Discussion of results
The results suggest that a substantial minority of these newly hired nurses had identified learning needs with regard to their ability to make appropriate decisions when asked to assess a clinically focused vignette. Overall, approximately 25% of nurses participating in the assessment were not able to recognize the clinical problem, safely prioritize care and implement independent nursing interventions. They appeared to have difficulty reporting relevant clinical data and anticipating medical orders, and were not able to convey clearly a rationale for their decision-making. It is unclear from the assessment process whether this resulted from lack of knowledge, lack of sufficient time to respond, or not completely presenting their rationale in writing. Nevertheless, it emphasizes the importance of continued assessment, mentoring and coaching to improve and validate decision-making skills.
The percentage of new graduates not meeting expectations in the present study did not fall within the range of previously published results (del Bueno 2005). In a study by del Bueno (2005), from a sample size of 10,988 inexperienced nurses (<1 year of experience) sampled between 1995 and 2004, between 65% and 76% did not meet expectations on the PBDS assessment. Of the 20,413 experienced nurses sampled in the same study, those not meeting expectations ranged between 8% and 69%. Experienced nurses not meeting expectations in the present study ranged from 18.3% to 25.1%. Areas of deficiency on subcategories from their reports were consistent with the present study.
Our findings suggest that, as would be anticipated, nurses with more years of experience were more likely to meet expectations on the PBDS assessment. However, there were differences related to level of preparation. Specifically, those with more experience who were prepared at the baccalaureate or associate level fared better on the assessment than experienced nurses with diploma level preparation. This finding may have resulted from differences in the scope of experience and/or commitment to continuing education fostered by the educational programme. Whether these or other reasons explain the differences are speculative, as our data did not suggest an explanation. This finding is not consistent with previous studies reporting PBDS results. In a study published in 2005, del Bueno reported that after 10 years of analysis there are no consistent findings which indicate differences in clinical judgment ability based on educational preparation or credentialing. Our findings, nevertheless, support a difference in testing outcome based on level of preparation. Further exploration is needed to determine the potential reasons for our results. Possible explanations include the value of and access to advancement via nursing education, the organizational emphasis placed on continuing education, or previous clinical experience.
What is already known about this topic
Critical thinking, advanced problem-solving, and expert communication skills are an integral part of nursing practice and should be developed through nursing education programmes.
Many nurses with a year or less of experience fail to meet expectations on the Performance Based Development System Assessment.
What this paper adds
Approximately 25% of newly hired nurses had deficiencies in critical thinking ability, including problem recognition, reporting essential clinical data, initiating independent nursing interventions, anticipating relevant medical orders, providing relevant rationale to support decisions, and differentiation of urgency.
Nurses prepared at the baccalaureate and associate level were more likely to meet expectations on the assessment as years of experience increased; a similar trend was not seen for diploma nurses.
New graduates were less likely to meet assessment expectations compared with nurses with 10 years’ experience or more.
Implications for practice and/or policy
PBDS can assist in providing information about critical thinking learning needs and facilitate individualized orientation.
Further study is needed to identify areas of critical thinking deficiency and begin to test objective, innovative educational strategies that enhance critical thinking in the nursing population.
Our findings support Benner’s conceptualization in her novice to expert framework (Benner 1984). Nurses with more experience were better able to identify appropriate actions when viewing the clinical vignettes, as would be expected. While it is of concern that a substantial minority of newly hired nurses did not meet expectations, it is important to emphasize that 75% were able to state actions that indicated their ability to manage critical situations independently and anticipate the care needed. They were able to prioritize clinical needs, consider potential actions and modify the plan of care based on prior experience. As might be anticipated, new graduates had a higher rate of not meeting expectations and struggled with the ability to make and implement independent nursing interventions in these same clinical scenarios.
Alternative critical thinking assessment methods are coming into vogue, e.g. high fidelity human simulation (HFHS) (Henrichs et al. 2002, Nehring et al. 2002, Parr & Sweeney 2006). HFHS may be a better option for assessing critical thinking and decision-making as it provides evaluation activities that are more interactive and offers the added benefit of debriefing to facilitate learning (Henrichs et al. 2002, Feingold et al. 2004, Bearnson & Wiker 2005, O’Donnell et al. 2005, Trossman 2005). Like the PBDS assessment, the HFHS can be used as a group learning tool without patient risk (Schwid et al. 2002). HFHS provides a more realistic assessment that includes the ability to assess blood pressure, palpable pulses, heart sounds, breath sounds. In addition, it offers the ability to programme responses that mimic physiological actions and patient responses to the timing and selection of interventions (Euliano 2001, Lupien & George-Gay 2001, Kozlowski 2004). Accordingly, HFHS may facilitate assessment of critical thinking and decision-making (Duchscher 2003). Studies comparing the various methods of assessment remain few in number and therefore it is not possible to determine objectively which approach is the most valid and cost-effective for assessing the learning needs of new graduates and experienced nurses.
To become a professional nurse requires that you learn to think like a nurse. What makes the thinking of a nurse different from a doctor, a dentist or an engineer? It is how we view the client and the type of problems we deal with in practice when we engage in client care. To think like a nurse requires that we learn the content of nursing; the ideas, concepts and theories of nursing and develop our intellectual capacities and skills so that we become disciplined, self-directed, critical thinkers.
Critical thinking is the disciplined, intellectual process of applying skilful reasoning as a guide to belief or action (Paul, Ennis & Norris). In nursing, critical thinking for clinical decision-making is the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care (Heaslip). Critical thinking when developed in the practitioner includes adherence to intellectual standards, proficiency in using reasoning, a commitment to develop and maintain intellectual traits of the mind and habits of thought and the competent use of thinking skills and abilities for sound clinical judgments and safe decision-making.
Intellectual Standards for Reasoning
Practitioners in nursing who are critical thinkers value and adhere to intellectual standards. Critical thinkers strive to be clear, accurate, precise, logical complete, significant and fair when they listen, speak, read and write. Critical thinkers think deeply and broadly. Their thinking is adequate for their intended purpose (Paul, Scriven, Norris & Ennis). All thinking can be examined in light of these standards and as we reflect on the quality of our thinking we begin to recognize when we are being unclear, imprecise, vague or inaccurate. As nurses, we want to eliminate irrelevant, inconsistent and illogical thoughts as we reason about client care. Nurses use language to clearly communicate in-depth information that is significant to nursing care. Nurses are not focused on the trivial or irrelevant.
Nurses who are critical thinkers hold all their views and reasoning to these standards as well as, the claims of others such that the quality of nurse's thinking improves over time thus eliminating confusion and ambiguity in the presentation and understanding of thoughts and ideas.
Elements of Reasoned Thinking
Reasoning in nursing involves eight elements of thought. Critical thinking involves trying to figure out something; a problem, an issue, the views of another person, a theory or an idea. To figure things out we need to enter into the thinking of the other person and then to comprehend as best we can the structure of their thinking. This also applies to our own thinking as well. When I read an author I'm trying to figure out what the author is saying; what problem or issue the author is addressing, what point of view or frame of reference he is coming from, what the goal or purpose is of this piece of writing, what evidence, data or facts are being used and what theories, concepts, principles or ideas are involved. I want to understand the interpretations and claims the author is making and the assumptions that underlie his thinking. I need to be able to follow the author's lines of formulated thought and the inferences which lead to a particular conclusion. I need to understand the implications and consequences of the author's thinking. As I come to understand the author in-depth I will also begin to recognize the strength and weakness of his reasoning. I will be able to offer my perspective on the subject at hand with a clear understanding of how the author would respond to my ideas on the subject.
The Elements of Thought
All thinking, if it is purposeful, includes the following elements of thought (Paul, 1990).
- The problem, question, concern or issue being discussed or thought about by the thinker. What the thinker is attempting to figure out.
- The purpose or goal of the thinking. Why we are attempting to figure something out and to what end. What do we hope to accomplish.
- The frame of reference, points of view or even world view that we hold about the issue or problem.
- The assumptions that we hold to be true about the issue upon which we base our claims or beliefs.
- The central concepts, ideas, principles and theories that we use in reasoning about the problem.
- The evidence, data or information provided to support the claims we make about the issue or problem.
- The interpretations, inferences, reasoning, and lines of formulated thought that lead to our conclusions.
- The implications and consequences that follow from the positions we hold on the issue or problem.
When nurses reason they use these elements of thought to figure out difficult questions and recognize that their thinking could be flawed or limited by lack of in-depth understanding of the problem at issue therefore, they critically monitor their thinking to ensure that their thinking meets the standards for intellectual thought.
In summary, as a critical thinker, I am able to figure out by reading or listening critically what nurse scholars believe about nursing and on what basis nurses act as they practice nursing. To do this I must clearly comprehend the thinking of another person by figuring out the logic of their thinking. I must comprehend clearly the thinking of myself by figuring out my own thoughts on the subject at hand. Finally, I must use intellectual standards to evaluate my thinking and the thinking of others on a given problem such that I can come to a defensible, well reasoned view of the problem and therefore, know what to believe or do in a given circumstance. To do this I must be committed to developing my mind as a self-directed, independent critical thinker. I must value above all else the intellectual traits and habits of thought that critical thinkers possess.
Intellectual Traits and Habits of Thought
To develop as a critical thinker one must be motivated to develop the attitudes and dispositions of a fair-minded thinker. That is, one must be willing to suspend judgments until one truly understands another point of view and can articulate the position that another person holds on an issue. Nurses come to reasoned judgments so that they can act competently in practice. They continually monitor their thinking; questioning and reflecting on the quality of thinking occurring in how they reason about nursing practice. Sloppy, superficial thinking leads to poor practice.
Critical inquiry is an important quality for safe practice. Nurses must pose questions about practice and be willing to attempt to seek answers about practice. Nurses must be willing to attempt to seek answers to the difficult questions inherent in practice, as well as the obvious. Question posing presupposes intellectual humility and a willingness to admit to one's areas of ignorance as well as, intellectual curiosity and perseverance and willingness to seek answers. Critical thinkers in nursing are truth seekers and demonstrate open-mindedness and tolerance for others' views with constant sensitivity to the possibility of their own bias.
Nurse's who are critical thinkers value intellectually challenging situations and are self-confident in their well reasoned thoughts. To reason effectively, nurses have developed skills and abilities essential for sound reasoning.
Critical Thinking Skills and Abilities
Critical thinkers in nursing are skilful in applying intellectual skills for sound reasoning. These skills have been defined as information gathering, focusing, remembering, organizing, analyzing, generating, integrating and evaluating (Registered Nurse's Association of British Columbia, 1990). The focus of classroom and clinical activities is to develop the nurse's understanding of scholarly, academic work through the effective use of intellectual abilities and skills. As you encounter increasingly more complex practice situations you will be required to think through and reason about nursing in greater depth and draw on deeper, more sophisticated comprehension of what it means to be a nurse in clinical practice. Nursing is never a superficial, meaningless activity. All acts in nursing are deeply significant and require of the nurse a mind fully engaged in the practice of nursing. This is the challenge of nursing; critical, reflective practice based on the sound reasoning of intelligent minds committed to safe, effective client care.
To accomplish this goal, students will be required to reason about nursing by reading, writing, listening and speaking critically. By doing so you will be thinking critically about nursing and ensuring that you gain in-depth knowledge about nursing as a practice profession.
Critical Thinking...a Holistic Approach
Critical Listening: A mode of monitoring how we are listening so as to maximize our accurate understanding of what another person is saying. By understanding the logic of human communication - that everything spoken expresses point of view, uses some ideas and not others, has implications, etc., critical thinkers can listen so as to enter empathetically and analytically into the perspective of others.
Critical Thinking: 1) Disciplined, self-directed thinking which implies the perfection of thinking appropriate to a particular mode or domain of thinking. 2) Thinking that displays master of intellectual skills and abilities. 3) The art of thinking about your thinking while you are thinking in order to make your thinking better: more clear, more accurate, or more defensible.
Critical Writing: To express oneself in languages required that one arrange ideas in some relationships to each other. When accuracy and truth are at issue, then we must understand what our thesis is, how we can support it, how we can elaborate it to make it intelligible to others, what objections can be raised to it from other points of view, what the limitations are to our point of view, and so forth. Disciplined writing requires disciplined thinking; disciplined thinking is achieved through disciplined writing.
Critical Reading: Critical reading is an active, intellectually engaged process in which the reader participates in an inner dialogue with the writer. Most people read uncritically and so miss some part of what is expressed while distorting other parts. A critical reader realizes the way in which reading, by its very nature, means entering into a point of view other than our own, the point of view of the writer. A critical reader actively looks for assumptions, key concepts and ideas, reasons and justifications, supporting examples, parallel experiences, implications and consequences, and any other structural features of the written text to interpret and assess it accurately and fairly. ( Paul, 1990, pp 554 & 545 )
Critical Speaking: Critical speaking is an active process of expressing verbally a point of view, ideas and thoughts such that others attain an in-depth understanding of the speaker's personal perspective on an issue. Monitoring how we express ourselves verbally will ensure that we maximize accurate understanding of what we mean through active dialogue and openness to feedback on our views. (Heaslip, 1993).
Paul, R.W. (1990). Critical Thinking: What Every Person Needs to Survive in a Rapidly Changing World. Rohnert Park, California: Center for Critical Thinking and Moral Critique
Norris, S. P. & Ennis, R.H. (1989). Evaluating critical thinking. Pacific Grove, CA: Midwest Publications, Critical Thinking Press