Critical thinking in nursing

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)[1]

Critical thinking is one of those things that one learns as a nurse. How do I then impart that wisdom and skill to a nursing student so they can function in real life?

I have been a nursing instructor in the clinical setting for approximately 5 years in both the pediatric and medical surgical setting. The students that I currently have in the medical surgical/ long-term care settings are fairly new, but incredibly determined.  While they might think that they are imposters and acting as if, they have the energy and focus of the younger brain –  a great benefit with the expected workload.

The students have taken pathophysiology to understand the human body. They are enrolled in the medical surgical classes to understand various diseases and the appropriate treatment and care for those diseases. They have also had skill labs to practice the necessary nursing treatments when caring for their patient.

In the clinical setting the students are working alongside various staff members, including nursing assistants, medication aide and RN. They are learning basic care, transferring techniques, patient assessment (determining current level of health), medication administration as well as skilled nursing care. The skilled nursing care includes wound care, blood sugars, IV medications, tube feedings and detailed patient assessments to name a few. Finally in the last week, they are providing total care for their two patients, including basic care, medications, nursing care and ongoing assessments and evaluations.

As a clinical instructor, my role is then to take the newly learned skills and guide them in using critical thinking skills for their patients through the use of a detailed nursing care plan. This can include:

  • Evaluating their patient and determining the nursing diagnoses, based on presentation and needs
  • Understanding the relevance of certain lab values and medications
  • Determining the educational needs for their patient
  • Connecting the dots between medical diagnosis, nursing diagnoses and nursing care

The nursing care plan is all-inclusive, with the necessary care but most importantly putting it all together. My goal is to have them understand the whole picture and what their responsibilities are as a nurse, while questioning and using critical thinking in the process. Examples then of their critical thinking might include:

Understanding the diagnoses and plan of care for patient in end stage cardiac disease who is in intractable pain. The students then need to understand the diagnoses, how to best provide a focused assessment, communicate with the RN and hospice providers and the plan for care and comfort.

Care for a patient who is a brittle diabetic with additional diagnoses of both kidney and heart disease. The students then need to provide an inclusive assessment for those major diagnoses along with provision of emotional/spiritual care for the loss of a body part and to forward think the safety concerns post amputation.

Care for an obese elderly woman after a recent fractured hip repair with wound infection and IV antibiotics. The care then centers around infection and IV antibiotics, positioning and fall prevention post hip repair and again, forward thinking for care and fall prevention once she is home.

While I am only with my students for 6 weeks, it is long enough to learn the importance of great assessment skills and critical thinking. They learn how to start to put the pieces together and in turn provide care. Lastly they learn good communication skills with patients and staff as well as the importance of using one’s voice when something is not quite right. My role then is to help them realize they are on the road to be enough, provided they study hard, connect the dots and use critical thinking. Lastly, my role is to hopefully help them know what an honor it is to have patient connections and the joy of simply being present with their patient.

[1] Heaslip, P, Critical Thinking and Nursing, 2008 at