Notez On Nursing....: Nurse Critical Thinking

Assessing Individual Frontline Nurse Critical Thinking

Steven Berkow JD
Katherine Virkstis ND
Jennifer Stewart BA
Sarah Aronson AB
Meghan Donohue AB

JONA: Journal of Nursing Administration
April 2011
Volume 41 Number 4
Pages 168 - 171

Enhancing the critical thinking skills of frontline nurses has been a longstanding concern for hospital nursing leaders, but increased complexity of care now lends renewed urgency to this challenge. Rising patient acuity and decreasing length of stay contribute to an environment that challenges even tenured nurses long recognized as strong critical thinkers. To ensure safe patient care in a fast-paced care environment, nurse leaders must invest in more individualized development of key critical-thinking competencies. As part of a broader research initiative on elevating frontline critical thinking, the Nursing Executive Center has developed a diagnostic tool for assessing individual performance on 25 critical thinking skills. The authors discuss the tool's development, methodology, and potential applications.

Three forces-dramatic decrease in length of stay,1 heightened patient acuity,2 and an expanding set of clinical protocols that busy frontline nurses must implement3-combine to create a perfect storm: frontline nurses must accomplish more in less time. In this time-compressed, seemingly task-oriented care environment, it is challenging for frontline nurses to think critically about the care they deliver. Yet there is widespread agreement among nursing leaders that critical thinking is a frontline nurse competency essential to providing safe and effective care.

Research from the Nursing Executive Center suggests there is ample room for improvement in the critical thinking skills of all frontline staff: both new graduates and tenured nurses.3 Furthermore, critical thinking can be learned at any point during a nurse's tenure.4 Indeed, all nurses must readily see a holistic picture of their patients' conditions to recognize emerging clinical patterns and know when to intervene earlier. But what action should nursing leaders take to ensure frontline staff members do not default to a "checkbox" approach and continue to see the larger picture?

The first step in helping nurses meaningfully improve their critical thinking skills is identifying and providing feedback on specific strengths and weaknesses. Yet, only a small fraction of all hospitals currently measure the performance of individual staff nurses on discrete critical-thinking competencies. Although many organizations include a broad review of critical thinking in annual performance appraisals, only about 10% of nursing leaders reported that they routinely conduct a detailed assessment of specific critical-thinking competencies.3 However, a handful of tools have been developed to assess critical-thinking skills of nurses and nonnurses alike. These include the Performance-Based Development System (PBDS), clinical narratives, Watson Glaser Critical Thinking Appraisal, California Critical Thinking Skills Test, California Critical-Thinking Disposition Inventory, Adult Medical Nursing Critical Thinking Test, Assessment of Critical Thinking in Perioperative Nurses, Enis-Weir Critical Thinking Test, Cornell Critical-Thinking Test, and the HESI Exam.5-7

For the minority of hospitals and health systems routinely conducting critical-thinking assessments for frontline nurses, 2 methodologies predominate: PBDS and clinical narratives.3 The PBDS is a scenario-based, online competency assessment completed by frontline nurses. The tool assesses critical-thinking skills, interpersonal relations, and technical skills based on frontline nurse responses to clinical vignettes. Because the tool is scenario-based with a free-text format for responses, it can capture how participants think through and respond to a variety of clinical situations.5 Hospitals deploying clinical narratives ask staff nurses to recount a recent clinical experience and reflect on the care they provided, articulate outstanding questions, and contemplate lessons learned. The narratives are then reviewed by a panel of tenured nurses who have been identified as expert critical thinkers. These individuals assess the narrative along Dr Patricia Benner's8 novice-to-expert continuum.

Among the roughly 90% of interviewed nurse executives not assessing discrete critical-thinking competencies, nearly all cited a lack of time and resources as the primary barrier. This finding prompted Nursing Executive Center researchers to develop a third option for assessing frontline nurse critical thinking: the Critical Thinking Diagnostic.

Data and Methods

Identifying 25 Core Critical-Thinking Competencies

In summer 2009, the Nursing Executive Center began to develop the 25 competencies included in the Critical Thinking Diagnostic (Table 1) using an iterative process. More than 100 industry leaders-including hospital-based nurse executives, directors, managers, nursing school deans, faculty members, and nursing education association representatives-were interviewed by telephone and in person during the course of this process. The instrument was repeatedly revised until all recommendations had been considered and typically incorporated. To be included in the Diagnostic, a competency had to be specific and actionable and reflect current hospital demands. Importantly, these 25 nursing competencies do not comprise a comprehensive list of attributes potentially supporting critical thinking in nursing practice. Instead, they are intended to reflect the core skills found at the heart of critical thinking, as identified by nursing industry experts. The competencies included in the final list were grouped into 5 broader skill categories: problem recognition, clinical decision making, prioritization, clinical implementation, and reflection.