New graduate = must meet expectations on subcategory 1–4.
Subcategory 6 is rated as met/did not meet expectations; rating is shared with unit preceptor but not included in overall rating
The PBDS overall assessment rating (met or did not meet expectations) was developed using a three-step process. Those taking the assessment were first given a preset amount of time to view a series of 10 videotaped vignettes depicting common clinical problems and write their responses. The nurse rater next determined if the nurse met expectations for each vignette using the method illustrated in Table 2 . Using an organizational algorithm reflecting patterns of inconsistency and safety in the answers that was based on the ability to meet expectations in each of the subcategories, the nurse rater then determined an overall assessment rating (met/did not meet expectations) for each nurse. When learning needs were identified, they were included in a summary given to the preceptor, along with an action plan to guide clinical orientation activities. The individual summary and action plan was sent to the unit manager and nurse educator to share with the orientee and preceptor. The nurse raters ( n = 5) all had Master’s degrees and over 10 years of clinical experience, and completed 9–12 months of PBDS rater training. Annual assessments were performed to determine inter-rater reliability and to validate rater competence. One nurse was assigned to rate all subcategories of each assessment. The department rates over 1000 PBDS assessments per year.
Reliability and validity of the PBDS assessment have been reported in previous publications ( del Bueno 1990 , 1994 , 2001 , 2005 ). Reliability estimates for the clinical vignettes, obtained using an equivalence approach, averaged 94% for individuals tested in parallel situations ( del Bueno 1990 ).
Approval for the study was obtained from a university institutional review board. Study data were de-identified; therefore participant consent was not required.
Descriptive statistics were calculated using SPSS, version 14.0. Descriptive data were available for the entire sample and included years of experience, academic preparation, and the overall assessment rating. Of the 539 nurses who did not meet expectations, 103 (19.1%) did not have complete subcategory scores and therefore were excluded when analyzing these scores. The chi-square test for independence likelihood ratio and Pearson chi-square were used to analyze differences in years of experience and level of preparation. The likelihood ratio was used because of the large sample size. The level of statistical significance was set a priori at 0.05.
Of the sample, 31.4% were diploma graduates, 41.0% associate degree graduates and 27.6% baccalaureate graduates ( Table 1 ). The majority (56.5%) were new graduates, defined as having ≤1 year of experience, while 24.5% had 10 or more years of experience.
The majority of newly hired nurses (74.9%) met expectations on the PBDS assessment. Of those who did not meet expectations, 436 (81%) had complete subcategory information. PBDS results indicated that 97.2% did not initiate appropriate nursing interventions, 67.0% did not differentiate urgency, 65.4% did not report essential clinical data, 62.8% did not anticipate relevant medical orders, 62.6% did not understand their decision rationale and 57.1% were deficient in problem recognition. Figure 1 summarizes the percentage of newly hired nurses not meeting expectations by subcategory and level of preparation.
Percentage of the sample ( n = 436) not meeting expectations by subcategory and level of preparation.
New graduates comprised 56.5% ( n = 1211) of the sample. The remaining nurses were categorized into >1 but <5 years of experience ( n = 197), ≥5 but <10 years of experience ( n = 211) and ≥10 years of experience ( n = 525). Years of experience differed statistically significantly in those meeting or failing to meet expectations (χ 2 = 21.631, d.f. = 3, P < 0.0004): those with the least experience had the highest rate of not meeting expectations, while those with the most experience had the lowest rate.
Controlling for level of preparation (diploma, associate, baccalaureate), rates at which nurses met expectations differed statistically significantly in those prepared at associate (χ 2 = 12.085, d.f. = 3, P = 0.007) and baccalaureate levels (χ 2 = 18.498, d.f. = 3, P < 0.0001) based on years of experience. Of these, 29.6% of the new graduates prepared at the baccalaureate level did not meet expectations on the PBDS, whereas only 11.5% with ≥10 years did not meet expectations ( Figure 2 ). At the associate level 31.0% of the new graduates did not meet expectations whereas 18.3% with ≥10 years did not meet expectations. In contrast, there were no statistically significant differences in the rate of meeting expectations for nurses prepared at the diploma level based on years of experience (χ 2 = 6.259, d.f. = 3, P = 0.100).
Percentage of the sample ( n = 539) not meeting expectations on the Performance Based Development System by years of experience and degree.
There was no statistically significant difference in the rate of meeting or not meeting expectations with regard to level of preparation when the data were analyzed for the total sample (χ 2 = 4.886, d.f. = 2, P = 0.087). However, on controlling for years of experience, new graduates (χ 2 = 6.158, d.f. = 2, P = 0.046) and nurses with ≥10 years of experience (χ 2 = 6.179, d.f. = 2, P = 0.046) differed statistically significantly in pass rates (in those with ≥10 years of experience, the likelihood ratio was statistically significant at P = 0.046, but the Pearson chi-square was not ( P = 0.055). New graduates prepared at the associate level did not meet expectations 31.0% of the time as compared with the baccalaureate (29.6%) and the diploma (23.6%) prepared graduates ( Figure 3 ). In nurses with ≥10 years of experience, those prepared at the diploma level did not meet expectations 22.0% of the time as compared with the associate (18.3%) and baccalaureate (11.5%).
Percentage of the sample ( n = 539) not meeting expectations on the Performance Based Development System by degree and years of experience.
This study had a number of limitations. The analysis was limited to data collected at the time of the PBDS assessment, i.e. level of preparation and years of nursing experience. Additional information on age, gender, prior healthcare experience in addition to nursing, employment location, and length of employment was not available. These and other potential predictor variables should be considered in future studies. The six subcategories delineating the reasons that newly hired nurses did not meet expectations on the assessment did not have complete data in 19.1% of cases. It is possible that these individuals differed from others with complete subcategory data. Finally, the assessment was based on simulated vignettes, and it is possible that actual clinical decision-making may have differed from the stated actions.
The results suggest that a substantial minority of these newly hired nurses had identified learning needs with regard to their ability to make appropriate decisions when asked to assess a clinically focused vignette. Overall, approximately 25% of nurses participating in the assessment were not able to recognize the clinical problem, safely prioritize care and implement independent nursing interventions. They appeared to have difficulty reporting relevant clinical data and anticipating medical orders, and were not able to convey clearly a rationale for their decision-making. It is unclear from the assessment process whether this resulted from lack of knowledge, lack of sufficient time to respond, or not completely presenting their rationale in writing. Nevertheless, it emphasizes the importance of continued assessment, mentoring and coaching to improve and validate decision-making skills.
The percentage of new graduates not meeting expectations in the present study did not fall within the range of previously published results ( del Bueno 2005 ). In a study by del Bueno (2005) , from a sample size of 10,988 inexperienced nurses (<1 year of experience) sampled between 1995 and 2004, between 65% and 76% did not meet expectations on the PBDS assessment. Of the 20,413 experienced nurses sampled in the same study, those not meeting expectations ranged between 8% and 69%. Experienced nurses not meeting expectations in the present study ranged from 18.3% to 25.1%. Areas of deficiency on subcategories from their reports were consistent with the present study.
Our findings suggest that, as would be anticipated, nurses with more years of experience were more likely to meet expectations on the PBDS assessment. However, there were differences related to level of preparation. Specifically, those with more experience who were prepared at the baccalaureate or associate level fared better on the assessment than experienced nurses with diploma level preparation. This finding may have resulted from differences in the scope of experience and/or commitment to continuing education fostered by the educational programme. Whether these or other reasons explain the differences are speculative, as our data did not suggest an explanation. This finding is not consistent with previous studies reporting PBDS results. In a study published in 2005, del Bueno reported that after 10 years of analysis there are no consistent findings which indicate differences in clinical judgment ability based on educational preparation or credentialing. Our findings, nevertheless, support a difference in testing outcome based on level of preparation. Further exploration is needed to determine the potential reasons for our results. Possible explanations include the value of and access to advancement via nursing education, the organizational emphasis placed on continuing education, or previous clinical experience.
Our findings support Benner’s conceptualization in her novice to expert framework ( Benner 1984 ). Nurses with more experience were better able to identify appropriate actions when viewing the clinical vignettes, as would be expected. While it is of concern that a substantial minority of newly hired nurses did not meet expectations, it is important to emphasize that 75% were able to state actions that indicated their ability to manage critical situations independently and anticipate the care needed. They were able to prioritize clinical needs, consider potential actions and modify the plan of care based on prior experience. As might be anticipated, new graduates had a higher rate of not meeting expectations and struggled with the ability to make and implement independent nursing interventions in these same clinical scenarios.
Alternative critical thinking assessment methods are coming into vogue, e.g. high fidelity human simulation (HFHS) ( Henrichs et al. 2002 , Nehring et al. 2002 , Parr & Sweeney 2006 ). HFHS may be a better option for assessing critical thinking and decision-making as it provides evaluation activities that are more interactive and offers the added benefit of debriefing to facilitate learning ( Henrichs et al. 2002 , Feingold et al. 2004 , Bearnson & Wiker 2005 , O’Donnell et al. 2005 , Trossman 2005 ). Like the PBDS assessment, the HFHS can be used as a group learning tool without patient risk ( Schwid et al. 2002 ). HFHS provides a more realistic assessment that includes the ability to assess blood pressure, palpable pulses, heart sounds, breath sounds. In addition, it offers the ability to programme responses that mimic physiological actions and patient responses to the timing and selection of interventions ( Euliano 2001 , Lupien & George-Gay 2001 , Kozlowski 2004 ). Accordingly, HFHS may facilitate assessment of critical thinking and decision-making ( Duchscher 2003 ). Studies comparing the various methods of assessment remain few in number and therefore it is not possible to determine objectively which approach is the most valid and cost-effective for assessing the learning needs of new graduates and experienced nurses.
Assessments such as PBDS can provide information about learning needs and facilitate individualized orientation targeted to increase performance level. Evaluation of clinical competence is difficult, as there are few measures that capture how a nurse will perform in an actual clinical emergency when rapid decisions must be made in a complex and emotionally charged environment. Further research is needed to identify further specific areas of deficiency and begin to test objective, innovative educational strategies to enhance the critical thinking ability of both new graduates and experienced nurses. Although a time-intensive endeavor, the outcome has the potential to contribute greatly to the advancement of nursing practice and safe patient care.
The lead author was recipient of the T-32 Technology Grant: Research in Chronic and Critical Illness (T32 NR008857) Pre-Doctoral Fellowship for Doctoral Study at the University of Pittsburg, PA, USA.
Author contributions
Laura J. Fero, Doctoral Candidate, University of Pittsburgh School of Nursing, Pennsylvania, USA.
Catherine M. Witsberger, Clinical Nurse Educator, Nursing Education and Research, University of Pittsburgh Medical Center, Pennsylvania, USA.
Susan W. Wesmiller, Director, Nursing Education and Research, University of Pittsburgh Medical Center, Pennsylvania, USA.
Thomas G. Zullo, Professor Emeritus, Dental Public Health, University of Pittsburgh, Pennsylvania, USA.
Leslie A. Hoffman, Professor and Chair, Department of Acute/Tertiary Care, University of Pittsburgh School of Nursing, Pennsylvania, USA.
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What is Critical Thinking in Nursing? (With Examples, ...
Critical Thinking in Nursing: Developing Effective Skills | ANA
The Value of Critical Thinking in Nursing
Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process. Effective thinking in nursing involves the integration of clinical knowledge and critical thinking to make the best decisions for patients. For example, if a nurse was caring for a patient ...
Here are some examples of how nurses can apply critical thinking. Assess Patient Data: Critical Thinking Action: Carefully review patient history, symptoms, and test results. Example: A nurse notices a change in a diabetic patient's blood sugar levels. Instead of just administering insulin, the nurse considers recent dietary changes, activity levels, and possible medication interactions ...
Developing critical-thinking skills involves continuous learning, reflection on practice, openness to diverse perspectives, and structured problem-solving approaches like SWOT analysis. These skills mature with experience, enabling nurses to navigate complex healthcare scenarios effectively.
Key Nursing Critical Thinking Skills. Some of the most important critical thinking skills nurses use daily include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Interpretation: Understanding the meaning of information or events. Analysis: Investigating a course of action based on objective and subjective data.
2. CRITICAL THINKING SKILLS. Nurses in their efforts to implement critical thinking should develop some methods as well as cognitive skills required in analysis, problem solving and decision making ().These skills include critical analysis, introductory and concluding justification, valid conclusion, distinguishing facts and opinions to assess the credibility of sources of information ...
2. Meeting with Colleagues: Collaborative Learning for Critical Thinking. Regular interactions with colleagues foster a collaborative learning environment. Sharing experiences, discussing diverse viewpoints, and providing constructive feedback enhance critical thinking skills. Colleagues' insights can challenge assumptions and broaden ...
Critical thinking in nursing involves the ability to question assumptions, analyze data, and evaluate outcomes. It's a disciplined process that includes observation, experience, reflection, reasoning, and communication. For nurses, critical thinking means being able to make sound clinical judgments that can significantly affect patient outcomes.
Critical thinking is the process of applying logic and reason to make decisions or solve problems. The ability to think critically will help you make better decisions on your own and collaborate with others when solving problems - both are essential skills for nurses. Nursing has always been a profession that relies on critical thinking.
Clinical Reasoning, Decisionmaking, and Action: Thinking ...
Tips to improve your critical thinking skills in nursing. Here are several tips to enhance your critical thinking skills as a nurse: 1. Ask patients open-ended questions. It's important to give all patients the same standard of care. Asking patients to elaborate on their medical history or point of view may help you communicate more effectively ...
To investigate the impact of web-based concept mapping education on nursing students' critical-thinking and concept-mapping skills. 34: Zarshenas et al., 2019 : n = 90: 2 h for 6 days: Problem-solving: To investigate how training problem-solving skills affected the rate of self-handicapping among nursing students. 33: Svellingen et al., 2021 ...
Nursing critical thinking skills drive the decision-making process and impact the quality of care provided," says Georgia Vest, DNP, RN and senior dean of nursing at the Rasmussen University School of Nursing. For example, nurses often have to make triage decisions in the emergency room. With an overflow of patients and limited staff, they ...
Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process. Effective thinking in nursing involves the integration of clinical knowledge and critical thinking to make the best decisions for patients. For example, if a nurse was caring for a patient ...
1 Introduction. Critical thinking in nursing is considered essential for delivering quality care and reflects the professional accountability of registered nurses (Chang et al., 2011). It is also a vital part of the clinical assignments and responsibilities nurses are expected to manage. Additionally, nurses' critical thinking has the ...
Critical thinking makes the nurse a professional achiever who picks, integrates, analyzes, and utilizes knowledge. Nurses' actions in the caregiving process are realized with critical thinking skills. Critical thinking in nursing practice helps make an inclusive care plan with considerable potential for success.
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.
Critical thinking in nursing clinical practice, education and ...
Critical thinking is an essential process for the safe, efficient and skillful nursing practice. The nursing education programs should adopt attitudes that promote critical thinking and mobilize the skills of critical reasoning. Key Words: critical thinking, nursing education, clinical nurse education, clinical nursing practice
Critical thinking, as described by Oxford Languages, is the objective analysis and evaluation of an issue in order to form a judgement. Active and skillful approach, evaluation, assessment, synthesis, and/or evaluation of information obtained from, or made by, observation, knowledge, reflection, acumen or conversation, as a guide to belief and action, requires the critical thinking process ...
Critical thinking, advanced problem-solving, and expert communication skills are an integral part of nursing practice and should be developed through nursing education programmes. Many nurses with a year or less of experience fail to meet expectations on the Performance Based Development System Assessment.