relationship of the nursing process to critical thinking

Critical thinking in nursing clinical practice, education and research: From attitudes to virtue

Affiliations.

• 1 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, Consolidated Research Group Quantitative Psychology (2017-SGR-269), University of Barcelona, Barcelona, Spain.
• 2 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, Consolidated Research Group on Gender, Identity and Diversity (2017-SGR-1091), University of Barcelona, Barcelona, Spain.
• 3 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, University of Barcelona, Barcelona, Spain.
• 4 Multidisciplinary Nursing Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Hospital, Barcelona, Spain.
• PMID: 33029860
• DOI: 10.1111/nup.12332

Critical thinking is a complex, dynamic process formed by attitudes and strategic skills, with the aim of achieving a specific goal or objective. The attitudes, including the critical thinking attitudes, constitute an important part of the idea of good care, of the good professional. It could be said that they become a virtue of the nursing profession. In this context, the ethics of virtue is a theoretical framework that becomes essential for analyse the critical thinking concept in nursing care and nursing science. Because the ethics of virtue consider how cultivating virtues are necessary to understand and justify the decisions and guide the actions. Based on selective analysis of the descriptive and empirical literature that addresses conceptual review of critical thinking, we conducted an analysis of this topic in the settings of clinical practice, training and research from the virtue ethical framework. Following JBI critical appraisal checklist for text and opinion papers, we argue the need for critical thinking as an essential element for true excellence in care and that it should be encouraged among professionals. The importance of developing critical thinking skills in education is well substantiated; however, greater efforts are required to implement educational strategies directed at developing critical thinking in students and professionals undergoing training, along with measures that demonstrate their success. Lastly, we show that critical thinking constitutes a fundamental component in the research process, and can improve research competencies in nursing. We conclude that future research and actions must go further in the search for new evidence and open new horizons, to ensure a positive effect on clinical practice, patient health, student education and the growth of nursing science.

Keywords: critical thinking; critical thinking attitudes; nurse education; nursing care; nursing research.

© 2020 John Wiley & Sons Ltd.

• Attitude of Health Personnel*
• Education, Nursing / methods
• Nursing Process
• Nursing Research / methods

Grants and funding

• PREI-19-007-B/School of Nursing. Faculty of Medicine and Health Sciences. University of Barcelona

Brain, Decision Making and Mental Health pp 179–189 Cite as

Critical Thinking in Nursing

• Şefika Dilek Güven 3  
• First Online: 02 January 2023

1032 Accesses

Part of the book series: Integrated Science ((IS,volume 12))

Critical thinking is an integral part of nursing, especially in terms of professionalization and independent clinical decision-making. It is necessary to think critically to provide adequate, creative, and effective nursing care when making the right decisions for practices and care in the clinical setting and solving various ethical issues encountered. Nurses should develop their critical thinking skills so that they can analyze the problems of the current century, keep up with new developments and changes, cope with nursing problems they encounter, identify more complex patient care needs, provide more systematic care, give the most appropriate patient care in line with the education they have received, and make clinical decisions. The present chapter briefly examines critical thinking, how it relates to nursing, and which skills nurses need to develop as critical thinkers.

Graphical Abstract/Art Performance

Critical thinking in nursing.

This painting shows a nurse and how she is thinking critically. On the right side are the stages of critical thinking and on the left side, there are challenges that a nurse might face. The entire background is also painted in several colors to represent a kind of intellectual puzzle. It is made using colored pencils and markers.

(Adapted with permission from the Association of Science and Art (ASA), Universal Scientific Education and Research Network (USERN); Painting by Mahshad Naserpour).

• Clinical decision-making
• Critical thinking
• Critical thinking skills
• Decision-making

Unless the individuals of a nation thinkers, the masses can be drawn in any direction. Mustafa Kemal Atatürk

This is a preview of subscription content, log in via an institution .

Buying options

• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Available as EPUB and PDF
• Compact, lightweight edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info
• Durable hardcover edition

Tax calculation will be finalised at checkout

Purchases are for personal use only

Bilgiç Ş, Kurtuluş Tosun Z (2016) Birinci ve son sınıf hemşirelik öğrencilerinde eleştirel düşünme ve etkileyen faktörler. Sağlık Bilimleri ve Meslekleri Dergisi 3(1):39–47

Article   Google Scholar  

Kantek F, Yıldırım N (2019) The effects of nursing education on critical thinking of students: a meta-analysis. Florence Nightingale Hemşirelik Dergisi 27(1):17–25

Ennis R (1996) Critical thinking dispositions: their nature and assessability. Informal Logic 18(2):165–182

Riddell T (2007) Critical assumptions: thinking critically about critical thinking. J Nurs Educ 46(3):121–126

Cüceloğlu D (2001) İyi düşün doğru karar ver. Remzi Kitabevi, pp 242–284

Google Scholar  

Kurnaz A (2019) Eleştirel düşünme öğretimi etkinlikleri Planlama-Uygulama ve Değerlendirme. Eğitim yayın evi, p 27

Doğanay A, Ünal F (2006) Eleştirel düşünmenin öğretimi. In: İçerik Türlerine Dayalı Öğretim. Ankara Nobel Yayınevi, pp 209–261

Scheffer B-K, Rubenfeld M-G (2000) A consensus statement on critical thinking in nursing. J Nurs Educ 39(8):352–359

Article   CAS   Google Scholar  

Rubenfeld M-G, Scheffer B (2014) Critical thinking tactics for nurses. Jones & Bartlett Publishers, pp 5–6, 7, 19–20

Gobet F (2005) Chunking models of expertise: implications for education. Appl Cogn Psychol 19:183–204

Ay F-A (2008) Mesleki temel kavramlar. In: Temel hemşirelik: Kavramlar, ilkeler, uygulamalar. İstanbul Medikal Yayıncılık, pp 205–220

Birol L (2010) Hemşirelik bakımında sistematik yaklaşım. In: Hemşirelik süreci. Berke Ofset Matbaacılık, pp 35–45

Twibell R, Ryan M, Hermiz M (2005) Faculty perceptions of critical thinking in student clinical experiences. J Nurs Educ 44(2):71–79

The Importance of Critical Thinking in Nursing. 19 November 2018 by Carson-Newman University Online. https://onlinenursing.cn.edu/news/value-critical-thinking-nursing

Suzanne C, Smeltzer Brenda G, Bare Janice L, Cheever HK (2010) Definition of critical thinking, critical thinking process. Medical surgical nursing. Lippincott, Williams & Wilkins, pp 27–28

Profetto-McGrath J (2003) The relationship of critical thinking skills and critical thinking dispositions of baccalaureate nursing students. J Adv Nurs 43(6):569–577

Elaine S, Mary C (2002) Critical thinking in nursing education: literature review. Int J Nurs Pract 8(2):89–98

Brunt B-A (2005) Critical thinking in nursing: an integrated review. J Continuing Educ Nurs 36(2):60–67

Carter L-M, Rukholm E (2008) A study of critical thinking, teacher–student interaction, and discipline-specific writing in an online educational setting for registered nurses. J Continuing Educ Nurs 39(3):133–138

Daly W-M (2001) The development of an alternative method in the assessment of critical thinking as an outcome of nursing education. J Adv Nurs 36(1):120–130

Edwards S-L (2007) Critical thinking: a two-phase framework. Nurse Educ Pract 7(5):303–314

Rogal S-M, Young J (2008) Exploring critical thinking in critical care nursing education: a pilot study. J Continuing Educ Nurs 39(1):28–33

Worrell J-A, Profetto-McGrath J (2007) Critical thinking as an outcome of context-based learning among post RN students: a literature review. Nurse Educ Today 27(5):420–426

Morrall P, Goodman B (2013) Critical thinking, nurse education and universities: some thoughts on current issues and implications for nursing practice. Nurse Educ Today 33(9):935–937

Raymond-Seniuk C, Profetto-McGrath J (2011) Can one learn to think critically?—a philosophical exploration. Open Nurs J 5:45–51

Download references

Author information

Authors and affiliations.

Nevşehir Hacı Bektaş Veli University, Semra ve Vefa Küçük, Faculty of Health Sciences, Nursing Department, 2000 Evler Mah. Damat İbrahim Paşa Yerleşkesi, Nevşehir, Turkey

Şefika Dilek Güven

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Şefika Dilek Güven .

Editor information

Editors and affiliations.

Universal Scientific Education and Research Network (USERN), Stockholm, Sweden

Nima Rezaei

Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Cite this chapter.

Güven, Ş.D. (2023). Critical Thinking in Nursing. In: Rezaei, N. (eds) Brain, Decision Making and Mental Health. Integrated Science, vol 12. Springer, Cham. https://doi.org/10.1007/978-3-031-15959-6_10

Download citation

DOI : https://doi.org/10.1007/978-3-031-15959-6_10

Published : 02 January 2023

Publisher Name : Springer, Cham

Print ISBN : 978-3-031-15958-9

Online ISBN : 978-3-031-15959-6

eBook Packages : Behavioral Science and Psychology Behavioral Science and Psychology (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

Fastest Nurse Insight Engine

• MEDICAL ASSISSTANT
• Abdominal Key
• Anesthesia Key
• Basicmedical Key
• Otolaryngology & Ophthalmology
• Musculoskeletal Key
• Obstetric, Gynecology and Pediatric
• Oncology & Hematology
• Plastic Surgery & Dermatology
• Clinical Dentistry
• Radiology Key
• Thoracic Key
• Veterinary Medicine
• Gold Membership

Critical Thinking, Clinical Judgment, and the Nursing Process

9 Critical Thinking, Clinical Judgment, and the Nursing Process Brenda Morris, EdD, RN, CNE OBJECTIVES At the completion of this chapter, the reader will be able to: •  Define critical thinking. •  Describe the components and characteristics of critical thinking. •  Understand the relationship of critical thinking to clinical judgment and the nursing process. •  Describe the steps of the nursing process and the relationships among those steps. •  Discuss nursing activities associated with each step of the nursing process. •  Evaluate the utility of the nursing process as a systematic framework for the delivery of nursing care. •  Apply critical thinking in nursing practice situations. The author acknowledges the important foundational work for this chapter developed by Dr. C. Fay Raines in the previous edition of this book. PROFILE IN PRACTICE Elizabeth R. Lenz PhD, RN, FAAN Dean and Professor, College of Nursing, The Ohio State University, Columbus, Ohio Critical thinking: it’s recognizable when someone does it well and certainly evident when it is not happening. During the past 20 years we have talked increasingly about critical thinking in nursing, but that wasn’t always the case. In the early 1960s, when I was entering the profession, serious efforts to change the “handmaiden” image of nursing were only just beginning. Clearly, if one’s role is defined as handmaiden, rather than as colleague or independent decision maker, critical thinking is not deemed particularly important or even desirable. Rather, blind, noncritical obedience is the order of the day. Fortunately, as nursing has become more truly professional and nurses have functioned with increasing autonomy in increasingly complex situations, critical thinking has become a most important and valued competency. What elements converge to produce a good critical thinker? It seems to me that there are several requisites, not the least of which is intelligence. However, even though intelligence is a necessary condition, critical thinking is not guaranteed to occur without training and a nourishing environment as well. We assume that critical thinking is something that can be learned; hence we address it at all levels of nursing curricula. Based on my experience, I believe that two essential types of learning provide the basis for critical thinking. The first is substantive. It is impossible to think truly critically about something you do not understand or about which you possess only partial information. Mastery of the theory and research findings that relate to the problem or issue to be addressed is critical, but this is not something that nurses always take time to achieve. Unfortunately, we have been less successful than other professions (namely, medicine) in socializing our practitioners to value learning as a career-long pursuit; yet pursuit of the most state-of-the-science information is an essential ingredient of critical thinking. The second type of learning involves the process of critical thinking itself. The skills of raising questions, using logic, and comprehensively considering alternative perspectives, explanations, and courses of action can often best be learned experientially within a structure that encourages and, in fact, mandates that kind of thoughtful consideration. The model that comes to mind is the daily medical rounds in which physicians-in-training are challenged to present cases and to lay out their diagnostic reasoning clearly for others to critique. Equally valid as an environment for cultivating critical thinking is that found in many of the social sciences and humanities, where freewheeling debate and open challenge of ideas are encouraged. At first frightened by that kind of candor during my doctoral studies in sociology, I later came to value greatly the critical input of my peers. More of that kind of willingness to challenge one another’s assumptions and ideas within an atmosphere of mutual respect would benefit our profession. For me, the groundwork for critical thinking was laid early in my education. Fortunately, the faculty responsible for the BSN program I attended were forward-thinking and highly committed to the emerging definition of nursing as a true profession, with the requisite obligation to base action on scientific knowledge and clear and logical thinking. Without labeling the goal as such, we were consistently encouraged, groomed, and enabled to be critical thinkers. We were continually challenged by being asked to provide rationales for our decisions, to make explicit all of the alternative approaches and explanations we had considered and rejected, and to explain why. Not inconsequentially, the school was in a small liberal arts institution, where we were exposed on a daily basis to a wide range of points of view and disciplinary perspectives and assumptions. If anything, the nursing students were the “oddballs” whose pragmatism and goal-directedness seemed strange to the arts, sciences, and music majors. I wrestled more than once with how in the world assignments such as dissecting the symbolism in Moby Dick might be relevant to my career in nursing, but I now appreciate the mind-expanding contribution that such activities made to my ability to think critically. The base hopefully having been laid during one’s professional education, critical thinking depends not only on training but also on an environment or context that enables, encourages, and rewards it. Regretfully, today’s employment picture in nursing is typically one with precious little time for contemplation. Downsizing, high proportions of nonprofessional personnel, high levels of acuity, and high productivity requirements may discourage critical thinking. That means every effort must be made to counter the tendency to let critical thinking slide and, instead, to encourage, nurture, and reward it, even if that means bucking the tide and incurring some additional short-term costs. The “community of scholars” type of environment to which top educational institutions aspire should, by definition, be conducive to critical thinking. Nevertheless, even in those settings, time and energy to engage in deliberation, to exchange ideas, and to critique those ideas openly are scarce, and the kind of culture that encourages such scholarly dialogue is relatively rare. When it is in place, it is wonderful. One of my most exciting opportunities to engage in intense and prolonged critical thinking occurred when a group of four colleagues and I were “freed up” from many of our routine responsibilities to plan a doctoral program “from scratch.” In weekly full-day sessions we argued, debated, challenged, cajoled, compromised, and created. We drew on what we knew substantively about nursing, science, philosophy, and the disciplines of our respective doctoral degrees (none of which were in nursing). It was hard work, but invigorating. The ground rules were that no idea was to be belittled or rejected out of hand; all perspectives were heard and considered. We were given time to think with minimal interruption and maximal flexibility; accordingly, the end product was excellent and the process truly energizing. Such time away from the routine is rarely available in today’s environment, but the model is certainly not without merit. Essential are a culture and leadership that permit and encourage critique without recrimination. In clinical settings, time to engage in deliberative critical thinking is even more difficult to attain. Rather, critical thinking seems to be expected to occur routinely without much cultivation. Benner’s model of progression from novice to expert suggests that excellent clinical experience fosters critical thinking that eventually becomes almost automatic and intuitive. However, I assert that the level of critical thinking displayed by clinical experts needs to be developed deliberately and strategically. The clinical environment in which I have seen critical thinking encouraged most effectively was one in which the expectations were explicit, critical thinking was measured routinely in the practice context, relevant learning and growth opportunities were provided, and critical thinking was taken into account in performance evaluation. In other words, the nursing leadership in that academic medical center truly valued critical thinking and was willing to assign it priority. Nursing has reached the point in its evolution in which a consistent and continuous pattern of critical thinking by its practitioners is a mandate—a sine qua non . The assurance that critical thinking will be truly woven into the fabric of our profession will depend on our ability to recruit and retain intelligent, interested, and committed nurses; to provide challenging educational opportunities that develop the requisite competencies; and to provide and sustain the kinds of environments in which critical thinking is valued and demanded. Introduction The ability to process information from multiple sources and make decisions is a fundamental ability of professional nursing practice. Dramatic changes in the health care system and the practice of nursing have occurred during the past decade as a result of an aging population, cost containment efforts, technological advances, increased complexity of clients’ health care needs, decreased average hospital length of stay, and a shift from acute care to community-based care. All of these changes have emphasized the need for professional nurses to think critically in order to provide safe and effective client care to diverse populations. To function effectively in complex, rapidly changing health care environments, nurses must use higher-order thinking skills and apply content knowledge to clinical practice. The critical thinking process provides nurses with the ability to use purposeful thinking and reflective reasoning to examine ideas, assumptions, principles, conclusions, beliefs, and actions in the context of professional nursing practice ( Brunt, 2005 ). Professional nurses must think critically to process complex data from multiple sources and make intelligent decisions in planning, managing, delivering, and evaluating the health care of their clients. Nurses also use their critical thinking skills to reduce health care errors and improve client safety ( Fero, Witsberger, Wesmiller, Zullo, & Hoffman, 2008 ). To become a critical thinker, a nurse must understand the concept of critical thinking; possess or acquire the essential knowledge, skills, and attributes required to think critically; and deliberately apply critical thinking principles in making clinical judgments. This chapter covers both classical and current sources to examine critical thinking, clinical judgment, and the nursing process. Defining Critical Thinking Critical thinking, as a concept, has been examined and presented from a variety of perspectives. An early definition, proposed by Watson and Glaser (1964) , described critical thinking as the combination of abilities needed to define a problem, recognize stated and unstated assumptions, formulate and select hypotheses, draw conclusions, and judge the validity of inferences. A less prescriptive definition was offered by Ennis (1989) , who characterized critical thinking as “reasonable reflective thinking focused on deciding what to believe or do” (p. 4). Paul (1992) stated that critical thinking is a process of disciplined, self-directed rational thinking that “certifies what we know and makes clear wherein we are ignorant” (p. 47). Alfaro-LeFevre (2006) presented critical thinking for nursing as informed, purposeful, and outcome-focused thinking that requires the ability to identify problems, issues, and risks and make judgments based on evidence. Bandman and Bandman (1995) describe critical thinking for nursing as “the rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs, and actions” (p. 7) and include the following functions: •  Discriminating among use and misuse of language •  Analyzing the meaning of terms •  Formulating nursing problems •  Analyzing arguments and issues into premises and conclusions •  Examining nursing assumptions •  Reporting data and clues accurately •  Making and checking inferences based on data •  Formulating and clarifying beliefs •  Verifying, corroborating, and justifying claims, beliefs, conclusions, decisions, and actions •  Giving relevant reasons for beliefs and conclusions •  Formulating and clarifying value judgments •  Seeking reasons, criteria, and principles that justify value judgments •  Evaluating the soundness of conclusions Conclusions are drawn as a result of this reasoning process. In nursing practice, the desired outcome of this reasoning is effective action. Conflicting viewpoints exist regarding whether critical thinking is subject specific or generalizable ( U.S. Department of Education, 1995 ). Most authors agree that the critical thinking processes are not discipline specific but, rather, are generalizable ( Ennis, 1987 ; Facione, 1990 ; Paul, 1992 ; Watson & Glaser, 1964 ). The same critical thinking skills of interpretation, analysis, inference, and evaluation are applied in different subjects. However, the difference lies in how the critical thinking processes are applied to specific disciplines. For example, professional nurses apply critical thinking skills to client care situations in order to make sound clinical judgments, whereas engineers apply critical thinking skills to business or industrial situations in order to make sound decisions. Meyers (1991) and McPeck (1990) believe that mastery of basic terms, concepts, and methodologies must occur before critical thinking skills can be developed. Ennis (1987) agrees that some familiarity with subject matter is necessary for the development of critical thinking; however, some principles of critical thinking bridge many disciplines and can transfer to new situations. An attempt to define critical thinking by consensus was begun in the late 1980s, and the results became known as the Delphi Report. The Delphi research project used an expert panel of theoreticians representing several disciplines from the United States and Canada to develop a conceptualization of critical thinking from a broad perspective ( Facione, 1990 ). The resulting work described critical thinking in terms of cognitive skills and affective dispositions. The outcome was a definition of critical thinking as the process of purposeful, self-regulatory judgments: an interactive, reflective reasoning process ( Facione & Facione, 1996 ). A critical thinker gives reasoned consideration to evidence, context, theories, methods, and criteria to form a purposeful judgment. At the same time, the critical thinker monitors, corrects, and improves the judgment. The Delphi project produced the following consensus definition from its panel of experts: We understand critical thinking (CT) to be purposeful, self-regulatory, judgment which results in interpretation, analysis, evaluation, and inference, as well as explanation of evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment is based. … CT is essential as a tool of inquiry. As such, CT is a liberating force in education and a powerful resource in one’s personal and civic life. ( American Philosophical Association, 1990 ) The Delphi participants identified core critical thinking skills as interpretation, analysis, inference, evaluation, and explanation. These critical thinking cognitive skills and subskills are listed in Box 9-1 . BOX 9-1     Critical Thinking Cognitive Skills and Subskills Interpretation Inference Categorization Querying evidence Decoding sentences Conjecturing alternatives Clarifying meaning Drawing conclusions Analysis Explanation Examining ideas Stating results Identifying arguments Justifying procedures Analyzing arguments Presenting arguments Evaluation Self-regulation Assessing claims Self-examination Assessing arguments Self-correction Critical Thinking in Nursing Scheffer and Rubenfeld (2000) replicated the Delphi study with a panel of 55 nurse educators to obtain a consensus definition of critical thinking for nursing. That study resulted in the identification of 17 dimensions of critical thinking and agreement on the definition of critical thinking for nursing as: … an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge. (p. 7) Although many areas overlap with the American Philosophical Association’s (1990) Delphi Report definition of critical thinking, some important differences also exist. According to Allen, Rubenfeld, and Scheffer (2004) , the dimensions of creativity, intuition, and transforming knowledge that are so crucial to effective clinical practice were not included in the Delphi Report definition. These dimensions emerged in the consensus definition of critical thinking for nursing. SUMMARY OF DEFINITIONS OF CRITICAL THINKING Although a universally accepted definition of critical thinking has not emerged, agreement exists that it is a complex process. The variety of definitions helps provide insight into the myriad dimensions of critical thinking. Commonalities in definitions include an emphasis on knowledge, cognitive skills, beliefs, actions, problem identification, and consideration of alternative views and possibilities ( Daly, 1998 ). The definitions presented earlier are summarized for comparison in Table 9-1 , and characteristics of critical thinking are listed in Box 9-2 . BOX 9-2     Characteristics of Critical Thinking Involves conceptualization Is rational and reasonable Is reflective Is partially attitudinal Is autonomous Includes creativity Is fair Focuses on what to believe and do From Wilkinson, J. M. (2001). Nursing process: A critical thinking approach (2nd ed.). Upper Saddle River, NJ: Prentice-Hall. TABLE 9-1 Definitions of Critical Thinking Author(s) Definition Watson and Glaser (1964) Combination of abilities needed to define problems, recognize assumptions, formulate and select hypotheses, draw conclusions, and judge validity of inferences Ennis (1989) Reasonable reflective thinking focused on deciding what to believe or do Paul (1992) Process of self-disciplined, self-directed, rational thinking that verifies what we know and clarifies what we do not know The Delphi Report ( American Philosophical Association, 1990 ); Facione, Facione, and Sanchez (1994) Purposeful, self-regulatory judgments resulting in interpretation, analysis, inference, evaluation, and explanation Bandman and Bandman (1995) Rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs, and actions Alfaro-LeFevre (2006) Informed, purposeful, and outcome-focused thinking that uses evidence to make clinical judgments The activities involved in the process of critical thinking include appraisal, problem solving, creativity, and decision making. The interrelationships among these concepts are illustrated in Figure 9-1 . These activities are embedded in the critical thinking process in both nursing education and nursing practice. FIGURE 9-1 Critical thinking model. (Modified from Strader, M. K., & Decker, P. J. [1995]. Role transition to patient care management. Upper Saddle River, NJ: Prentice-Hall.) CRITICAL THINKING AND THE NURSING PROCESS In nursing, critical thinking has often been portrayed as a rational, linear process that is synonymous with clinical judgment, problem solving, and the nursing process ( Ford & Profetto-McGrath, 1994 ; Huckabay, 2009 ; Jones & Brown, 1993 ; Kintgen-Andrews, 1991 ; Wilkinson, 1996 ). However, some critics believe that the problem-solving emphasis of the nursing process constrains critical thinking because it does not incorporate the creativity and open-mindedness components of critical thinking ( Conger & Mezza, 1996 ; Duchscher, 1999 ; Jones & Brown, 1993 ; Miller & Malcolm, 1990 ). Although critical thinking skills are important components of the nursing process and problem solving, these are not synonymous terms. The nursing process serves as a tool for applying critical thinking to nursing practice. The nurse uses critical thinking throughout the nursing process, by sorting and categorizing data; identifying patterns in the data; drawing inferences; developing hypotheses that are stated in the form of outcomes; testing these hypotheses as care is delivered; and making criterion-based judgments of effectiveness. Therefore critical thinking can distinguish between fact and fiction, providing a rational basis for clinical judgments and the delivery of nursing care. Although an argument can be made that the nursing process constrains critical thinking because of its structured format, general agreement exists that critical thinking skills and subskills are evident throughout the nursing process ( Alfaro-LeFevre, 2006 ). Although the components of the nursing process are described as separate and distinct steps, they become an integrated way of thinking as nurses gain more clinical experience. An overview of critical thinking throughout the nursing process is presented in Table 9-2 . A thorough understanding of the nursing process reveals that critical thinking is indeed an integral part of its most effective use. TABLE 9-2 Overview of Critical Thinking Throughout the Nursing Process Nursing Process Critical Thinking Assessment Observing Distinguishing relevant from irrelevant data Distinguishing important from unimportant data Validating data Organizing data Categorizing data Analysis/diagnosis Finding patterns and relationships Making inferences Stating the problem Suspending judgment Planning Generalizing Transferring knowledge from one situation to another Developing evaluative criteria Hypothesizing Implementation Applying knowledge Testing hypotheses Evaluation Deciding whether hypotheses are correct Making criterion-based evaluations and judgments Modified from Wilkinson, J. M. (2001). Nursing process: A critical thinking approach (2nd ed.). Upper Saddle River, NJ: Prentice-Hall. The Nursing Process The nursing process is a systematic, problem-solving approach used extensively in the United States and Canada for the delivery of nursing care. The nursing process was first described in the literature in 1955 by Lydia Hall. Her approach was built around three interrelated spheres of nursing activity: care, core, and cure. The focus in the care sphere is the body, including assessment and evaluation of the client’s ability to perform basic functions and activities of daily living. The focal point in the core sphere was on the therapeutic use of self in providing nursing care, whereas nursing activities related to the cure sphere centered on the administration of treatments and therapies, as well as supporting the patient and family during the treatment process. Subsequently, many others have described a “nursing process,” but the model that has withstood the test of time is that developed by Yura and Walsh (1988) . They proposed a four-step nursing process model that consisted of assessing, planning, implementing, and evaluating. The current model closely resembles the Yura and Walsh model, but with the addition of a diagnostic component. The five-step nursing process consists of the following elements: •  Assessment —gathering and validating client health data, strengths, risks, and concerns •  Analysis/diagnosis —processing client data and identifying appropriate nursing diagnoses •  Planning —designing strategies to solve identified problems and build on client strengths •  Implementation —delivering and documenting the planned care •  Evaluation —determining the effectiveness of the care delivered The American Nurses Association (ANA), in its publication Nursing: Scope and Standards of Practice (2004), parallels the steps of the nursing process and supports its use. Outcome identification, which follows the nursing diagnosis phase and precedes the planning phase, is identified as a separate step in the ANA model. The nursing process is sometimes depicted as a systematic, linear model proceeding from assessment through diagnosis, planning, implementation, and evaluation. It is more appropriately conceptualized as a continuous and interactive model ( Figure 9-2 ), thereby providing a flexible and dynamic approach to client care. This model can accommodate changes in the client’s health status or failure to achieve expected outcomes through a feedback mechanism. The interactive nature of the model with its feedback mechanism permits the nurse to reenter the nursing process at the appropriate stage to collect additional data, restructure nursing diagnoses, design a new plan, or change implementation strategies. This model is consistent with the concept of critical thinking as a continuous reflective process. Further examination of the elements of the nursing process reveals the multiple activities embedded in each step. FIGURE 9-2 The interactive nursing process model. (Modified from Christensen, P. J., & Kenney J. W. [1995]. Nursing process: Application of conceptual models [4th ed.], St. Louis: Mosby.) ASSESSMENT In the assessment phase, the nurse deliberately and systematically collects data to determine the client’s health, functional status, strengths, and risk factors ( Carpenito, 2008 ). Data collection centers on the use of multiple sources and types of data, a variety of data collection techniques, and the use of reliable and valid measurement instruments. All these elements are critical to building a comprehensive database. Sources of Data The primary source of data is the client, whether the client is defined as the individual, the family, or the community. Secondary sources of data include written records, other health care providers, and significant others (e.g., family members, friends). To strengthen the overall assessment and validate client data, it is important to use primary and secondary data sources. Data Collection Techniques Assessment techniques include measurement, observation, and interview. Measurement is used to determine the dimensions of a given indicator (e.g., blood pressure) or to ascertain characteristics such as quantity, size, or frequency. Measurement may require the use of specialized equipment (e.g., stethoscope, thermometer) or specialized assessment tools (e.g., pain scale, depression scale) to assess functional, behavioral, social, or cognitive domains. Data collection by observation requires the use of the senses, including visual observation and tactile (palpation) and auditory techniques (auscultation). Observation provides a variety and depth of data that may be difficult to obtain by other methods. A structured or unstructured interview may be used to obtain information such as a health history and demographic data. A structured interview is commonly used in emergency situations when the nurse needs to gather specific information. An unstructured interview is commonly used in situations in which the nurse wishes to elicit information from the client’s perspective or gain insight to the client’s understanding of a problem. The unstructured interview allows the nurse to use active listening skills while building rapport with the client through the use of an open-ended interview format. These communication techniques are discussed in chapter 8 Types of Data To complete a comprehensive assessment, objective and subjective data are obtained. Objective data are factual data, usually obtained through observation or measurement. An example of objective data occurs when the nurse uses an otoscope to assess the client’s tympanic membrane and observes that it is reddened and inflamed. Subjective data are based on the client’s perception of the health problem. An example of subjective data occurs when the client states that he is having pain in his right ear. It is important to collect both objective and subjective data to complete a comprehensive assessment. Care should be taken to record data factually and to avoid personal or biased interpretations. Data Collection Instruments The use of selected data collection measures and instruments can assist the nurse in compiling a comprehensive database and organizing data into meaningful patterns. Assessment usually begins by taking a nursing history and conducting a physical examination. Many clinical areas have developed nursing history and physical forms specific to the type of agency and the clients served. Regardless of the format, the nursing database should include the following categories of information ( Edelman & Mandle, 1994 ): •  Demographic data •  Current and past medical problems •  Family medical history •  Surgical and (if appropriate) obstetrical history •  Childhood illnesses •  Allergies •  Current medications •  Psychological status •  Social history •  Environmental background •  Physical assessment

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related posts:

• Genetics and Genomics in Professional Nursing
• Intimate Partner Violence as a Health Care Problem
• Ethical Dimensions of Nursing and Health Care
• Theories and Frameworks for Professional Nursing Practice

Stay updated, free articles. Join our Telegram channel

Comments are closed for this page.

Full access? Get Clinical Tree

What is Critical Thinking in Nursing? (With Examples, Importance, & How to Improve)

Successful nursing requires learning several skills used to communicate with patients, families, and healthcare teams. One of the most essential skills nurses must develop is the ability to demonstrate critical thinking. If you are a nurse, perhaps you have asked if there is a way to know how to improve critical thinking in nursing? As you read this article, you will learn what critical thinking in nursing is and why it is important. You will also find 18 simple tips to improve critical thinking in nursing and sample scenarios about how to apply critical thinking in your nursing career.

What Is Critical Thinking In Nursing?

4 reasons why critical thinking is so important in nursing, 1. critical thinking skills will help you anticipate and understand changes in your patient’s condition., 2. with strong critical thinking skills, you can make decisions about patient care that is most favorable for the patient and intended outcomes., 3. strong critical thinking skills in nursing can contribute to innovative improvements and professional development., 4. critical thinking skills in nursing contribute to rational decision-making, which improves patient outcomes., what are the 8 important attributes of excellent critical thinking in nursing, 1. the ability to interpret information:, 2. independent thought:, 3. impartiality:, 4. intuition:, 5. problem solving:, 6. flexibility:, 7. perseverance:, 8. integrity:, examples of poor critical thinking vs excellent critical thinking in nursing, 1. scenario: patient/caregiver interactions, poor critical thinking:, excellent critical thinking:, 2. scenario: improving patient care quality, 3. scenario: interdisciplinary collaboration, 4. scenario: precepting nursing students and other nurses, how to improve critical thinking in nursing, 1. demonstrate open-mindedness., 2. practice self-awareness., 3. avoid judgment., 4. eliminate personal biases., 5. do not be afraid to ask questions., 6. find an experienced mentor., 7. join professional nursing organizations., 8. establish a routine of self-reflection., 9. utilize the chain of command., 10. determine the significance of data and decide if it is sufficient for decision-making., 11. volunteer for leadership positions or opportunities., 12. use previous facts and experiences to help develop stronger critical thinking skills in nursing., 13. establish priorities., 14. trust your knowledge and be confident in your abilities., 15. be curious about everything., 16. practice fair-mindedness., 17. learn the value of intellectual humility., 18. never stop learning., 4 consequences of poor critical thinking in nursing, 1. the most significant risk associated with poor critical thinking in nursing is inadequate patient care., 2. failure to recognize changes in patient status:, 3. lack of effective critical thinking in nursing can impact the cost of healthcare., 4. lack of critical thinking skills in nursing can cause a breakdown in communication within the interdisciplinary team., useful resources to improve critical thinking in nursing, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. will lack of critical thinking impact my nursing career, 2. usually, how long does it take for a nurse to improve their critical thinking skills, 3. do all types of nurses require excellent critical thinking skills, 4. how can i assess my critical thinking skills in nursing.

• Ask relevant questions • Justify opinions • Address and evaluate multiple points of view • Explain assumptions and reasons related to your choice of patient care options

5. Can I Be a Nurse If I Cannot Think Critically?

• school Campus Bookshelves
• menu_book Bookshelves
• perm_media Learning Objects
• login Login
• how_to_reg Request Instructor Account
• hub Instructor Commons
• Download Page (PDF)
• Download Full Book (PDF)
• Periodic Table
• Physics Constants
• Scientific Calculator
• Reference & Cite
• Tools expand_more
• Readability

selected template will load here

This action is not available.

1.3: Critical Thinking and Clinical Reasoning

• Last updated
• Save as PDF
• Page ID 63335

• Ernstmeyer & Christman (Eds.)
• Chippewa Valley Technical College via OpenRN

Before learning how to use the nursing process, it is important to understand some basic concepts related to critical thinking and nursing practice. Let’s take a deeper look at how nurses think.

Critical Thinking and Clinical Reasoning

Nurses make decisions while providing patient care by using critical thinking and clinical reasoning. Critical thinking is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” [1] Using critical thinking means that nurses take extra steps to maintain patient safety and don’t just “follow orders.” It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research.

“Critical thinkers” possess certain attitudes that foster rational thinking. These attitudes are as follows:

• Independence of thought: Thinking on your own
• Fair-mindedness: Treating every viewpoint in an unbiased, unprejudiced way
• Insight into egocentricity and sociocentricity: Thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
• Intellectual humility: Recognizing your intellectual limitations and abilities
• Nonjudgmental: Using professional ethical standards and not basing your judgments on your own personal or moral standards
• Integrity: Being honest and demonstrating strong moral principles
• Perseverance: Persisting in doing something despite it being difficult
• Confidence: Believing in yourself to complete a task or activity
• Interest in exploring thoughts and feelings: Wanting to explore different ways of knowing
• Curiosity: Asking “why” and wanting to know more

Clinical reasoning is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.” To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. [3]

The ANA’s Standards of Professional Nursing Practice associated with each component of the nursing process are described below.

Assessment is the first step of the nursing process. The American Nurses Association (ANA) “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.”    This includes collecting “pertinent data related to the health and quality of life in a systematic, ongoing manner, with compassion and respect for the wholeness, inherent dignity, worth, and unique attributes of every person, including but not limited to, demographics, environmental and occupational exposures, social determinants of health, health disparities, physical, functional, psychosocial, emotional, cognitive, spiritual/transpersonal, sexual, sociocultural, age-related, environmental, and lifestyle/economic assessments.” [1]

A registered nurse uses a systematic method to collect and analyze patient data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. For example, a nurse’s assessment of a hospitalized patient in pain includes the patient’s response to pain, such as the inability to get out of bed, refusal to eat, withdrawal from family members, or anger directed at hospital staff. Nurses assess patients to gather clues, make generalizations, and diagnose human responses to health conditions and life processes. Patient data is considered either subjective or objective, and it can be collected from multiple sources.

The “Diagnosis” Standard of Practice is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.” [13] A nursing diagnosis is the nurse’s clinical judgment about the client's response to actual or potential health conditions or needs. Nursing diagnoses are the bases for the nurse’s care plan and are different than medical diagnoses.

Outcomes Identification

The “Outcomes Identification” Standard of Practice is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the patient based on their assessment data and nursing diagnoses.

The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” [16] Assessment data, diagnoses, and goals are used to select evidence-based nursing interventions customized to each patient’s needs and concerns. Goals, expected outcomes, and nursing interventions are documented in the patient’s nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care. [17]

Nursing Care Plans

Creating nursing care plans is a part of the “Planning” step of the nursing process. A nursing care plan is a type of documentation that demonstrates the individualized planning and delivery of nursing care for each specific patient using the nursing process. Registered nurses (RNs) create nursing care plans so that the care provided to the patient across shifts is consistent among health care personnel. 

Implementation

The “Implementation” Standard of Practice is defined as, “The nurse implements the identified plan.” Nursing interventions are implemented or delegated with supervision according to the care plan to assure continuity of care across multiple nurses and health professionals caring for the patient. Interventions are also documented in the patient’s electronic medical record as they are completed.

The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” During evaluation, nurses assess the patient and compare the findings against the initial assessment to determine the effectiveness of the interventions and overall nursing care plan. Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated and modified as needed.

Benefits of Using the Nursing Process

Using the nursing process has many benefits for nurses, patients, and other members of the health care team. The benefits of using the nursing process include the following:

• Promotes quality patient care
• Decreases omissions and duplications
• Provides a guide for all staff involved to provide consistent and responsive care
• Encourages collaborative management of a patient’s health care problems
• Improves patient safety
• Improves patient satisfaction
• Identifies a patient’s goals and strategies to attain them
• Increases the likelihood of achieving positive patient outcomes
• Saves time, energy, and frustration by creating a care plan or path to follow

By using these components of the nursing process as a critical thinking model, nurses plan interventions customized to the patient’s needs, plan outcomes and interventions, and determine whether those actions are effective in meeting the patient’s needs. In the remaining sections of this chapter, we will take an in-depth look at each of these components of the nursing process. Using the nursing process and implementing evidence-based practices are referred to as the “science of nursing.” Let’s review concepts related to the “art of nursing” while providing holistic care in a caring manner using the nursing process.

Holistic Nursing Care

The American Nurses Association (ANA) recently updated the definition of nursing as, “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.”

The ANA further describes nursing is a learned profession built on a core body of knowledge that integrates both the art and science of nursing. The art of nursing is defined as, “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.”

Nurses care for individuals holistically, including their emotional, spiritual, psychosocial, cultural, and physical needs. They consider problems, issues, and needs that the person experiences as a part of a family and a community as they use the nursing process. 

Caring and the Nursing Process

The American Nurses Association (ANA) states, “The act of caring is foundational to the practice of nursing.” Successful use of the nursing process requires the development of a care relationship with the patient. A care relationship is a mutual relationship that requires the development of trust between both parties. This trust is often referred to as the development of rapport and underlies the art of nursing. While establishing a caring relationship, the whole person is assessed, including the individual’s beliefs, values, and attitudes, while also acknowledging the vulnerability and dignity of the patient and family. Assessing and caring for the whole person takes into account the physical, mental, emotional, and spiritual aspects of being a human being.   Caring interventions can be demonstrated in simple gestures such as active listening, making eye contact, touching, and verbal reassurances while also respecting and being sensitive to the care recipient’s cultural beliefs and meanings associated with caring behaviors. 

• Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41 (4), 215-221. ↵
• Powers, L., Pagel, J., & Herron, E. (2020). Nurse preceptors and new graduate success. American Nurse Journal, 15 (7), 37-39. ↵
• “ The Detective ” by paurian is licensed under CC BY 2.0 ↵
• “ In the Quiet Zone… ” by C.O.D. Library is licensed under CC BY-NC-SA 2.0 ↵
• NCSBN. (n.d.). NCSBN clinical judgment model . https://www.ncsbn.org/14798.htm ↵
• American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
• “ The Nursing Process ” by Kim Ernstmeyer at Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
• “Patient Image in LTC.JPG” by ARISE project is licensed under CC BY 4.0 ↵
• American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/ ↵
• American Nurses Association. (n.d.). The nursing process . https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/ ↵
• American Nurses Association. (2021). Nursing: Scope and standards of practice (3rd ed.). American Nurses Association. ↵
• American Nurses Association. (n.d.) The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process / ↵
• American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process / ↵
• Walivaara, B., Savenstedt, S., & Axelsson, K. (2013). Caring relationships in home-based nursing care - registered nurses’ experiences. The Open Journal of Nursing, 7 , 89-95. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722540/pdf/TONURSJ-7-89.pdf ↵
• “ hospice-1793998_1280.jpg ” by truthseeker08 is licensed under CC0 ↵
• Watson Caring Science Institute. (n.d.). Watson Caring Science Institute. Jean Watson, PHD, RN, AHN-BC, FAAN, (LL-AAN) . https://www.watsoncaringscience.org/jean-bio/ ↵

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Lippincott Open Access
• PMC10241415

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