Strong critical thinking skills are crucial for registered nurses to practice safely and effectively. In critical care, its significance is heightened as one decision by a registered nurse can change a patient's outcome. So, how do nurses ensure their critical thinking skills are firing? And if it's lacking, how do they develop it?

Dr Jessica Stokes-Parish, a registered nurse in clinical research and intensive care, says critical thinking skills help nurse process relevant information and make evidence-based choices for better patient care.

"It's easy to think that nursing is all about tasks, but it's the cognitive skills that are crucial to the nursing profession.

"This is particularly evident in critical care or intensive care nursing. In these time-pressured environments, you operate with more autonomy, and you need to be able to think and act on your feet."

The key components of critical thinking skills, said Dr Stokes-Parish, are analysing information and data, applying standards, information seeking, reasoning, predicting needs and transforming knowledge into action.

It's also important to be aware of tunnel vision, a common pitfall of critical thinking, and to embrace professional development, explained Dr Stokes-Parish.

"We have strong cognitive biases for information that we've seen before, which can sometimes lead to decision-making and diagnosis errors.

"Critical thinking is embedded in undergraduate education through problem-solving activities, simulations and reflective activities.

"It's important to be active in identifying areas for growth and to set goals to address them.

"I find that immersing myself in active learning activities, like simulations, really challenge my thinking and help me to address areas of concern."

Brooke Batchelor, a nurse educator, said critical thinking is the ability to keep an open mind while drawing on the research and evidence that support the best course of action towards better patient outcomes.

"It's how we think and respond to what we see is happening with our patients.

"We carefully consider our patient's changing health or status while at the same time, think ahead to our patient goals, in returning to full health or better health, and plan and adjust our care according to these changes.

"Underpinning these decisions is a sound knowledge of the research evidence that supports our decision making on which course of action to take."

Critical thinking is the invisible work of registered nurses.

"We're often seen as 'doing' tasks when there's a lot of thought behind actions, given there are many paths we could take to get results.

"Critical thinking requires us to weigh up the risks and benefits of each possibility and choose the best course of action."

Critical thinking is a skill on its own, said Ms Batchelor, but it's underpinned by knowledge of anatomy and physiology, medication knowledge, treatment plan pathways and interpretation of patient data, such as vital signs, blood and pathology results. 

"Many student nurses and early career nurses feel daunted with 'not knowing everything', but the truth is, the goalposts are constantly moving due to the latest research declaring a new, better way.

"That's why it is important to invest time in learning. Our learning journey never ends. There is always something changing, so you have to be resilient and adaptable, but that's what keeps it interesting!"

Registered nurses develop critical thinking skills in training, from collecting vital signs accurately (blood pressure, pulse rates, respiratory rates, temperature, neurological assessments) to learning about anatomy and physiology.

"As these skills and knowledge build, we then encourage clinical placement.

"I help students develop mind maps to help them visualise all the different things that impact on the person's health.

"We start with their diagnosis and gain an understanding of what has gone wrong with the normal function of the body parts or organs involved. Then we look at what symptoms we would expect the patient to display or experience and how these might impact them."

Next, Ms Batchelor encourages nurses to look for solutions through identifying factors that are relevant to a patient, including:

Medications
What medications is the patient taking and what side effects might occur? It's important to consider how we can mitigate these safely.

Pathology
What do pathology results indicate? Identify if there are changes and what this may signify. Do we need to respond to help correct something?

Scans
What do the scan results reveal? Perhaps this will impact on the plan of care.

Assistance
What assistance will the patient need to perform their daily living skills such as showering, eating, toileting?

In ICU or emergency care, this list is more complex, explained Ms Batchelor, but it provides insight into the juggling act of a nurse.

Attributes of good critical thinkers in nursing

Ms Batchelor explains that being reflective, giving and receiving feedback, being open-minded, curious and emotional intelligence are attributes of good critical thinkers.

Reflective
"To be a good critical thinker, it's important to reflect. It takes courage and humility to say, 'this went well, or that went terribly' and to learn. Often you would rather pretend it never happened and move on … but to be a good critical thinker, you need to face these situations and learn from them."

Feedback
"It's important to give and receive feedback. When there is a big event in the clinical space, we will often hold a debrief where the team can express their emotion about the situation before we reflect on our actions and give and receive feedback.

"It can be confronting to hear that there could have been a better way, but the truth is, we are all there wanting the best for our patients, so we owe it to them to grow a thick skin, accept the feedback, learn and do better next time.

"Most of the time, however, there is nothing more that could have been done, and you're just receiving feedback on refining your skills so that you can respond more quickly next time."

Open-minded and curious

"Being open-minded has allowed me to put my own opinions and assumptions aside to look at the bigger picture from a place of objectivity.

"Having a mind of enquiry and always asking, 'Why is this happening?' you will naturally be led to critical thinking.

"You cannot ask 'why' without looking at the bigger picture and once you understand 'why' you start to see the possibilities."

Emotional Intelligence

"You need to be able to make decisions without being emotionally attached to them. You may make a decision and discover it isn't working or be told by a more senior staff member that it has been tried and didn't work.

"If you are emotionally attached to being 'right' you will struggle to pivot to a different solution to the detriment of your patient."


ICU nursing: critical thinking in action

Nurses need to be able to manage high-stress situations and communicate clearly and with empathy in ICU, explained Dr Stokes-Parish.

"A shift can be very slow when the patient is stable, or you can be run off your feet without a break!"

Dr Stokes-Parish recalls her critical thinking skills in action when she was one-to-one nursing a ventilated patient in the ICU.

"The patient was unsettled and agitated, but otherwise stable.

"While going about their cares, I suddenly heard a gasping sound coming from the patient, and the ventilator began alarming.

"I quickly assessed the situation, trying to identify the problem area. It turned out the patient had chewed the pilot tube from their endotracheal tube.

"I quickly identified that this patient required re-intubation, so called for assistance and set up the room for intubation. At the same time, blowing up the pilot tube and clamping it to secure their airway.

"All went well but required solid assessment and critical thinking skills to resolve the issue without incident."