Promoting Critical Thinking Skills in Nursing

By Rose O. Sherman, EdD, RN, FAAN

“The important thing is to not stop questioning.  Curiosity has its own reason for existing.”   Albert Einstein

If you talk with any group of nurse leaders, the challenge of promoting critical thinking with their nursing staff will inevitably enter the conversation as a key concern.  A nurse leader recently told me about a sentinel incident in her hospital.  “As I read the root cause analysis report”, she reflected, “I was struck by how the staff seemed to be on auto pilot and did not ask key questions that might have led to a different outcome”.  She is not alone with this concern.  The frantic pace of healthcare today has led many nurses to become very task oriented as a survival mechanism.  Reflection on one’s work is rare although experts advise that it is necessary for professional growth.  So the challenge for nurse leaders is how to promote critical thinking so it becomes integrated into everyday nursing practice.

What is Critical Thinking?

A simple definition of critical thinking is that it is reasonable, reflective thinking focused on deciding what to believe or do.  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).  A key concept in critical thinking is the art of reflection.   Dr. Robert Ennis at Illinois State University has identified key behaviors of critical thinkers.  These include:

A critical thinker:

• Is open-minded and mindful of alternative
• Desires to be, and is, well-informed
• Judges well the credibility of sources
• Identifies reasons, assumptions and conclusions
• Asks appropriate clarifying questions
• Judges well the quality of an argument, including its reasons, assumptions, evidence, and their degree of support for the conclusion
• Can well develop and defend a reasonable position regarding a belief or an action, doing justice to challenges
• Formulates plausible hypothesis
• Defines terms in a way appropriate for the context
• Draws conclusions when warranted – but with caution

The above are skills that we would like to see in our nursing staff.  Some nurses are intuitively better critical thinkers than others but there are strategies that nurse leaders can use in their environments to promote these skills.

Creating a Learning Environment to Promote Critical Thinking

Judith Ross in a 2009 Harvard Business Review Blog suggested that the most effective questions create value.  Here are some examples of the value that can be built and the sample questions that can be asked:

1.  To create clarity – Can you explain more about this situation?  What do you think the issue is here?

2.  To help staff think analytically and more critically – What are the consequences if you take this action?  If our organization does not take action to decrease our financial costs, what will happen when reimbursements decline?

3.  To inspire reflection – Why do you think you were successful in that situation?  What is different about today’s healthcare environment that when you initially began your career?

4.  To encourage breakthrough thinking – Is there another way that we could do this?  If you were redesigning care today with a blank slate, what type of delivery system would you develop?

5.  To challenge assumptions – What would happen if we fail to take action in view of what is happening with health reform?  Do you think that this type of care needs to be delivered in a hospital setting?

6.  To create ownership of solutions – Based on your nursing experience, what do you suggest that we do here?  What changes would be in the best interest of your patients?  How would you deal with the dilemma of the 12 hour?

With the focus today on evidence-based practice, nurse leaders need to promote a culture of critical thinking and inquiry.  A culture of inquiry begins by valuing the use of questions in one’s own leadership practice.  Without asking questions, you may falsely assume you have consensus or that staff understand an issue or problem.  Moving from telling to asking may be challenging but it is the way to help staff grow.

Read to Lead

Critical Thinking and Nursing.  The Critical Thinking Website

Critical Thinking – A Definition.  Critical Thinking. Net Website