methods for students, scenario simulation, roleplay and objective structured clinical examinations are often used. However, these methods view nursing competency from a behaviorist point of view, and the major focus is on performance in many clinical settings. Problem-based learning tutorial training is a well-known method where students work in small groups, present a nursing scenario with a problem and situation, create their own learning tasks and engage in active learning. This method involves student-centered learning; instead of active teaching, lessons that encourage active learning are crucial for training thinking skills. Therefore, future studies are needed to identify components of nursing competency and test each training method to verify which method is effective for training each competency. 29

Next, we examined clinical nurses’ competency training methods. Clinical nursing practice is providing patient-centered care to achieve certain objectives. Nurses provide everyday care in fast-changing clinical settings using abilities acquired through knowledge and skill acquisition processes. An important aspect connecting knowledge and skills is clinical judgment. The clinical judgment process involves reflection, which connects one’s own actions and their outcomes. This reflection is a component of clinical judgment. 30 Integrating knowledge and skills in clinical settings is a feature of nursing competency and is associated with a core ability to provide care based on the needs of the person who is receiving the care. In other words, effective reflection is closely related to nursing competency improvement. Professional nursing practice includes making judgments, both as a care provider and learner, and reflecting upon one’s actions as the care is being delivered, and after the care is completed. Nursing practice, by itself, is crucial for competency improvement.

Needless to say, nursing practice is situation-dependent. To reflect on a particular clinical situation, it is important to understand the background of that situation. Once a nurse determines and shares the direction of the nursing care with the person receiving the care and explains the reasons and anticipated outcomes, reflection becomes a factor for competency improvement. Clinical judgment training through reflection is important for improving nursing competency; however, reflection by itself does not improve all competencies. Nursing competency includes a variety of components, such as knowledge, skills, attitudes, thinking ability and values; therefore, nursing competency training should incorporate various educational programs. To train all areas of nursing competency, it is necessary to understand the attributes and components of these nursing competencies as parts of the clinical ladder and develop training methods that address the order of competency acquisition. Moreover, in addition to evaluating nursing competency, further discussions and research are needed to examine the outcomes of competency improvement.

Nursing competency is a core ability that is required for fulfilling nursing responsibilities. Therefore, it is important to clearly define nursing competency in order to establish a foundation for nursing education curriculum. It is also important to identify the developmental process of nursing competency for continuous professional development after obtaining a nursing license. However, while competencies are important in improving the quality of nursing, the concept of nursing competency has not been fully developed. Thus, challenges remain in establishing the definition and structure of nursing competency, competency levels necessary for nursing professionals, training methods and so on. Therefore, further investigation is needed to establish a full concept of nursing competency.

Acknowledgments

Acknowledgments : This study was supported by a Grant-in-Aid for Scientific Research (No. 17K12117).

The authors declare no conflict of interest.

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