Teaching Critical Thinking In Nursing

(Penny Heaslip, 1993, Revised 2008 Thompson Rivers University, Box 3010, 900 McGill Road, Kamloops, BC Canada, V2C 5N3 pheaslip@tru.ca )

To become a professional nurse requires that you learn to think like a nurse. What makes the thinking of a nurse different from a doctor, a dentist or an engineer?  It is how we view the client and the type of problems we deal with in practice when we engage in client care. To think like a nurse requires that we learn the content of nursing; the ideas, concepts and theories of nursing and develop our intellectual capacities and skills so that we become disciplined, self-directed, critical thinkers.

Critical thinking is the disciplined, intellectual process of applying skilful reasoning as a guide to belief or action (Paul, Ennis & Norris). In nursing, critical thinking for clinical decision-making is the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care (Heaslip). Critical thinking when developed in the practitioner includes adherence to intellectual standards, proficiency in using reasoning, a commitment to develop and maintain intellectual traits of the mind and habits of thought and the competent use of thinking skills and abilities for sound clinical judgments and safe decision-making.

Intellectual Standards for Reasoning

Practitioners in nursing who are critical thinkers value and adhere to intellectual standards. Critical thinkers strive to be clear, accurate, precise, logical complete, significant and fair when they listen, speak, read and write. Critical thinkers think deeply and broadly. Their thinking is adequate for their intended purpose (Paul, Scriven, Norris & Ennis). All thinking can be examined in light of these standards and as we reflect on the quality of our thinking we begin to recognize when we are being unclear, imprecise, vague or inaccurate. As nurses, we want to eliminate irrelevant, inconsistent and illogical thoughts as we reason about client care. Nurses use language to clearly communicate in-depth information that is significant to nursing care. Nurses are not focused on the trivial or irrelevant.

Nurses who are critical thinkers hold all their views and reasoning to these standards as well as, the claims of others such that the quality of nurse's thinking improves over time thus eliminating confusion and ambiguity in the presentation and understanding of thoughts and ideas.

Elements of Reasoned Thinking

Reasoning in nursing involves eight elements of thought. Critical thinking involves trying to figure out something; a problem, an issue, the views of another person, a theory or an idea. To figure things out we need to enter into the thinking of the other person and then to comprehend as best we can the structure of their thinking. This also applies to our own thinking as well. When I read an author I'm trying to figure out what the author is saying; what problem or issue the author is addressing, what point of view or frame of reference he is coming from, what the goal or purpose is of this piece of writing, what evidence, data or facts are being used and what theories, concepts, principles or ideas are involved. I want to understand the interpretations and claims the author is making and the assumptions that underlie his thinking. I need to be able to follow the author's lines of formulated thought and the inferences which lead to a particular conclusion. I need to understand the implications and consequences of the author's thinking. As I come to understand the author in-depth I will also begin to recognize the strength and weakness of his reasoning. I will be able to offer my perspective on the subject at hand with a clear understanding of how the author would respond to my ideas on the subject.

The Elements of Thought

All thinking, if it is purposeful, includes the following elements of thought (Paul, 1990).

  1. The problem, question, concern or issue being discussed or thought about by the thinker. What the thinker is attempting to figure out.
  2. The purpose or goal of the thinking. Why we are attempting to figure something out and to what end. What do we hope to accomplish.
  3. The frame of reference, points of view or even world view that we hold about the issue or problem.
  4. The assumptions that we hold to be true about the issue upon which we base our claims or beliefs.
  5. The central concepts, ideas, principles and theories that we use in reasoning about the problem.
  6. The evidence, data or information provided to support the claims we make about the issue or problem.
  7. The interpretations, inferences, reasoning, and lines of formulated thought that lead to our conclusions.
  8. The implications and consequences that follow from the positions we hold on the issue or problem.

When nurses reason they use these elements of thought to figure out difficult questions and recognize that their thinking could be flawed or limited by lack of in-depth understanding of the problem at issue therefore, they critically monitor their thinking to ensure that their thinking meets the standards for intellectual thought.

In summary, as a critical thinker, I am able to figure out by reading or listening critically what nurse scholars believe about nursing and on what basis nurses act as they practice nursing. To do this I must clearly comprehend the thinking of another person by figuring out the logic of their thinking. I must comprehend clearly the thinking of myself by figuring out my own thoughts on the subject at hand. Finally, I must use intellectual standards to evaluate my thinking and the thinking of others on a given problem such that I can come to a defensible, well reasoned view of the problem and therefore, know what to believe or do in a given circumstance. To do this I must be committed to developing my mind as a self-directed, independent critical thinker. I must value above all else the intellectual traits and habits of thought that critical thinkers possess.

Intellectual Traits and Habits of Thought

To develop as a critical thinker one must be motivated to develop the attitudes and dispositions of a fair-minded thinker. That is, one must be willing to suspend judgments until one truly understands another point of view and can articulate the position that another person holds on an issue. Nurses come to reasoned judgments so that they can act competently in practice. They continually monitor their thinking; questioning and reflecting on the quality of thinking occurring in how they reason about nursing practice. Sloppy, superficial thinking leads to poor practice.

Critical inquiry is an important quality for safe practice. Nurses must pose questions about practice and be willing to attempt to seek answers about practice. Nurses must be willing to attempt to seek answers to the difficult questions inherent in practice, as well as the obvious. Question posing presupposes intellectual humility and a willingness to admit to one's areas of ignorance as well as, intellectual curiosity and perseverance and willingness to seek answers. Critical thinkers in nursing are truth seekers and demonstrate open-mindedness and tolerance for others' views with constant sensitivity to the possibility of their own bias.

Nurse's who are critical thinkers value intellectually challenging situations and are self-confident in their well reasoned thoughts. To reason effectively, nurses have developed skills and abilities essential for sound reasoning.

Critical Thinking Skills and Abilities

Critical thinkers in nursing are skilful in applying intellectual skills for sound reasoning. These skills have been defined as information gathering, focusing, remembering, organizing, analyzing, generating, integrating and evaluating (Registered Nurse's Association of British Columbia, 1990). The focus of classroom and clinical activities is to develop the nurse's understanding of scholarly, academic work through the effective use of intellectual abilities and skills. As you encounter increasingly more complex practice situations you will be required to think through and reason about nursing in greater depth and draw on deeper, more sophisticated comprehension of what it means to be a nurse in clinical practice. Nursing is never a superficial, meaningless activity. All acts in nursing are deeply significant and require of the nurse a mind fully engaged in the practice of nursing. This is the challenge of nursing; critical, reflective practice based on the sound reasoning of intelligent minds committed to safe, effective client care.

To accomplish this goal, students will be required to reason about nursing by reading, writing, listening and speaking critically. By doing so you will be thinking critically about nursing and ensuring that you gain in-depth knowledge about nursing as a practice profession.

Critical Thinking...a Holistic Approach

Critical Listening: A mode of monitoring how we are listening so as to maximize our accurate understanding of what another person is saying. By understanding the logic of human communication - that everything spoken expresses point of view, uses some ideas and not others, has implications, etc., critical thinkers can listen so as to enter empathetically and analytically into the perspective of others.

Critical Thinking: 1) Disciplined, self-directed thinking which implies the perfection of thinking appropriate to a particular mode or domain of thinking. 2) Thinking that displays master of intellectual skills and abilities. 3) The art of thinking about your thinking while you are thinking in order to make your thinking better: more clear, more accurate, or more defensible.

Critical Writing: To express oneself in languages required that one arrange ideas in some relationships to each other. When accuracy and truth are at issue, then we must understand what our thesis is, how we can support it, how we can elaborate it to make it intelligible to others, what objections can be raised to it from other points of view, what the limitations are to our point of view, and so forth. Disciplined writing requires disciplined thinking; disciplined thinking is achieved through disciplined writing.

Critical Reading: Critical reading is an active, intellectually engaged process in which the reader participates in an inner dialogue with the writer. Most people read uncritically and so miss some part of what is expressed while distorting other parts. A critical reader realizes the way in which reading, by its very nature, means entering into a point of view other than our own, the point of view of the writer. A critical reader actively looks for assumptions, key concepts and ideas, reasons and justifications, supporting examples, parallel experiences, implications and consequences, and any other structural features of the written text to interpret and assess it accurately and fairly. ( Paul, 1990, pp 554 & 545 )

Critical Speaking: Critical speaking is an active process of expressing verbally a point of view, ideas and thoughts such that others attain an in-depth understanding of the speaker's personal perspective on an issue. Monitoring how we express ourselves verbally will ensure that we maximize accurate understanding of what we mean through active dialogue and openness to feedback on our views. (Heaslip, 1993).


Paul, R.W. (1990). Critical Thinking: What Every Person Needs to Survive in a Rapidly Changing World. Rohnert Park, California: Center for Critical Thinking and Moral Critique

Norris, S. P. & Ennis, R.H. (1989). Evaluating critical thinking. Pacific Grove, CA: Midwest Publications, Critical Thinking Press

*Note: This post is the third in a series.

In the second post in this series on active learning strategies in nursing, I shared one nursing instructor’s way to set realistic expectations of her students beginning with the first time they step into the classroom. Now in this third post, let’s look at the ultimate question I hear everywhere I go: “How do I get my students to think critically?”

I attended an all-day conference by a nationally known speaker on this very topic. It was called, “How To Get Students to Think Critically.” I was pretty excited and looking forward to the day. It became pretty clear within the first hour of the day what the answer was. It was this: Involve your students. The speaker lectured to us for eight hours about how important it was to involve learners actively in the process. I found this amazing. We were not ourselves involved as learners once in that day. We were lectured to. We were lectured at, but we were never involved. I wanted to know how to involve my learners. That day ended without me gaining that knowledge.

I don’t blame the speaker. Her content was good. After all, she was doing what so many who teach nursing do - she was lecturing. To many people who teach, that’s all they have seen modeled. They are familiar with it. They can come in and do a “content dump” and feel they have done their job well. But who knows the content at the end of that lecture? The educator who give it knows it. The bad news is, he/she may be the only person retaining and understands that knowledge. Many educators have discovered that if they want to teach their students to think critically, they must create opportunities for their students to think critically. It’s like putting in a catheter. Can a student catheterize someone by hearing a lecture on it? No, one masters it by gathering the knowledge, watching a demo, getting the right supplies, and practicing on a manikin until feeling competent enough to get checked off by the teacher. The same is true for critical thinking.

So, how do you do that? I like to start off the thinking at the very beginning of class with something that looks fun or simple to start the brain thinking. Many of these activities can be found by putting these words into a search engine, “Brain puzzle of thinking puzzle.”  Here is one example I put on a PowerPoint slide and ask the students: “Based on the pattern established below, where do the 0, 7, and 9 go?”

Complete the series:

8, 5, 4, __, 1, __, 6, 10, 3, 2, __.

Where do 0, 7 and 9 go?

See if you can figure this problem out without reading further yourself. Have you solved it?

After two minutes I poll the group and ask why people made the selections. I then show them the completed list so they can check whether or not they were right. Also, check yourself:

Complete the series:

8, 5, 4, 9, 1, 7, 6, 10, 3, 2, 0.

Did you solve the pattern this way? You may be asking why is this the right answer. Well, if you write the numbers out, you can see the list is an alphabetical one. Eight, Five, Four, Nine, One, Seven, Six, Ten, Three, Two, Zero. What point does this make? Nursing is all about recognizing patterns. What do we expect to see in a patient with CHF? What would be normal and what would not? What are the expected effects of a diuretic? What is an alarming effect? One must know the patterns to problem solve and act appropriately for the patient.

One could also use a short patient scenario or NCLEX-style question at the beginning of class as the “problem of the day.” Present this and ask each learner to record what he or she thinks the answer to the question before you lecture. Then stop every 20 minutes or so and ask your learners to individually think and write down if they have changed their initial choice. If so, write down why. What principles or information have you learned that has changed your answer or caused you to know your choice is correct? In the last segment of the class, have the learners share and discuss the answers they have and the correct answer with rationales. This makes it safe to make mistakes of judgment on paper, not on people. The only way one learns is to be involved in making situational choices. The number pattern and/or the patient scenario offer learner practice in critical thinking.

Might you use one or both of these ideas? What do you think of these teaching strategies? Are they useful to you? Which strategies do you currently use that gives you great learner results?

Michele Deck presents nationally and internationally on innovative teaching methods in the field of health care education and training. She is co-founder and chief executive officer of G.A.M.E.S., a company that specializes in seminars on adult learning and interactive training methods, and Tool Thyme for Trainers, a company which supplies innovative and creative presentation tools for educators worldwide. Honors include ANPD’s prestigious Belinda E. Puetz Award, election to Sigma Theta Tau National Nursing Honor Society, Business Woman of the Year by the National Business Council, and Best Over All Trainer by Creative Training Techniques Companies. She serves on ANPD’s Education committee and was a member of the Editorial board of the Journal for 8 years.

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