critical thinking new graduate nurses

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Philippines, south korea, turning new nurses into critical thinkers.

As nurses know, seconds can often mean the difference between life and death.  With increasing responsibility and higher patient acuity, it’s imperative for nurses and bedside clinicians to be able to make quick, accurate decisions in response to unforeseen circumstances.

The term ‘critical thinking’ is often used interchangeably with problem-solving and clinical decision-making in nursing literature. Problem-solving focuses on identification and resolution, whereas critical thinking goes beyond this and incorporates asking questions and critiquing solutions. The concept of clinical decision-making focuses attention on the clinical nature of a problem, but falls short of facilitating understanding of the broader spectrum of the issue.

Creative thinking, a combination of imagination and knowledge, can also be helpful in understanding solutions that have failed and coming up with new ideas.

There are many skills necessary to be an effective critical thinker. Decision-making and critical thinking need to happen together in order to produce reasoning, clarification, and potential solutions. To advance nursing practice, it is necessary to develop and evaluate strategies to help new nurses develop these essential critical thinking skills.

Strategies for instituting critical thinking in new nurses

In assessing new graduate nurses’ critical-thinking capabilities, it’s helpful to consider the fundamental principles of critical thinking.  Ask the following 4 questions:

• Can the nurse recognize that the patient has a problem?
• Can the nurse manage the problem safely and effectively, recognizing his or her scope of practice?
• Does the nurse have a relative sense of urgency?
• Does the nurse take the right action for the right reason?

Just as there are similarities among the definitions of critical thinking across subject areas and levels, there are several generally recognized hallmarks of teaching for critical thinking. These include:

• Promote interaction among students as they learn. Learning in a group setting often helps each member achieve more.
• Ask open-ended questions that do not assume “one right answer.” Critical thinking is often exemplified best when the problems are inherently ill-defined and don't have a “right” answer. Open-ended questions also encourage students to think and respond creatively, without fear of giving the “wrong” answer.
• Allow sufficient time to reflect on the questions asked or problems posed. Critical thinking seldom involves snap judgments; therefore, posing questions and allowing adequate time before soliciting responses helps new nurses understand that they are expected to deliberate and to ponder, and that the immediate response is not always the best response.
• Teach for transfer . The skills for critical thinking should travel well. They generally will do so only if teachers provide opportunities for students to see how a newly acquired skill can apply to other situations and experiences.

Attributes of nurse critical thinkers

After evaluating where new nurses are at in terms of critical-thinking skills, look at the attributes of a critical thinker. Strong critical thinkers demonstrate the following characteristics: (Based on the APA Expert Consensus Delphi Report  description of strong critical thinkers.)

• inquisitiveness with regard to a wide range of issues
• concern to become and remain well-informed
• alertness to opportunities to use critical thinking
• self-confidence in one’s own abilities to reason
• open-mindedness regarding divergent world views
• flexibility in considering alternatives and opinions
• understanding of the opinions of other people
• fair-mindedness in appraising reasoning
• honesty in facing one’s own biases, prejudices, stereotypes, or egocentric tendencies
• prudence in suspending, making or altering judgments
• willingness to reconsider and revise views where honest reflection suggests that change is warranted.

Impact of critical thinking on patient safety

Patient safety can be directly affected by the critical thinking ability of a nurse. Nurses must have the ability to recognize changes in patient condition, perform independent nursing interventions, anticipate orders, and prioritize. These actions require critical thinking ability, advanced problem-solving skills and the ability to communicate clearly.

Patient safety may be compromised if a nurse cannot provide clinically competent care. Assessments such as a performance-based development system (PBDS) can provide information about learning needs and facilitate individualized orientation targeted to increase performance level. PBDS evaluates a nurse’s ability to think critically in clinical situations, assessing ability to use clinical knowledge in real-world situations.

Research has shown that these instruments predict strength in critical thinking in problem situations and success on professional licensure examinations.

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Improving Critical Thinking in New Graduate Nurses: Are Practical Methods the Answer?

• PMID: 36445276
• DOI: 10.3928/00220124-20221107-04

Critical thinking is an essential skill of health care professionals. Not sufficiently matured during undergraduate studies, critical thinking skills need continued development. One solution could be a practical guide of teaching methods for clinical educators and professional development specialists to use with new graduate nurses. This column describes a few practical methods that can improve critical thinking. [ J Contin Educ Nurs . 2022;53(12):530-532.] .

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Capturing New Nurses' Experiences and Supporting Critical Thinking

This study analyzed the contents of critical reflective journals written by new nurses during their orientations using a text network. This study aimed to find ways to reduce turnover and improve clinical field adaptability among new nurses. The authors analyzed the content of reflective journals written by 143 new nurses from March 2020 to January 2021. Text network analysis was performed using the NetMiner 4.4.3 program. After data preprocessing, frequency of occurrence, degree centrality, closeness centrality, betweenness centrality, and eigenvector community were analyzed. In total, 453 words were extracted and refined, and words with high simple frequency and centrality were “incompetence,” “preparation,” “explanation,” “injection,” “time,” “examination,” and “first try.” “Medication” had the highest frequency of occurrence, and “incompetence” was the most important keyword in the centrality analysis. In addition, component analysis and eigenvector community analysis revealed three sub-theme groups: (1) basic nursing skills required for new nurses, (2) insufficient competency, and (3) explanation of nursing work. Significantly, this study is the first to use the text network method to analyze the subjective experiences of the critical reflective journals of new nurses. In conclusion, changes are needed to improve the education system for new nurses and promote efficient sharing of nursing tasks.

“New nurses” are nurses who work in hospitals within their first year of acquiring a nursing license. New nurses experience several challenges while adapting to the clinical environment because they often identify patient problems and make high-quality clinical decisions in rapidly changing clinical settings. Critical thinking ability is essential to overcoming difficulties in meeting these demands. 1 In particular, critical thinking ability positively affects clinical decisions through communication and may help new nurses adapt to their working environment. 2 However, new nurses tend to have lower critical thinking abilities than tenured nurses and require time to develop clinical competencies. 3 Because inadequate critical thinking skills may make it difficult for new nurses to provide optimal nursing care and thus may negatively affect patient safety, 3 new nurses must develop strong critical thinking skills.

Furthermore, critical thinking is a reflective thinking process that enables one to decide what to believe and what to do, 4 and reflection is essential to enhance critical thinking ability. 5 Reflective journaling is an approach to internalizing learned knowledge through reflective thinking and objectifying activities, 6 which in turn may strengthen critical thinking and clinical decision-making abilities. 3 Reflective thinking connects new knowledge with existing knowledge, enables abstract thinking, and enables individuals to use specific solution-oriented strategies based on their knowledge and experiences in response to new problems. 7 In the context of nursing education, reflective journaling crucially allows learners to observe their emotional and psychological states. 8 For new nurses, the process of transitioning from being a nursing student to working as a nurse may be confusing and difficult, and reflective journaling during this period may improve clinical decision-making skills, relieve the challenges associated with the transition process, and promote communication with preceptors and nursing managers. 9 , 10

Reflective journaling is a clinically viable educational method for the self-analysis of clinical decision making in residency programs for new nurses. 11 In particular, reflective journaling is a useful educational method for strengthening clinical adaptation capacity in new nurses. 8 – 10 Analyzing the content of these journals can reveal how best to shape pedagogy to strengthen the competencies of new nurses.

Many studies have been conducted to help new nurses adapt and decrease their turnover. These studies include research on the factors affecting the retention intention and turnover of new nurses, 12 , 13 qualitative research on the practical adaptation experience of new nurses, and literature reviews on new nurse education programs. 14 , 15 However, no study has yet analyzed the reflective journals written by new nurses; therefore, it is necessary to review these journals, which offer insights into the actual experiences of new nurses. Other disciplines, such as pedagogy, have applied text network analysis (TNA) for more objective document research by linking content analysis and social network analysis. 16 The TNA method is an analysis technique that interprets a phenomenon using a network that displays the relationships between the words appearing in the text as “links.” Notably, TNA is a useful analysis method to identify the relationship between core keywords and other keywords. 17 In addition, this method can enhance knowledge of related phenomena through quantitatively examining the words appearing in text and identifying words that co-occur with other specific words. 18 Recently, in the field of nursing, studies have used network analyses to uncover research trends and knowledge structures, 19 , 20 including by analyzing the contents of the practices of nursing students. 21

In response to the gap in the literature, the authors sought to uncover the clinical experiences of new nurses during the orientation period by analyzing their critical reflective journals using the TNA method. In particular, the authors examined the relationships between keywords and main words and experiences. This study's specific objectives were as follows:

• To extract keywords based on their frequency and identify core keywords.
• To identify core topic and sub-theme groups.

Research Design

In this quantitative content analysis study, the authors applied the TNA method to identify the core keywords from new nurses' critical reflective journals on their clinical experiences during their orientation period.

Research Sample and Data Collection

The authors analyzed the critical reflective journals written by 143 new nurses who joined a university hospital located in an urban area of Korea from March 2020 to January 2021. The nurses recorded their experiences in the critical reflective journals six times during the orientation period (8 weeks). The nurses were instructed to record, in the form of narration, the most memorable aspects of their nursing interactions with patients and list their performance strengths and shortcomings in each situation. The journal structure was configured to assist them in establishing and writing goals, as well as with developing plans to improve their shortcomings. The researcher obtained the nurses' consent to participate in the study after detailing the purpose and method of writing critical reflective journals for 30 minutes during the common orientation period. New nurses were introduced to critical thinking as a very important and necessary process for improving clinical judgment. In addition, clinical nurse educators prompted new nurses to reflect on the situations they experienced in the field when writing in their journals; in particular, they asked the nurses to contextualize these situations and consider alternative ways they may have solved problems they encountered in the field. The researchers explained to the new nurses that the journals would only be used to analyze basic data to uncover how best to help new nurses adapt to the field. Next, new nurses who voluntarily agreed to participate were provided with a journal before being assigned to a department. Research participants were notified they could withdraw from the study at any time, and they were asked to contact the clinical nurse educators with any difficulties or questions related to journaling. After orientation, the nursing education team collected the journals.

Data Analysis

In the analysis of the collected data, the main semantic structure was visualized as a sociogram through preprocessing and network analysis. Analysis was performed using NetMiner 4.4.3 (Cyram Co. Ltd., Gyeonggi-do, Korea).

Preprocessing Stages

The journals were transcribed to Microsoft Office Excel (Microsoft Inc., Redmond, WA, USA) and converted into databases. Four researchers divided the reflective journals, copied them, and then went through the process of reconfirming each other's work. The data were extracted from long texts and included only nouns identified using the morpheme analysis function of NetMiner 4.4.3. Using the NetMiner's “import unstructured text” menu, the database data were read and morphemes were extracted. A thesaurus was created to unify words with similar meanings. While examining the extracted morphemes, meaningful morphemes were extracted using the thesaurus, defined words, and excluded words, and word purification was performed using the extraction results.

The thesaurus grouped words (phrases) with similar meanings, and the researcher designated the representative words for each group. 22 In Korean alphabet (Hangeul), words with the same meaning are often presented differently, 23 so the authors paid attention to the selection of representative words and their registration in the thesaurus. For example, “alcohol cotton” was made to represent “alcohol swab,” “disinfection cotton,” “cotton,” and “alcohol.” Phrases consisting of two or more words were also added to the dictionary to establish that the multiple words comprising the phrase should be read as a unit. 24 For example, the words “intravenous” and “injection” were registered within the dictionary as comprising “intravenous injection.” The dictionary of excluded words went through a refining process to exclude stop words, such as pronouns and adverbs without important meanings. The process of word refinement involved several rounds of consultation between joint researchers to reduce subjective bias. In addition, “frequency of appearance” refers to the number of times a keyword appears in an entire document. In order to exclude commonly used words that appear frequently in all documents, words with a term frequency–inverse document frequency (TF-IDF) value of 0.5 or less were excluded by referring to previous studies. 25 The frequency of words appearing in one document is called “term frequency,” and the number of documents in which a word appears is called “document frequency.” “Inverse document frequency” is the logarithmic expression of the inverse of document frequency. A high term frequency value may be recognized as a keyword due to a high frequency in one document, but if the term frequency value is equally high in other documents, it is considered a commonly used word in several documents, even if it may not be necessarily a keyword. Therefore, it should be excluded when extracting keywords by calculating inverse document frequency values of words. For this purpose, TF-IDF, which represents the importance of any word in a particular document, is obtained by multiplying term frequency and inverse document frequency, and used for word extraction. The larger the TF-IDF value, the higher the importance of any word in the document. 26 In this study, five words with a TF-IDF value of 0.5 or less (eg, “teacher,” “patient,” “work,” “think,” and “confirm”) were included in the dictionary of excluded words.

Finally, 274 thesaurus, 301 defined words, and 1759 excluded words were registered in the user dictionary. As a result, a total of 453 words were extracted in the critical reflective journals written by the new nurses. In this study, the top 30 keywords' frequency of appearance was analyzed based on refined words to extract keywords. To intuitively represent keywords, frequency of appearance was generated by using NetMiner 4.4.3.

Process of Network Formation

The network formation process generated a keyword co-occurrence matrix to reflect that the two keywords appeared next to each other in one sentence or were located among the other keywords. 27 Repeated co-occurrence can be interpreted as forming a semantic structure between the words. The higher the degree of connection, the more co-occurrence exists across different types of keywords, which yields a semantic structure in various contexts. In the one-mode matrix of the “keyword × keyword” relationship, the degree value was 1 to 48, 70.4% (1649) for less than 1 and 85.4% (1999) for less than 2.

To grasp the main phenomenon in network analysis, only keywords with an appropriate level of connection are included, but the reference value for the connection degree is not presented, 28 and the study result is determined considering ease of interpretation and network visualization. 27 In this study, a one-mode matrix composed of 401 keywords with a connection degree of two or higher was generated and used for network analysis.

Network Statistical Analysis and Visualization

Statistical analysis was performed and visualized using a one-mode network to discover the core keywords in the journals.

The centrality of the network was analyzed for degree centrality, closeness centrality, and betweenness centrality, which are indicators of centrality, and the average and concentration of each centrality were confirmed. Centrality indicators show that words with high centrality are considered core keywords to the extent that words in the network are centered. 29 The value of the centrality indicator exists between 0 and 1; the larger the value, the higher the centrality of the word. 28 The average centrality indicator refers to the center value of the entire network centrality indicator, and centralization represents the degree to which a network is structurally concentrated or distributed across a specific word. Thus, an intensive link flow in a small number of words indicates that the network is highly concentrated. 29

Degree centrality refers to the degree of connection between nodes (in this study, keywords used in the analysis) in the network; this indicates co-occurrence between words and indicates the number of connections between nodes. 28 Keywords with high connection centrality are often connected to other keywords, which means that they are important keywords. Closeness centrality refers to the degree to which a node is located close to another node in the network. 28 Keywords with high proximity centrality may be interpreted as keywords that play a central role in the network while reaching other keywords the fastest. Betweenness centrality refers to the degree to which other nodes and intermediaries play a role in the network. 28 Keywords with high mediation betweenness centrality serve as bridges that interconnect sub-keywords between networks. The top 30 words with high degree centrality, closeness centrality, and betweenness centrality were visualized as sociograms. The larger the node size, the larger the centrality index, and the thicker the link, the higher the co-occurrence frequency.

Sub-theme Analysis

To identify the sub-theme groups, the authors first extracted the largest component based on cohesion in the NetMiner program and then performed an eigenvector community analysis. A component is a group in which keywords are connected without being broken. Communities refer to subgroups with relatively low modularity, high connection density inside the group, and relatively low connection density outside the group within the component structure. The modularity value is used to determine the optimality of the community structure; eigenvector community modularity can have a value between negative (−) infinity and “1”—the larger the value, the better the modularity. 30

Ethical Considerations

This study was approved by the institutional review board (CNUH-2020-247) of the university hospital located in an urban area of Korea to protect the participants, where the current study was conducted. Participants were informed about the purpose of the study, their rights to anonymity and confidentiality, and their freedom to withdraw from the study. Written informed consent was obtained from those who wished to participate in the study.

Keywords of the Critical Reflective Journal of New Nurses

The top 30 keywords by simple frequency, degree centrality, closeness centrality, and betweenness centrality were identified as core keywords in the journals (Table ​ (Table1). 1 ). The simple frequency appeared in following order: “medication,” “intravenous (IV) cannulation,” “preparation,” “incompetence,” and “explanation.” In this study, the means of the degree centrality, closeness centrality, and betweenness centrality of the word networks were 0.216, 0.501, and 0.037, respectively, and the concentrations were 24.9%, 30.2%, and 14.0%, respectively. Regarding degree centrality, “incompetence,” “explanation,” “preparation,” “medication,” and “properly” were the most important keywords. Regarding closeness centrality, “incompetence,” “preparation,” “explanation,” and “time” were the most important keywords. Regarding betweenness centrality, “incompetence,” “preparation,” “first try,” “understand,” and “explanation” were the most important keywords. In the analysis of the most memorable events during the orientation period for new nurses, words such as “incompetence,” “preparation,” “explanation,” and “injection” were high in both frequency and centrality. Regarding the simple frequency, “medication” was the most frequent keyword. Regarding the centrality analysis, “incompetence” was the most important keyword.

Top 30 Keywords That Emerged From the Reflective Journal of New Nurses

Visualizing the Main Semantic Structure

Figure ​ Figure1 1 presents a sociogram, a graph consisting of nodes and links, of the top 30 keywords. The size of a node indicates the degree centrality, and the thickness of a link indicates the strength of the connection, that is, the frequency of co-occurrence. The researchers examined the semantic structure by focusing on five core topics: “medication,” which is strongly tied with “study,” “explanation,” “examination,” and “remember”; “preparation,” which is part of a semantic structure with “injection,” “operation,” “medication,” “time,” and “fluid”; “time,” which is strongly tied with “nursing” and “performance”; and “explanation,” which is part of a semantic structure with “caregiver,” “incompetence,” and “nursing.” Finally, “IV cannulation,” “fluid,” and “organization” formed the semantic structures; “first try,” “IV cannulation,” “admission,” and “night” appeared as meaningful structures; and “properly” and “explanation,” “need,” and “study” appeared as meaningful structures.

Keyword network analysis of the reflective journal of new nurses.

Regarding degree centrality and closeness centrality, “night,” “operation,” “condition,” and “suction” showed low degree centrality and centered on “incompetent,” which demonstrated the highest centrality. Regarding betweenness centrality, “night,” “blood glucose management,” “fluid,” “condition,” “operation,” and “suction” showed low betweenness centrality and centered on “incompetent,” which again demonstrated the highest centrality.

Sub-thematic Groups

The component analysis and eigenvector community analysis based on cohesion in the keyword network yielded three sub-thematic groups with an optimal modularity of 0.257 identified with sociograms (Figure ​ (Figure2). 2 ). Group 1 was classified into “medication,” “preparation,” “IV cannulation,” “first try,” “administration,” “injection,” “examination,” “blood glucose management,” “operation,” “fluid,” “blood sampling,” “blood,” “night,” and “caregiver.” Group 2 was classified into “incompetence,” “time,” “nursing,” “properly,” “electronic medical record (EMR),” “understand,” “study,” “organization,” “performance,” “condition,” and “suction.” Group 3 was classified into “explanation,” “need,” “remember,” “situation,” and “admission.” The research topic groups were named based on the contexts in which the keywords of each subgroup were used. The three sub-themes were (1) basic nursing skills required for new nurses, (2) insufficient competency, and (3) explanation of nursing work.

Visualization of subgroup analysis from the reflective journal of new nurses.

This study sought to understand the work experiences of new nurses by using a TNA method to analyze the contents of the critical reflective journals they wrote during their orientation (the first 8 weeks after they began working in the hospital). The main semantic structure specifically showed the context of the core topic.

More specifically, the frequency and centrality analyses confirmed that, in terms of working directly with patients, the new nurses had the most difficulty with tasks related to medication. The contents of the analysis suggest that a new nurse must prepare drugs for patients and explain the medication to the patient while administering the drug through injection. The new nurses described their experiences with this process in their journals as follows: “When I went to the patient to inject the drugs, the patient asked a question about why the drug was being used, but I did not explain the reason properly” and “I don't know how to explain the efficacy and side effects of various types of drugs administered to patients.” These excerpts suggest that new nurses lack knowledge about medications and experience job stress and low confidence; if these problems are not resolved, they may lead to job turnover. 31 New nurses must learn to administer medications; this is a core basic nursing skill in nursing colleges. A practical training room in the hospital is necessary to provide systematic and sufficient opportunities for repeated practice to improve the confidence of new nurses in their core basic nursing skills and reduce work stress. 32

This study uncovered the following main semantic structures. First, new nurses experience a lack of clinical knowledge about medication and feel a need to study on their own. In addition, a lack of drug-related knowledge caused new nurses to feel burdened when teaching a patient or their caregivers about a medication before administering it. Additionally, new nurses felt that they should remember what they learned on their own and in clinical practice from their preceptors. They also felt the need to learn and study the drugs used in many tests. Medication errors are an important factor in patient safety and are the most frequent medical accidents. 33 Administering the correct drug to the correct patient, providing information about the drug to the patient, and confirming and reporting the side effects of a drug is necessary to reduce medication errors; therefore, it is crucial to emphasize this in nursing programs. 33 Because this study found that new nurses experienced many difficulties with medication, it is necessary to establish a protocol for clinical practice and improve systematic education through simulation. 34

Second, this study confirmed that new nurses must prepare to successfully give injections, oral medications, and fluids and to facilitate operations (eg, preparing dressing materials). 35 In addition, new nurses were frequently pressed for time while taking care of patients. The results were similar to those from a study in which new nurses reported that the confidence level for the item “I can completely care for a patient within the allotted time” was low at 20%–50%. 36 New nurses often work overtime at hospitals; for example, some nurses go to work 2 hours early and complete their records after work because they do not have enough time to complete their duties within their scheduled hours. 37 This suggests that nursing tasks should be more appropriately distributed. 36

Third, new nurses need skills to explain their care to patients or caregivers while working. Accordingly, new nurses need to have strong relationship and communication skills. 38 The journals revealed that new nurses feel their work requires them to be able to properly explain different elements of care to patients and their caregivers; however, they often felt that they did not have the knowledge or skills necessary to carry out this duty. Moreover, the new nurses themselves felt they needed to study to ensure that they were not ignorant in ways that may harm the patient. Therefore, a system should be established to help new nurses strengthen their skills by actively utilizing support resources at the hospital level; notably, this may reduce turnover. Along these lines, a simulation program related to communication should be used during orientation to increase the communication abilities of new nurses. 39

Fourth, new nurses reported difficulties with IV cannulation and their first inpatient admissions. They felt pressured to complete an IV cannulation for the first time and struggled to connect and arrange various fluids. Simulations that teach new nurses how to administer intravenous injections should be included in orientations in response to this trend. Most wards in this research institute use functional nursing, with different numbers of people per service. Therefore, new nurses completed different tasks during day and evening shifts, such as IV cannulation, injection, and vital sign and blood glucose testing during the former and overseeing patients, checking prescriptions, and entering records during the latter. Accordingly, they reported that night work was very complicated and that they felt that they were lacking in their skills to complete it successfully. Previous studies reported that new nurses in Korea experienced excessive workload, communication difficulties, and low confidence in their work, suggesting that active intervention is needed to improve clinical adaptation in new nurses. 36 Therefore, there is a need to develop various programs, such as communication programs and basic nursing skill simulations, for new nurses.

Finally, based on the analysis of the three sub-thematic groups, the first subject group was “basic nursing skills required for new nurses.” The ability to perform basic nursing skills is an essential element for new nurses to adapt to practice: when nursing skills are lacking, they experience overload in the clinical field; this leads to increased stress, which increases the resignation rate. 40 In 2019, Korean institutions began to ensure they were offering clinical nurse educator systems and training programs to reduce the resignation rate of new nurses by improving their competency. 41 Programs that intensively train new nurses in basic nursing skills at the initial stage of their employment are essential in hospitals to help new nurses adapt to practice. The second thematic group was “insufficient competency.” New nurses start clinical work with insufficient clinical experience and competency; experience difficulties in providing and selecting appropriate treatments for patients; and must cope with overload, which increases their role burden. 37 Therefore, it is necessary to reduce the amount of work assigned to new nurses and to develop educational programs that can identify problems by presenting various situations that can help them understand their work. The third topic group was “explanation of nursing work.” New nurses most frequently deal with patients and caregivers and thus feel pressured to properly explain things to them (eg, why patients are hospitalized, what medications they are receiving); this feeds their desire to remember what they have learned. In addition, new nurses often complain of communication difficulties 38 ; accordingly, clinical communication programs should be developed to overcome this problem.

Unlike previous studies, this study analyzed the experiences of new nurses by applying TNA to the critical reflective journals they wrote during orientation. However, the information was only collected over the course of a year, which limits the generalizability of the research results. In addition, the fact that the nursing manager reports and provides feedback on the journals may have limited direct expression. To overcome these limitations, a program for the in-depth analysis of new nurses' experiences should be implemented in the future. Ultimately, this study sets the foundation for further analysis of the experiences of new nurses by being the first to use a TNA to effectively explore the subjective experiences of new nurses.

This study applied a TNA to identify, group, and analyze core keywords in the critical reflective journals new nurses wrote during their orientation at tertiary general hospitals in Korea. New nurses' most memorable events during orientation were reflected by high-frequency and high-centrality words, such as “incompetence,” “preparation,” “explanation,” and “injection.”

This study's results can guide best practice for improving the field adaptability of new nurses and reducing their turnover rate. Currently, nursing students in Korea nursing mainly complete observation-oriented practicums; this increases the burden on their basic nursing skills. Being compelled to perform extensive duties beyond their competencies is causing exhaustion among new nurses. To mitigate these issues, changes should be made to the new nurse education system to better prepare new nurses and nursing duties should be more efficiently distributed.

This study was financially supported from Back Ui Association, Chonnam National University Hospital (2021).

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Ethical Approval: The study was approved by the Chonnam National University Hospital Institutional Review Board (approval number: CNUH-2020-247).

Hye Won Jeong: https://orcid.org/0000-0001-5664-8672

Shin Hye Ahn: https://orcid.org/0000-0002-1403-2711

College of Nursing

Critical thinking in new graduate nurses.

Although leaders in academia and practice share the goal of ensuring new nurses are prepared to meet the demands of the constantly evolving healthcare landscape, transitioning new graduate nurses (NGNs) from school to the clinical environment has been a longstanding challenge. As the nurse's role transforms from an occupation to a profession, the depth and breadth of what nurses are expected to know and do has grown exponentially. It is not possible for NGNs to enter practice being 100% competent in all areas of nursing. While this shift in thinking has been difficult for practice leaders to overcome, the implementation of nurse residency programs like the Iowa Online Nurse Residency Program and other efforts around the transition to practice experience have helped bridge the academic practice gap and support the ongoing skill development of NGNs.

In recent years, we have seen a growth in the number of healthcare organizations making nurse residency programs a standard part of their professional development offerings. However, a new gap continues to strain this transition period. Workforce shortages are leaving healthcare organizations short-staffed, pushing healthcare organizations to speed up the orientation and training needed for new graduate nurses. At the same time, patient care continues to become more complex thanks to complicated technology integration and patients being sicker than ever before. 2 Not only are we seeing fewer nurses working in the clinical setting taking care of sicker patients, but the experience of those working clinically has also decreased. The National Nursing Workforce Survey conducted by the National Council State Boards of Nursing in partnership with the National Forum of State Nursing Workforce Centers reported a decrease from an average of 20 years of experience in the 2020 survey to 15 years of experience in 2022. 37.9% of the workforce sample have only been licensed for ten years or less, this being the highest since 2015. An additional 24.6% were licensed between 11 and 20 years, resulting in more than 62% of RNs reporting fewer than 20 years of experience. 37.6% of RNs reported being licensed for more than 20 years, nearly 10% points lower than in 2015 (47%). 1 What experts have termed the experience-complexity gap is making the transition from academic to practice more difficult than ever before. 2

Given the current healthcare landscape in which we don't just have a workforce shortage but an experience shortage, nurses must have the ability to not only carry out the hundreds of clinical competencies required to provide nursing care they must be able to assess situations, make sense of the information collected, decide on the best course of action, take action, and evaluate the outcomes of those actions independently. Whether you call it critical thinking, clinical reasoning, clinical decision-making, problem-solving, or clinical judgment, this competency is the most vital for nursing professionals today. While there are hundreds of other competencies nurse professionals need, this one demands nurse leaders' and nurse educators' attention, and thankfully, that is exactly what is happening.

Recently, I joined a group of academic and practice leaders strategically addressing the academic practice gap. The International Consortium for Outcomes of Nursing Education (ICONEd), led by Mary Ann Jesse, Ph.D., RN , Associate Professor, and Assistant Dean for Academics at Vanderbilt University School of Nursing, is actively looking at what competencies practice partners across the continuum expect NGNs to have upon entry to practice and how they are measured. More specifically, they are exploring how clinical judgment is assessed at the end of formal academic preparation and upon entry to practice by practice partners.

This group has been working quickly and making significant progress in conducting literature reviews and gathering important information from transition to practice program leadership and their accrediting bodies across the US and Canada. You can learn more about this group and the work being conducted on the website . While we wait for more to come, I encourage you to do an assessment at your own healthcare organization. What competencies do you expect your new graduate nurses to have upon entry into practice? How are they being assessed? Are your preceptors skilled in the expected assessment process? How are you assessing clinical judgment/critical thinking in your new graduate nurses? In addition, I encourage you to reach out to academic partners in your local area and start a discussion if you haven't already. Continuing to bridge the gap, supporting nurses during their transition into practice will take academic and practice partners working together.

Nicole Weathers, MSN, RN, NPD-BC

Iowa Online Nurse Residency Program Manager

[email protected]

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Smiley, R. A., Allgeyer, R. L., Shobo, Y., Lyons, K. C., Letourneau, R., Zhong, E., Kaminski-Ozturk, N., & Alexander, M. (2023). The 2022 National Nursing Workforce Survey. Journal of Nursing Regulation , 14 (1), S1-S90. https://doi.org/10.1016/S2155-8256(23)00047-9

Virkstis, K. (2023, March 20). America can’t hire enough nurses. But that’s not the only problem. Advisory Board. https://www.advisory.com/daily-briefing/2021/09/22/nursing-skills-gap