EVIDENCE- Critical Thinking: the Nursing Process and Competent

BASED CARE Patient Care

SHEET
What We Know
› Critical thinking can be broadly defined as a complex cognitive process that involves the
development and effective utilization of multiple dimensions of cognition to interpret and
analyze a situation and arrive at and act on an appropriate conclusion or solution(7,10,16,18)
• Critical thinkers demonstrate the ability to ask relevant questions, clearly define a
problem or situation, use knowledge and previous experience to guide problem solving,
examine their own thinking and the thinking of others, and arrive at a conclusion that
reflects thorough analysis of all aspects of a situation(10,18)
–According to the American Nurses Association (ANA), an essential feature of
professional nursing is the “application of scientific knowledge to the processes of
diagnosis and treatment through the use of judgment and critical thinking”(1)
• For general information about critical thinking in nursing, see Evidence-Based Care
Sheet: Critical Thinking: an Overview
› The number of complex patients admitted to hospitals is only rising, which makes the
importance of critical thinking in nurses (such as recognizing changes in health status and
being aware of deterioration) more vital(9)
› The nursing process, which is a systematic, problem solving approach to diagnose and
guide treatment for patient responses to health and illness, is considered a critical thinking
competency(4,10,16,18)
• The five steps of the nursing process are assessment, analysis/diagnosis, planning,
implementation, and evaluation. Critical thinking is important in all five steps(10,18)
–Assessment involves data collection through physical examination and taking a health
history(10,18)
Authors - Accurate assessment requires skilled observation, data verification, and
Eliza Schub, RN, BSN
Cinahl Information Systems, Glendale, CA differentiation of pertinent from irrelevant data(18)
Arsi L. Karakashian, RN, BSN - Critical thinking is key to performing complete, systematic patient assessments. In
Armenian American Medical Society of recognizing the nurse’s crucial role in identifying and responding to signs of patient
California
deterioration following surgery, an international team of expert nurses developed
a clinical algorithm to guide less experienced nurses in the systematic surveillance
Reviewers
Tanja Schub, BS and management of post-surgical patients. The algorithm is based on an expert-level
Cinahl Information Systems, Glendale, CA approach to patient care, providing information on possible etiologies for clinical
Sara Richards, MSN, RN changes post-surgery, strategies to effectively communicate those changes to the
Cinahl Information Systems, Glendale, CA
healthcare team, and potentially helpful interventions. It aids nurses in developing
critical thinking skills necessary to provide high-quality patient care(5)
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA - The subsequent steps of the nursing process rely on the accuracy and thoroughness of
the data collected during the assessment step(18)
Editor
Diane Pravikoff, RN, PhD, FAAN
–Nursing diagnosis is the step during which the nurse summarizes assessment data and
Cinahl Information Systems, Glendale, CA formulates a statement about the patient’s need for nursing care(4,10,12,18)
- Nursing diagnosis requires a critical analysis of assessment data in order to make an
accurate clinical judgment about a patient’s response to current or potential physical,
February 2, 2018
psychological, or emotional stressors(18)

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2018, Cinahl Information Systems. All rights
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or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
 - Investigators in a descriptive study involving undergraduate nursing students at a university in Brazil identified the
following eight aspects of critical thinking in the nursing diagnostic process:(4)
- Scientific and technical knowledge (i.e., knowledge of current, evidence-based nursing as presented in the literature)
- Analysis (i.e., research and evaluation of a clinical situation to understand it holistically)
- Logical reasoning (i.e., the nurse’s perception of the situation and of the relationships that exist among assessment
data)
- Clinical experience (i.e., how the nurse responded in similar situations in the past)
- Knowledge of the patient (i.e., awareness of the patient’s physical, emotional, social, and spiritual status)
- Discernment (i.e., how assessment data are judged to arrive at a decision)
- Applying patterns (i.e., use of information in the literature to assist with identification, evaluation, and grouping of
data)
- Contextual perspective (i.e., view of the clinical situation as a whole)
- The North American Nursing Diagnosis Association (NANDA) provides a list of approved nursing diagnoses that can
be selected based on individualized patient characteristics to guide nursing intervention(12)
- In a randomized controlled trial published in 2010 involving 100 student nurses, investigators examined how
disposition (i.e., inclination) toward critical thinking affects the accuracy of nursing diagnoses. Interestingly and
contrary to the investigators’ expectations, results of the study indicated no correlation between high critical thinking
disposition (as measured by the California Critical Thinking Disposition Inventory; CCTDI) and accuracy of nursing
diagnosis (as measured by the D-catch)(12)
- Simulation provides nursing students with a safe and controlled environment to learn skills. Strategic management
simulations (SMS), a tool developed in other industries, can be used to improve critical thinking skills and complex
decision making among nursing students. Nurse educators simulate challenging and stressful clinical scenarios and
implements SMS strategies of assessment, feedback, and training but additional research is required to determine the
efficacy of SMS among nursing students(11)
- There is no single, accepted method for measuring critical thinking in nurses. (For more information, see
Evidence-Based Care Sheet: Critical Thinking: Evaluation of Critical Thinking Skills )
–Planning is the step that provides an essential link between nursing diagnosis and implementation of patient care
interventions(10,18)
- Planning involves identifying short- and long-termpatient goals and desired outcomes, prioritizing nursing diagnoses,
identifying appropriate nursing interventions for each diagnosis, and using goal-directed critical thinking to develop a
plan for applying interventions, including a plan for providing patient education
–Implementation is the step during which the plan for nursing interventions is carried out through the provision of direct
patient care(10,18)
- As the nurse provides direct patient care, critical thinking is necessary in order to identify appropriate health-promoting
actions, designate specific personnel to provide patient care, monitor the patient’s response to actions and interventions,
and monitor the risks and benefits of interventions and actions(18)
–Evaluation, which is the final step of the nursing process, involves analyzing the plan of care and adjusting it as needed to
meet the patient’s continued health needs(10,18)
- The nurse critically analyzes the patient’s response to interventions and determines whether goals were achieved or the
plan requires modification(18)
› It is generally accepted that critical thinking drives the nursing process and results in the provision of competent patient
care(4,7,8,16)
• Clinical competence can be defined as the implementation of evidence-based nursing practice in consideration of the
individualized needs of the patient and family members;(15)nursing competence requires sound nursing knowledge, clinical
skills, and effective communication and relationship-building skills(13)
• In a study of 188 nurses in Korea, investigators found that critical thinking disposition (which incorporates such qualities
as objectiveness, intellectual fairness and eagerness, and healthy skepticism) was the most important predictor of clinical
competence. Other factors associated with clinical competence included, in descending order of importance, self-directed
readiness to learn, work setting, number of years of professional experience, and clinical position(13)
–The noted correlation between clinical experience and nursing competence is consistent with
 - findings reported by investigators in a large scale, 2-year study of nurses in a university medical center, who assessed
nurses’ critical thinking abilities using the Performance-Based Development System and found that experienced nurses
demonstrated significantly better critical thinking skills than new nurse graduates(8)
- The investigators in this study emphasized that patient safety is affected by the critical thinking ability of a nurse, and
that critical thinking skills can be developed and improved throughout a nurse’s career
- findings in a qualitative study examining the impact of critical thinking on the implementation of a nursing process that
emphasizes safe and effective decision-making. Twenty nurses were asked to identify the specific elements of critical
thinking they used to resolve a clinical case presented to them. The most common elements included clinical experience,
technical and scientific knowledge, and clinical reasoning and judgment(7)
• In a comparative study on critical thinking skills of undergraduate and graduate students in critical care
nursing,undergraduate students of nursing had a higher competency in critical thinking compared to the graduate students(3)
–This study can further validate that self-directed readiness to learn is more important than clinical position or professional
experience
• The utilization of research findings in clinical nursing is an expected practice of baccalaureate-level nurses and is consistent
with the increasing emphasis on evidence-based nursing care.(15,19)In a study of 600 nurses in Norway, critical thinking
disposition as measured by the CCTDI was identified as a reliable predictor of the use of research results(19)

What We Can Do
› Become knowledgeable about the effects of critical thinking on the nursing process and competent patient care so you can
appreciate the importance of evaluating and promoting critical thinking competence among nurses; share this information
with your colleagues
› Encourage yourself and others to think critically from the start of your formation (rather than later) in order to organize and
build knowledge in nursing(2)
• Studies have proven that instilling the importance of critical or creative thinking in nurses during training can later help
them develop effective critical thinking competence
› Utilize problem-based learning to develop further skills and competency(6)
• Problem-based learning is a method that allows nurses in training to learn subjects through the experience of solving an
open-endedproblem
• Attempting to solve an open-ended problem can help in developing creative methods of approach, but more importantly, it
encourages nurses to think critically
› Educate nurses about the characteristics of a critical thinker and about opportunities during the nursing process to engage in
critical thinking
› Promote the continued development of self-reflection, problem solving skills, and other elements of critical thinking that can
improve patient care. Examples of promoting this continued development include
• encouraging new nurse graduates to record their experiences in a nursing diary/journal and to reflect on them
periodically(14)
• engaging nurses in role-playing, problem-solving exercises(8)
• collaborating with your facility’s nursing education department to implement a formal, on-the-job training program for
critical thinking in nurses(1)
› Include critical thinking activities in orientation, preceptor curriculums, and ongoing education activities specific to nursing
specialties(17)

Coding Matrix
References are rated using the following codes, listed in order of strength:

M Published meta-analysis RV Published review of the literature PP Policies, procedures, protocols

SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
C Case histories, case studies
G Published guidelines
RU Published research utilization report
QI Published quality improvement report
L Legislation
PGR Published government report
PFR Published funded report
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation
References
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UFPE, 10(Suppl 4), 3669-3675. (SR)
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care nursing. Nursing & Midwifery Studies, 6(2), 1-4. doi:10.5812/nmsjournal.37464 (C)
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