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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

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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?

• Research article
• Open access
• Published: 07 October 2020

Impact of social problem-solving training on critical thinking and decision making of nursing students

• Soleiman Ahmady 1 &
• Sara Shahbazi   ORCID: orcid.org/0000-0001-8397-6233 2 , 3  

BMC Nursing volume  19 , Article number:  94 ( 2020 ) Cite this article

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The complex health system and challenging patient care environment require experienced nurses, especially those with high cognitive skills such as problem-solving, decision- making and critical thinking. Therefore, this study investigated the impact of social problem-solving training on nursing students’ critical thinking and decision-making.

This study was quasi-experimental research and pre-test and post-test design and performed on 40 undergraduate/four-year students of nursing in Borujen Nursing School/Iran that was randomly divided into 2 groups; experimental ( n  = 20) and control (n = 20). Then, a social problem-solving course was held for the experimental group. A demographic questionnaire, social problem-solving inventory-revised, California critical thinking test, and decision-making questionnaire was used to collect the information. The reliability and validity of all of them were confirmed. Data analysis was performed using SPSS software and independent sampled T-test, paired T-test, square chi, and Pearson correlation coefficient.

The finding indicated that the social problem-solving course positively affected the student’ social problem-solving and decision-making and critical thinking skills after the instructional course in the experimental group ( P  < 0.05), but this result was not observed in the control group ( P  > 0.05).

Conclusions

The results showed that structured social problem-solving training could improve cognitive problem-solving, critical thinking, and decision-making skills. Considering this result, nursing education should be presented using new strategies and creative and different ways from traditional education methods. Cognitive skills training should be integrated in the nursing curriculum. Therefore, training cognitive skills such as problem- solving to nursing students is recommended.

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Continuous monitoring and providing high-quality care to patients is one of the main tasks of nurses. Nurses’ roles are diverse and include care, educational, supportive, and interventional roles when dealing with patients’ clinical problems [ 1 , 2 ].

Providing professional nursing services requires the cognitive skills such as problem-solving, decision-making and critical thinking, and information synthesis [ 3 ].

Problem-solving is an essential skill in nursing. Improving this skill is very important for nurses because it is an intellectual process which requires the reflection and creative thinking [ 4 ].

Problem-solving skill means acquiring knowledge to reach a solution, and a person’s ability to use this knowledge to find a solution requires critical thinking. The promotion of these skills is considered a necessary condition for nurses’ performance in the nursing profession [ 5 , 6 ].

Managing the complexities and challenges of health systems requires competent nurses with high levels of critical thinking skills. A nurse’s critical thinking skills can affect patient safety because it enables nurses to correctly diagnose the patient’s initial problem and take the right action for the right reason [ 4 , 7 , 8 ].

Problem-solving and decision-making are complex and difficult processes for nurses, because they have to care for multiple patients with different problems in complex and unpredictable treatment environments [ 9 , 10 ].

Clinical decision making is an important element of professional nursing care; nurses’ ability to form effective clinical decisions is the most significant issue affecting the care standard. Nurses build 2 kinds of choices associated with the practice: patient care decisions that affect direct patient care and occupational decisions that affect the work context or teams [ 11 , 12 , 13 , 14 , 15 , 16 ].

The utilization of nursing process guarantees the provision of professional and effective care. The nursing process provides nurses with the chance to learn problem-solving skills through teamwork, health management, and patient care. Problem-solving is at the heart of nursing process which is why this skill underlies all nursing practices. Therefore, proper training of this skill in an undergraduate nursing program is essential [ 17 ].

Nursing students face unique problems which are specific to the clinical and therapeutic environment, causing a lot of stresses during clinical education. This stress can affect their problem- solving skills [ 18 , 19 , 20 , 21 ]. They need to promote their problem-solving and critical thinking skills to meet the complex needs of current healthcare settings and should be able to respond to changing circumstances and apply knowledge and skills in different clinical situations [ 22 ]. Institutions should provide this important opportunity for them.

Despite, the results of studies in nursing students show the weakness of their problem-solving skills, while in complex health environments and exposure to emerging diseases, nurses need to diagnose problems and solve them rapidly accurately. The teaching of these skills should begin in college and continue in health care environments [ 5 , 23 , 24 ].

It should not be forgotten that in addition to the problems caused by the patients’ disease, a large proportion of the problems facing nurses are related to the procedures of the natural life of their patients and their families, the majority of nurses with the rest of health team and the various roles defined for nurses [ 25 ].

Therefore, in addition to above- mentioned issues, other ability is required to deal with common problems in the working environment for nurses, the skill is “social problem solving”, because the term social problem-solving includes a method of problem-solving in the “natural context” or the “real world” [ 26 , 27 ]. In reviewing the existing research literature on the competencies and skills required by nursing students, what attracts a lot of attention is the weakness of basic skills and the lack of formal and systematic training of these skills in the nursing curriculum, it indicates a gap in this area [ 5 , 24 , 25 ]. In this regard, the researchers tried to reduce this significant gap by holding a formal problem-solving skills training course, emphasizing the common social issues in the real world of work. Therefore, this study was conducted to investigate the impact of social problem-solving skills training on nursing students’ critical thinking and decision-making.

Setting and sample

This quasi-experimental study with pretest and post-test design was performed on 40 undergraduate/four-year nursing students in Borujen nursing school in Shahrekord University of Medical Sciences. The periods of data collection were 4 months.

According to the fact that senior students of nursing have passed clinical training and internship programs, they have more familiarity with wards and treatment areas, patients and issues in treatment areas and also they have faced the problems which the nurses have with other health team personnel and patients and their families, they have been chosen for this study. Therefore, this study’s sampling method was based on the purpose, and the sample size was equal to the total population. The whole of four-year nursing students participated in this study and the sample size was 40 members. Participants was randomly divided in 2 groups; experimental ( n  = 20) and control (n = 20).

The inclusion criteria to take part in the present research were students’ willingness to take part, studying in the four-year nursing, not having the record of psychological sickness or using the related drugs (all based on their self-utterance).

Intervention

At the beginning of study, all students completed the demographic information’ questionnaire. The study’s intervening variables were controlled between the two groups [such as age, marital status, work experience, training courses, psychological illness, psychiatric medication use and improving cognitive skills courses (critical thinking, problem- solving, and decision making in the last 6 months)]. Both groups were homogeneous in terms of demographic variables ( P  > 0.05). Decision making and critical thinking skills and social problem solving of participants in 2 groups was evaluated before and 1 month after the intervention.

All questionnaires were anonymous and had an identification code which carefully distributed by the researcher.

To control the transfer of information among the students of two groups, the classification list of students for internships, provided by the head of nursing department at the beginning of semester, was used.

Furthermore, the groups with the odd number of experimental group and the groups with the even number formed the control group and thus were less in contact with each other.

The importance of not transferring information among groups was fully described to the experimental group. They were asked not to provide any information about the course to the students of the control group.

Then, training a course of social problem-solving skills for the experimental group, given in a separate course and the period from the nursing curriculum and was held in 8 sessions during 2 months, using small group discussion, brainstorming, case-based discussion, and reaching the solution in small 4 member groups, taking results of the social problem-solving model as mentioned by D-zurilla and gold fried [ 26 ]. The instructor was an assistant professor of university and had a history of teaching problem-solving courses. This model’ stages are explained in Table  1 .

All training sessions were performed due to the model, and one step of the model was implemented in each session. In each session, the teacher stated the educational objectives and asked the students to share their experiences in dealing to various workplace problems, home and community due to the topic of session. Besides, in each session, a case-based scenario was presented and thoroughly analyzed, and students discussed it.

Instruments

In this study, the data were collected using demographic variables questionnaire and social problem- solving inventory – revised (SPSI-R) developed by D’zurilla and Nezu (2002) [ 26 ], California critical thinking skills test- form B (CCTST; 1994) [ 27 , 28 ] and decision-making questionnaire.

SPSI-R is a self - reporting tool with 52 questions ranging from a Likert scale (1: Absolutely not – 5: very much).

The minimum score maybe 25 and at a maximum of 125, therefore:

The score 25 and 50: weak social problem-solving skills.

The score 50–75: moderate social problem-solving skills.

The score higher of 75: strong social problem-solving skills.

The reliability assessed by repeated tests is between 0.68 and 0.91, and its alpha coefficient between 0.69 and 0.95 was reported [ 26 ]. The structural validity of questionnaire has also been confirmed. All validity analyses have confirmed SPSI as a social problem - solving scale.

In Iran, the alpha coefficient of 0.85 is measured for five factors, and the retest reliability coefficient was obtained 0.88. All of the narratives analyzes confirmed SPSI as a social problem- solving scale [ 29 ].

California critical thinking skills test- form B(CCTST; 1994): This test is a standard tool for assessing the basic skills of critical thinking at the high school and higher education levels (Facione & Facione, 1992, 1998) [ 27 ].

This tool has 34 multiple-choice questions which assessed analysis, inference, and argument evaluation. Facione and Facione (1993) reported that a KR-20 range of 0.65 to 0.75 for this tool is acceptable [ 27 ].

In Iran, the KR-20 for the total scale was 0.62. This coefficient is acceptable for questionnaires that measure the level of thinking ability of individuals.

After changing the English names of this questionnaire to Persian, its content validity was approved by the Board of Experts.

The subscale analysis of Persian version of CCTST showed a positive high level of correlation between total test score and the components (analysis, r = 0.61; evaluation, r = 0.71; inference, r = 0.88; inductive reasoning, r = 0.73; and deductive reasoning, r = 0.74) [ 28 ].

A decision-making questionnaire with 20 questions was used to measure decision-making skills. This questionnaire was made by a researcher and was prepared under the supervision of a professor with psychometric expertise. Five professors confirmed the face and content validity of this questionnaire. The reliability was obtained at 0.87 which confirmed for 30 students using the test-retest method at a time interval of 2 weeks. Each question had four levels and a score from 0.25 to 1. The minimum score of this questionnaire was 5, and the maximum score was 20 [ 30 ].

Statistical analysis

For analyzing the applied data, the SPSS Version 16, and descriptive statistics tests, independent sample T-test, paired T-test, Pearson correlation coefficient, and square chi were used. The significant level was taken P  < 0.05.

The average age of students was 21.7 ± 1.34, and the academic average total score was 16.32 ± 2.83. Other demographic characteristics are presented in Table  2 .

None of the students had a history of psychiatric illness or psychiatric drug use. Findings obtained from the chi-square test showed that there is not any significant difference between the two groups statistically in terms of demographic variables.

The mean scores in social decision making, critical thinking, and decision-making in whole samples before intervention showed no significant difference between the two groups statistically ( P  > 0.05), but showed a significant difference after the intervention ( P  < 0.05) (Table  3 ).

Scores in Table  4 showed a significant positive difference before and after intervention in the “experimental” group ( P  < 0.05), but this difference was not seen in the control group ( P  > 0.05).

Among the demographic variables, only a positive relationship was seen between marital status and decision-making skills (r = 0.72, P  < 0.05).

Also, the scores of critical thinking skill’ subgroups and social problem solving’ subgroups are presented in Tables  5 and 6 which showed a significant positive difference before and after intervention in the “experimental” group (P < 0.05), but this difference was not seen in the control group ( P  > 0.05).

In the present study conducted by some studies, problem-solving and critical thinking and decision-making scores of nursing students are moderate [ 5 , 24 , 31 ].

The results showed that problem-solving skills, critical thinking, and decision-making in nursing students were promoted through a social problem-solving training course. Unfortunately, no study has examined the effect of teaching social problem-solving skills on nursing students’ critical thinking and decision-making skills.

Altun (2018) believes that if the values of truth and human dignity are promoted in students, it will help them acquire problem-solving skills. Free discussion between students and faculty on value topics can lead to the development of students’ information processing in values. Developing self-awareness increases students’ impartiality and problem-solving ability [ 5 ]. The results of this study are consistent to the results of present study.

Erozkan (2017), in his study, reported there is a significant relationship between social problem solving and social self-efficacy and the sub-dimensions of social problem solving [ 32 ]. In the present study, social problem -solving skills training has improved problem -solving skills and its subdivisions.

The results of study by Moshirabadi (2015) showed that the mean score of total problem-solving skills was 89.52 ± 21.58 and this average was lower in fourth-year students than other students. He explained that education should improve students’ problem-solving skills. Because nursing students with advanced problem-solving skills are vital to today’s evolving society [ 22 ]. In the present study, the results showed students’ weakness in the skills in question, and holding a social problem-solving skills training course could increase the level of these skills.

Çinar (2010) reported midwives and nurses are expected to use problem-solving strategies and effective decision-making in their work, using rich basic knowledge.

These skills should be developed throughout one’s profession. The results of this study showed that academic education could increase problem-solving skills of nursing and midwifery students, and final year students have higher skill levels [ 23 ].

Bayani (2012) reported that the ability to solve social problems has a determining role in mental health. Problem-solving training can lead to a level upgrade of mental health and quality of life [ 33 ]; These results agree with the results obtained in our study.

Conducted by this study, Kocoglu (2016) reported nurses’ understanding of their problem-solving skills is moderate. Receiving advice and support from qualified nursing managers and educators can enhance this skill and positively impact their behavior [ 31 ].

Kashaninia (2015), in her study, reported teaching critical thinking skills can promote critical thinking and the application of rational decision-making styles by nurses.

One of the main components of sound performance in nursing is nurses’ ability to process information and make good decisions; these abilities themselves require critical thinking. Therefore, universities should envisage educational and supportive programs emphasizing critical thinking to cultivate their students’ professional competencies, decision-making, problem-solving, and self-efficacy [ 34 ].

The study results of Kirmizi (2015) also showed a moderate positive relationship between critical thinking and problem-solving skills [ 35 ].

Hong (2015) reported that using continuing PBL training promotes reflection and critical thinking in clinical nurses. Applying brainstorming in PBL increases the motivation to participate collaboratively and encourages teamwork. Learners become familiar with different perspectives on patients’ problems and gain a more comprehensive understanding. Achieving these competencies is the basis of clinical decision-making in nursing. The dynamic and ongoing involvement of clinical staff can bridge the gap between theory and practice [ 36 ].

Ancel (2016) emphasizes that structured and managed problem-solving training can increase students’ confidence in applying problem-solving skills and help them achieve self-confidence. He reported that nursing students want to be taught in more innovative ways than traditional teaching methods which cognitive skills training should be included in their curriculum. To this end, university faculties and lecturers should believe in the importance of strategies used in teaching and the richness of educational content offered to students [ 17 ].

The results of these recent studies are adjusted with the finding of recent research and emphasize the importance of structured teaching cognitive skills to nurses and nursing students.

Based on the results of this study on improving critical thinking and decision-making skills in the intervention group, researchers guess the reasons to achieve the results of study in the following cases:

In nursing internationally, problem-solving skills (PS) have been introduced as a key strategy for better patient care [ 17 ]. Problem-solving can be defined as a self-oriented cognitive-behavioral process used to identify or discover effective solutions to a special problem in everyday life. In particular, the application of this cognitive-behavioral methodology identifies a wide range of possible effective solutions to a particular problem and enhancement the likelihood of selecting the most effective solution from among the various options [ 27 ].

In social problem-solving theory, there is a difference among the concepts of problem-solving and solution implementation, because the concepts of these two processes are different, and in practice, they require different skills.

In the problem-solving process, we seek to find solutions to specific problems, while in the implementation of solution, the process of implementing those solutions in the real problematic situation is considered [ 25 , 26 ].

The use of D’zurilla and Goldfride’s social problem-solving model was effective in achieving the study results because of its theoretical foundations and the usage of the principles of cognitive reinforcement skills. Social problem solving is considered an intellectual, logical, effort-based, and deliberate activity [ 26 , 32 ]; therefore, using this model can also affect other skills that need recognition.

In this study, problem-solving training from case studies and group discussion methods, brainstorming, and activity in small groups, was used.

There are significant educational achievements in using small- group learning strategies. The limited number of learners in each group increases the interaction between learners, instructors, and content. In this way, the teacher will be able to predict activities and apply techniques that will lead students to achieve high cognitive taxonomy levels. That is, confront students with assignments and activities that force them to use cognitive processes such as analysis, reasoning, evaluation, and criticism.

In small groups, students are given the opportunity to the enquiry, discuss differences of opinion, and come up with solutions. This method creates a comprehensive understanding of the subject for the student [ 36 ].

According to the results, social problem solving increases the nurses’ decision-making ability and critical thinking regarding identifying the patient’s needs and choosing the best nursing procedures. According to what was discussed, the implementation of this intervention in larger groups and in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students, in the future, is recommended.

Social problem- solving training by affecting critical thinking skills and decision-making of nursing students increases patient safety. It improves the quality of care because patients’ needs are better identified and analyzed, and the best solutions are adopted to solve the problem.

In the end, the implementation of this intervention in larger groups in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students in the future is recommended.

Study limitations

This study was performed on fourth-year nursing students, but the students of other levels should be studied during a cohort from the beginning to the end of course to monitor the cognitive skills improvement.

The promotion of high-level cognitive skills is one of the main goals of higher education. It is very necessary to adopt appropriate approaches to improve the level of thinking. According to this study results, the teachers and planners are expected to use effective approaches and models such as D’zurilla and Goldfride social problem solving to improve problem-solving, critical thinking, and decision-making skills. What has been confirmed in this study is that the routine training in the control group should, as it should, has not been able to improve the students’ critical thinking skills, and the traditional educational system needs to be transformed and reviewed to achieve this goal.

Availability of data and materials

The datasets used and analyzed during the present study are available from the corresponding author on reasonable request.

Abbreviations

California critical thinking skills test

Social problem-solving inventory – revised

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Acknowledgments

This article results from research project No. 980 approved by the Research and Technology Department of Shahrekord University of Medical Sciences. We would like to appreciate to all personnel and students of the Borujen Nursing School. The efforts of all those who assisted us throughout this research.

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Department of Medical Education, Virtual School of Medical Education and Management, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Soleiman Ahmady

Virtual School of Medical Education and management, Shahid Beheshty University of Medical Sciences, Tehran, Iran

Sara Shahbazi

Community-Oriented Nursing Midwifery Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran

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SA and SSH conceptualized the study, developed the proposal, coordinated the project, completed initial data entry and analysis, and wrote the report. SSH conducted the statistical analyses. SA and SSH assisted in writing and editing the final report. All authors read and approved the final manuscript.

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Ahmady, S., Shahbazi, S. Impact of social problem-solving training on critical thinking and decision making of nursing students. BMC Nurs 19 , 94 (2020). https://doi.org/10.1186/s12912-020-00487-x

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DOI : https://doi.org/10.1186/s12912-020-00487-x

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• Social problem solving
• Decision making
• Critical thinking

BMC Nursing

ISSN: 1472-6955

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The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

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Nurse leaders as problem-solvers

Addressing lateral and horizontal violence.

Anthony, Michelle R. PhD, RN; Brett, Anne Liners PhD, RN

Michelle R. Anthony is a program coordinator at Columbia (S.C.) VA Health Care System. Anne Liners Brett is doctoral faculty at the University of Phoenix in Tempe, Ariz.

Acknowledgment: The authors acknowledge the support of the University of Phoenix Center for Educational and Instructional Technology Research.

The contents of this article do not represent the views of the US Department of Veterans Affairs or the United States Government.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

For more than 126 additional continuing-education articles related to management topics, go to NursingCenter.com/CE .

Earn CE credit online: Go to http://nursing.ceconnection.com and receive a certificate within minutes .

Read about a qualitative, grounded theory study that looked to gain a deeper understanding of nurse leaders' perceptions of their role in addressing lateral and horizontal violence, and the substantive theory developed from the results.

The issue of lateral and horizontal violence (LHV) has plagued the nursing profession for more than 3 decades, yet solutions remain elusive. The significance of LHV isn't lost on nurse leaders because it creates an unhealthy work environment. Research literature worldwide has continued to report the prevalence of disruptive behaviors experienced by nursing students, novice nurses, and seasoned nurses in the workforce. The World Health Organization, International Council of Nurses, and Public Services International have recognized this issue as a major global public health priority. 1

LHV, also called nurse-on-nurse aggression, disruptive behavior, or incivility, undermines a culture of safety and negatively impacts patient care. 2,3 This experience, known to nurses as “eating their young,” isn't only intimidating and disruptive, it's also costly and demoralizing to the nursing profession and healthcare organizations. 4,5 Although the impact of LHV can be dreadful for both the institution and its staff, little is known about the reasons for these behaviors among nursing professionals. 2

LHV encompasses all acts of meanness, hostility, disruption, discourtesy, backbiting, divisiveness, criticism, lack of unison, verbal or mental abuse, and scapegoating. 6 The sole intent of bullying behaviors is to purposefully humiliate and demean victims. Bullying behaviors also taint healthcare organizations; cause irreparable harm to workplace culture; breakdown team communication; and severely impact the quality of the care provided, thereby jeopardizing patient safety. 7,8 Researchers have reported that acts of LHV are used to demonstrate power, domination, or aggression; for retribution; to control others; and to enhance self-image. 9-12

Previous studies have shown that the frequency of LHV in healthcare organizations is quite severe, with about 90% of new nurses surveyed reporting acts of incivility by their coworkers. 13 Sixty-five percent of nurses in one survey reported witnessing incidents of despicable acts, whereas another 46% of coworkers in the same survey reported the issue as “very serious” and “somewhat serious.” 13

LHV poses a significant challenge for nurse leaders who are legally and morally responsible for providing a safe working environment. 2,6 The purpose of this qualitative, grounded theory study was to gain a deeper understanding of nurse leaders' perceptions of their role in addressing LHV and develop a substantive theory from the results.

Literature review

A paucity of evidence exists in the literature regarding how nurse leaders perceive their role in addressing LHV. 14 Studies have shown that this phenomenon is attributed to heavy workloads, a stressful work environment, and lack of workgroup cohesiveness, as well as organizational factors such as misuse of authority and the lack of organizational policies and procedures for addressing LHV behaviors. 15

In one study, one-third of the nurses reported that they had observed emotional abuse during several of their work shifts. 16 Another study indicated that 30% of survey respondents (n = 2,100) stated LHV occurs weekly. 17 A third study revealed that 25% of participants noted LHV happened monthly, and a fourth study of ED nurses reported that about 27.3% of the nurses had experienced LHV perpetrated by nursing leadership (managers, supervisors, charge nurses, and directors), physicians, or peers in the last 6 months. 18

In a survey completed by members of the Washington State Emergency Nurses Association, 27% of respondents experienced acts of bullying in the past 6 months. 19 Another study reported that 27% to 85% of nurse respondents had experienced some form of uncivil behavior. 20 Other data have shown that those more vulnerable to violent, disruptive, and intimidating behaviors are newly licensed nurses beginning their careers. 21

Although nurse leaders can be perpetrators of LHV, they play an essential role in addressing LHV behaviors and creating a safe work environment. 22 The literature suggests that, in many cases, a lack of awareness and response by nurse leaders adds to the prevalence of LHV. 23 This may be due, in part, to nurse leaders being aligned with the perpetrators who are creating the toxic work environment. 6 The literature suggests that an environment where staff members feel safe to practice results in a culture that decreases burnout and promotes nurse retention and quality outcomes. 24,25

This qualitative, grounded theory study focused on nurse leaders' perception of their role in breaking the cycle of LHV for staff members whom they supervise. Two research questions guided the study: 1. How do nurse leaders perceive their role in addressing LHV among nursing staff members under their supervision? 2. What substantive theory may emerge from the data collected during interviews with nurse leaders?

A grounded theory methodology was used to explore the nurse leader's role in addressing LHV with the intent of developing a substantive theory through the meaningful organization of data themes to provide a framework to address the phenomenon of LHV. Purposive sampling was used to recruit a total of 14 participants for this study from a large healthcare system in the Southeastern US. The participants were chosen because of their experience with LHV and their ability to discuss and reflect on those experiences. Informed consent was obtained before the start of the study, which included explaining the reason for the study and what to expect. In addition, permission was obtained from the Institutional Review Board.

Data collection and analysis

Demographic data collected to describe the sample included gender, age range, number of years holding a management position, supervisory responsibility, and highest degree obtained. (See Table 1 .)

Semistructured, in-depth interviews were the primary mode of data collection. The recorded interviews were conducted face-to-face and lasted about 60 minutes. Data collection continued until saturation was achieved. Data saturation occurred when no new descriptive codes, categories, or themes were emerging from the analyzed data. The interviews were transcribed verbatim and verified through a member check process.

During the data analysis process, themes and patterns were identified. Data from each participant's interview were examined to determine if the responses were aligned with the identified themes. Analysis of the data included coding at increasingly abstract levels and constant comparison. Qualitative software assisted in coding the information and uncovering subtle trends.

Four themes emerged from core categories developed during the qualitative data coding process.

Theme 1: Understanding/addressing LHV . In question one, participants were asked to describe their understanding of LHV. Five subthemes emerged from the data collected with this question. (See Table 2 .)

Theme 2: Experience addressing LHV . In the second question, participants were asked about their experience with addressing incidents of LHV. Six subthemes were identified. (See Table 3 .)

Theme 3: Role perception in addressing LHV . In the third question, participants were asked what they perceive their role to be in addressing LHV. Six subthemes resulted from this question. (See Table 4 .)

Theme 4: Organizational impediment to addressing LHV . In question four, participants were asked to describe the factors within the organization that influence or impede their role in addressing LHV. This question yielded nine subthemes. (See Table 5 .)

Substantive theory

As a result of the themes that emerged from the data, a substantive theory was developed. This is especially important for the nursing profession to develop as a scientifically based practice. Theories help guide research and provide the expansion, generation, and validation of the science of nursing knowledge. 26 The substantive theory will help nurse leaders become more cognizant of the role that effective leadership plays in preventing or intervening in incidents of LHV in the workplace. The analysis revealed that nurse leaders are aware that the quality of patient care and staff well-being can be adversely affected by the impact of LHV.

Data themes were used to formulate the following theory: Nurse leaders address LHV affecting their staff members by solving problems, creating a safe work environment, and reducing institutional barriers that impede addressing LHV in a timely fashion. Nurse leaders perceive their role as a problem-solver, which is a necessary step in advocacy. 27 Problem-solving is a process that contains the elements of decision-making and critical thinking. 28

The theory that emerged from the core categories explicitly focused on the central phenomenon of LHV in the nursing work environment. Figure 1 shows the interrelatedness of the themes to the resultant substantive theory.

Discussion and implications

The study results have several implications for both the nursing profession and nurse leaders. The nursing profession requires decisive and robust leadership, and the role of the nurse leader is to be a combination of nurturer, investigator, and judge to examine incidents of LHV. 26,29-32 Nurse leaders are responsible for setting the tone and expectations for a safe work environment. This includes modeling the expected ethical behaviors; for example, doing the right things for the right reasons, being collegial toward each other, and being respectful of other's differences. One participant remarked, “This is a different world based on how I was raised. I was raised to be respectful to people.”

In addition, nurse leaders are responsible for enforcing policies created to address disruptive behaviors and working with the administration as soon as an incident occurs. Past research indicates that a healthy and collaborative work environment fosters nurse engagement and patient safety. 25,30 Staff members and patients need a leader to protect them when necessary; thus, the nurse leader needs to “walk the walk” in providing a safe environment for all. Nurse leaders engaged in these kinds of behaviors are providing strong leadership and practicing strong decision-making, thus ensuring the continued robustness of their organizations.

Recommendations and limitations

Future research could replicate this study in a different geographic region to explore the causes of LHV by soliciting the views of nursing students, new graduate nurses, and nurse educators from unionized and nonunionized hospital systems and comparing the results to further understand this phenomenon. Additionally, developing a tool to test the substantive theory could substantiate the nurse leader's role as a problem-solver to address incidence of LHV in the workplace.

The decision to conduct this study in one type of healthcare organization limits the ability to compare the interviewed nurse leaders' experiences with nurse leaders in other healthcare organizations. The experiences of nurses in other healthcare organizations may be different; thus, overall generalizability of the study may be limited.

Say “no” to the status quo

The results of this study support the findings of previous researchers. 23,31,33,34 Accepting the status quo is unacceptable and can cause irreparable harm to organizational well-being if LHV isn't addressed. Collaboration between nurse leaders and administrators is essential to successfully reduce institutional obstacles that prevent the timely handling of LHV incidents. The role of the nurse leader as a problem-solver should be clear, defined, and well supported to seek resolutions to toxic behaviors that are hurting the work environment. But we must remember that creating a policy doesn't equal change. Every employee from the lowest level in the organization to the highest ranks of administration must model civil behaviors.

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Effective decision-making: applying the theories to nursing practice.

Samantha Watkins

Emergency Department Staff Nurse, Frimley Health NHS Foundation Trust, Frimley

View articles · Email Samantha

Many theories have been proposed for the decision-making conducted by nurses across all practices and disciplines. These theories are fundamental to consider when reflecting on our decision-making processes to inform future practice. In this article three of these theories are juxtaposed with a case study of a patient presenting with an ST-segment elevation myocardial infarction (STEMI). These theories are descriptive, normative and prescriptive, and will be used to analyse and interpret the process of decision-making within the context of patient assessment.

Decision-making is a fundamental concept of nursing practice that conforms to a systematic trajectory involving the assessment, interpretation, evaluation and management of patient-specific situations ( Dougherty et al, 2015 ). Shared decision-making is vital to consider in terms of patient autonomy and professional duty of care as set out in the Nursing and Midwifery Council (NMC) (2018) Code, which underpins nursing practice. Consequently, the following assessment and decision-making processes were conducted within the remits of practice as a student nurse. Decision-making is a dynamic process in nursing practice, and the theories emphasise the importance of adaptability and reflective practice to identify factors that impact on patient care ( Pearson, 2013 ). Three decision-making theories will be explored within the context of a decision made in practice. To abide by confidentiality requirements, the pseudonym ‘Linda’ will be used throughout. Patient consent was obtained prior to writing.

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Critical Thinking and Decision-Making Skills

Chapter 4 Critical Thinking and Decision-Making Skills Betsy Frank http://evolve.elsevier.com/Huber/leadership/ In an era of changing reimbursements, value based purchasing, and expanded roles for nursing in the health care delivery system, critical thinking and decision making are important skills for nurses caring for patients and for nurse leaders and managers. Both the American Nurses Association’s (2009) and American Association of Nurse Executives’ (2005) standards for practice for nurse administrators and executives support the fact that in a fast-paced health care delivery environment, staff nurses, leaders, and managers must be able to analyze and synthesize a large array of information, use critical thinking and decision making skills to deliver effective day to day patient care, and solve complex problems that occur in complex health care delivery systems (see Figure 4-1 ). Furthermore, the Magnet Hospital initiative and the Institute of Medicine’s ( Committee on the Robert Wood Johnson Foundation, 2011 ) Future of Nursing report highlight the need for nurses to be able to be fully involved and even take the lead in decision making from the unit level to the larger health care delivery system. FIGURE 4-1 Differences and interactions among critical thinking, problem solving, and decision making. Nurses are a cadre of knowledge workers within the health care system. As such, they need information, resources, and support from their environment. In fact, the nurse manager’s expertise in critical thinking and shared decision making are essential for creating healthy work environments where quality and effective care can be delivered ( Kramer et al., 2010 ; Zori et al., 2010 ). Critical thinking and decision-making competences include analytical skills as well as intuition. Just as intuition is part of expert clinical practice ( Benner, 1984 ), intuition plays an important role in developing managerial and leadership expertise (Shirey, 2007). DEFINITIONS Critical thinking can be defined as a set of cognitive skills including “interpretation, analysis, evaluation, inference, explanation, and self-regulation” ( Facione, 2007 , p. 1). Using these skills, nurses in direct patient care and leaders and managers can reflect analytically, reconceptualize events, and avoid the tendency to make decisions and problem solve hastily or on the basis of inadequate information. Facione also pointed out that critical thinking is not only a skill but also a disposition that is grounded in a strong ethical component. Critical thinking in nursing can be defined as “purposeful, informed, outcomes focused thinking…[that] applies logic, intuition, creativity and is grounded in specific knowledge, skills, and experience” ( Alfaro-LeFevre, 2009 , p. 7). Alfaro-LeFevre noted that outcomes-focused thinking helps to prevent, control, and solve problems. Tanner (2000) noted that critical thinking is much more than just the five steps of the nursing process. Problem solving involves moving from an undesirable to a desirable state ( Chambers, 2009 ). Problem solving occurs in a variety of nursing contexts, including direct client care, team-level leadership, and systems-level leadership. Nurses and nurse managers are challenged to move from step-by-step problem-solving techniques to incorporating creative thinking, which involves considering the context when meeting current and future challenges in health care delivery ( Chambers, 2009 ; Rubenfeld & Scheffer, 2006 ). Decision making is the process of making choices that will provide maximum benefit ( Drummond, 2001 ). Decision making can also be defined as a behavior exhibited in selecting and implementing a course of action from alternative courses of action for dealing with a situation or problem. It may or may not be the result of an immediate problem. Critical thinking and effective decision making are the foundation of effective problem solving. If problems require urgent action, then decisions must be made rapidly; if solutions do not need to be identified immediately, decision making can occur in a more deliberative way. Because problems change over time, decisions made at one point in time may need to be changed ( Choo, 2006 ). For example, decisions about how to staff a unit when a nurse calls in sick have to be made immediately. However, if a unit is chronically short-staffed, a decision regarding long-term solutions will have to be made. The process of selecting one course of action from alternatives forms the basic core of the definition of decision making. Choo (2006) noted that all decisions are bounded by cognitive and mental limits, how much information is processed, and values and assumptions. In other words, no matter the decision-making process, all decisions are limited by a variety of known and unknown factors. In a chaotic health care delivery environment, where regulations and standards of care are always changing, any decision may cause an unanticipated future problem. BACKGROUND Critical Thinking Critical thinking is both an attitude toward handling issues and a reasoning process. Critical thinking is not synonymous with problem solving and decision making ( Figure 4-1 ), but it is the foundation for effective decision making that helps to solve problems ( Fioratou et al., 2011 ). Figure 4-2 illustrates the way obstacles such as poor judgment or biased thinking create detours to good judgment and effective decision making. Critical thinking helps overcome these obstacles. Critical thinking skills may not come naturally. The nurse who is a critical thinker has to be open-minded and have the ability to reflect on present and past actions and to analyze complex information. Nurses who are critical thinkers also have a keen awareness of their surroundings ( Fioratou et al., 2011 ). FIGURE 4-2 Decision-making maze. Critical thinking is a skill that is developed for clarity of thought and improvement in decision-making effectiveness. The roots of the concept of critical thinking can be traced to Socrates, who developed a method of questioning as a way of thinking more clearly and with greater logical consistency. He demonstrated that people often cannot rationally justify confident claims to knowledge. Confused meanings, inadequate evidence, or self-contradictory beliefs may lie below the surface of rhetoric. Therefore it is important to ask deep questions and probe into thinking sequences, seek evidence, closely examine reasoning and assumptions, analyze basic concepts, and trace out implications. Other thinkers, such as Plato, Aristotle, Thomas Aquinas, Francis Bacon, and Descartes, emphasized the importance of systematic critical thinking and the need for a systematic disciplining of the mind to guide it in clarity and precision of thinking. In the early 1900s, Dewey equated critical thinking with reflective thought ( The Critical Thinking Community, 2008 ). Critical thinking, then, is characterized by thinking that has a purpose, is systematic, considers alternative viewpoints, occurs within a frame of reference, and is grounded in information ( The Critical Thinking Community, 2008 ). Questioning is implicit in the critical thinking process. The following are some of the questions to be asked when thinking critically about a problem or issue ( Elder & Paul, n.d. ): •  What is the question being asked? •  Is this the right question? •  Is there another question that must be answered first? •  What information is needed? •  Given the information, what conclusions are justified? •  Are there alternative viewpoints? No matter what questions are asked, critical thinkers need to know the “why” of the thinking, the mode of reasoning (inductive or deductive), what the source and accuracy of the information is, what the underlying assumptions and concepts are, and what might be the outcome of the thinking ( The Critical Thinking Community, 2008 ). Critical Thinking in Nursing Nurses in clinical practice continually make judgments and decisions based on the assessment and diagnosis of client needs and practice problems or situations. Clinical judgment is a complex skill grounded in critical thinking. Clinical judgment results in nursing actions directed toward achieving health outcomes ( Alfaro-LeFevre, 2009 ). Scheffer and Rubenfeld (2000) have stated that habits of the mind that are characteristic of critical thinking by nurses include confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, open-mindedness, perseverance, and reflection. Emphasizing the value of expert experience and holistic judgment ability, Benner (2003) cautioned that clinical judgments must not rely too heavily on technology and that the economic incentives to use technology must not come at the expense of human critical thinking and reasoning in individual cases. Critical thinkers have been distinguished from traditional thinkers in nursing. A traditional thinker, thought to be the norm in nursing, preserves status quo. Critical thinkers go beyond the step-by-step processes outlined in the nursing process and traditional problem solving. A critical thinker challenges and questions the norm and considers in the context of decision making potential unintended consequences. Unlike traditional thinkers, critical thinkers are creative in their thinking and anticipate the consequences of their thinking ( Rubenfeld & Scheffer, 2006 ). Creativity is necessary to deal with the complex twenty-first century health care delivery environment. Nurse leaders and managers have an obligation to create care delivery climates that promote critical thinking, which leads to innovative solutions to problems within the system of care ( Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine; Institute of Medicine, 2011 ; Porter-O’Grady, 2011 ). Such a climate encourages deep reflection, especially so that nurses feel safe to learn from mistakes, and encourages nurses to ask questions and consider a variety of viewpoints and alternative solutions to problems. What specific strategies can be used to promote a climate in which critical thinking is fostered? First and foremost, the nurse manager/leader, in the role of mentor, coach, or preceptor, should encourage questions such as “Is what you are doing or proposing based on sound evidence?” ( Ignatavicius, 2008 ). However, Snowden and Boone (2007) cautioned that “best practice, by definition is past practice” (p. 71). Therefore use of best practices needs to be examined carefully in order to use them appropriately. Staff nurses and managers must use critical thinking skills in order to determine the appropriateness of implementing recommended practice protocols. As managers, allowing staff and self “think time” is essential for reflection and is a key component of critical thinking ( Zori & Morrison, 2009 ). Nurse managers’ critical thinking abilities promotes a positive practice environment which can lead to better patient outcomes ( Zori, Nosek, & Musil, 2010 ). Coaching new and experienced nurses to develop expertise in clinical judgment is critically important. Many new nurses, in particular, need to further develop their critical thinking skills ( Fero et al., 2008 ; Forneris & Peden-McAlpine, 2009 ). In addition to having preceptors and others ask questions of new nurses, nurse managers and leaders can use other strategies to enhance critical thinking in nursing staff. Developing concept maps is another useful strategy to promote critical thinking. Although typically used in prelicensure programs ( Ellermann et al., 2006 ), nurse managers can encourage their preceptors to use concept maps with orientees ( Toofany, 2008 ). Developing concept maps in concert with others further develops a nurse’s critical thinking through the process of dialogue. Simulations also promote critical thinking or “thinking like a nurse” ( Tanner, 2006 ). According to Tanner, simulations can promote clinical reasoning, which leads to making conclusions in the form of clinical judgments and, thus, effective problem solving. The use of human patient simulators is well known in educational settings. Simulators may also be useful in orienting new graduates to the acute care setting ( Leigh, 2011 ). Pulman and colleagues (2009) have reported on the use of simulators to promote critical thinking role development in inter-professional environments. Decision Making Decision making is the essence of leadership and management. It is what leaders and managers are expected to do ( Keynes, 2008 ). Thus decisions are visible outcomes of the leadership and management process. The effectiveness of decision making is one criterion for evaluating a leader or manager. Yet staff nurses and nurse managers and leaders must make decisions in uncertain and complex environments ( Clancy & Delaney, 2005 ). Within a climate of uncertainty and complexity, nurse managers and leaders must also understand that all decision making involves high-stakes risk taking ( Clancy & Delaney, 2005 ; Keynes, 2008 ). If poor decisions are made, progress can be impeded, resources wasted, harm caused, and a career adversely affected. The results of poor decisions may be subtle and not appear until years later. Take, for instance, a decision to reduce expenses by decreasing the ratio of registered nurses to nurses’ aides. There may be a short-term cost savings, but if not implemented appropriately, this tactic may result in the gradual erosion of patient care over time (Kane et al., 2007). Unintended effects may include higher turnover of experienced nurses, increased adverse events such as medication errors, decreased staff morale, and lower patient satisfaction scores. The long-term outcome of this decision may actually result in increased expenses not reduced expenses. Thus it is vital for nurses to understand decision making and explore styles and strategies to enhance decision-making skills. Decision making, like traditional problem solving, has been traditionally thought of as a process with identifiable steps yet influenced by the context and by whether there is an intuitive grasp of the situation. However, Effken and colleagues (2010) stated that decision making is much more. Expert decision making is a constructive process in which the outcomes are not preplanned or simply pulled out of a memory bank. Instead, expert decision-making activities are creative, innovative, and adapted to uncertainty and the context of the current problem, using learning from prior experience (p. 189). Nurses make decisions in personal, clinical, and organizational situations and under conditions of certainty, uncertainty, and risk. Various decision-making models and strategies exist. Nurses’ control over decision making may vary as to amount of control and where in the process they can influence decisions. Although decision-making is more than a step-by-step process as noted by Effken and colleagues (2010) , awareness of the components, process, and strategies of decision making contributes to effectiveness in nursing leadership and management decision making. The basic elements of decision making, which enhances day to day activities, contributes to strategic planning and solves problems can be summarized into the following two parts: (1) identifying the goal for decision-making, and (2) making the decision. According to Guo (2008, p. 120) , the steps of the decision-making process can be illustrated as follows, using DECIDE: •  D efine the problem and determine why anything should be done about it and explore what could be happening. •  E stablish desirable criteria for what you want to accomplish. What should stay the same and what can be done to avoid future problems? •  C onsider all possible alternative choices that will accomplish the desired goal or criteria for problem solution. •  I dentify the best choice or alternative based on experience, intuition, experimentation. •  D evelop and implement an action plan for problem solution. •  E valuate decision through monitoring, troubleshooting, and feedback. Notice how these steps are analogous to the traditional problem-solving process or nursing process well-known by nurses and nurse managers. Thus decision making is used to solve problems. However, decision making is more than just problem solving. Decision making may also be the result of opportunities, challenges, or more long-term leadership initiatives as opposed to being triggered by an immediate problem. In any case, the processes are virtually the same, but their purposes may be slightly different. Nurse managers use decision making in managing resources and the environment of care delivery. Decision making involves an evaluation of the effectiveness of the outcomes that result from the decision-making process itself. Whether nurse managers are the sole decision makers or facilitate group decision making, all the factors that influence the problem-solving process also impact how decisions are made: who owns the problem that will result in a decision, what is the context of the decision to be made, and what lenses or perspectives influence the decision to be made? For example, the chief executive officer may frame issues as a competitive struggle not unlike a sports event. The marketing staff may interpret problems as military battles that need to be won. Nurse executives may view concerns from a care or family frame that emphasizes collaboration and working together. Learning and understanding which analogies and perspectives offer the best view of a problem or issue are vital to effective decision making. It may be necessary for nurse managers to expand their frame of reference and be willing to consider even the most outlandish ideas. Obviously, it is important to begin the goal definition phase with staff members who are closest to the issue. That includes staff nurses in concert with their managers. Often, decisions can originate within the confines of the shared governance system that may be in place within an organization ( Dunbar et al., 2007 ). It is wise, also, to consider adding individuals who have no connection with the issue whatsoever. Often it is these “unconnected” staff members who bring new decision frames to the meeting and have the most unbiased view of the problem. One of the core competencies for all health professionals is working in interprofessional teams ( Interprofessional Education Collaborative Expert Panel, 2011 ). Therefore using interprofessional teams for problem solving and decision making can be assumed to be more effective than working in disciplinary silos. No matter who is involved in the decision-making process, the basic steps to arrive at a decision to resolve problems remain the same. One critical aspect to note, however, is that in making decisions, nurse managers must have situational awareness ( Sharma & Ivancevic, 2010 ). That is, decision makers must always consider the context in which the outcome of the decision is to occur. A decision that leads to a desired outcome on one patient care unit may lead to undesirable outcomes on another unit because the patient care environment and personnel are different. DECISION OUTCOMES When looking at outcomes, one critical aspect of decision making is to determine the desired outcome. The desired outcome may vary, according to Guo (2008) , from an ideal or short-term resolution to covering up a situation. What is desired may be (1) for a problem to go away forever, (2) to make sure that all involved in this problem are satisfied with the solution and gain some benefit from it, or (3) to obtain an ideal solution. Sometimes a quick decision is desired, and researching different aspects of the problem or allowing for participation in decision making is not appropriate. For example, in disaster management, the nurse leader will use predetermined procedures for determining roles of the various personnel involved (Coyle et al., 2007). Desired decisions can be categorized into two end points: minimal and optimal. A minimal decision results in an outcome that is sufficient, satisfies basic requirements, and minimally meets desired objectives. This is sometimes called a “satisficing” decision . An optimizing decision includes comparing all possible solutions with desired objectives and then selecting the optimal solution that best meets objectives ( Choo, 2006 ; Guo, 2008 ). In addition to these two strategies, Layman (2011) drawing from Etzioni (1986) , discussed two other strategies: mixed scanning and incrementalism. Incrementalism is slow progress toward an optimal course of action. Mixed scanning combines the stringent rationalism of optimizing with the “muddling through” approach of incrementalism to form substrategies. Optimizing has the goal of selecting the course of action with the highest payoff (maximization). Limitations of time, money, or people may prevent the decision maker from selecting the more deliberative and slower process of optimizing. Still, the decision maker needs to focus on techniques that will enhance effectiveness in decision-making situations. Barriers to effective decision making exist and, once identified, can lead to going back through the decision-making process. Flaws in thinking can create hidden traps in decision making. These are common psychological tendencies that create barriers or biases in cognitive reflection and appraisal. Six common distortions are as follows ( Hammond et al., 1998 ; 2006 ): 1.  Anchoring trap: When a decision is being considered, the mind gives a disproportionate weight to the first information it receives. Past events, trends, and numbers outweigh current and future realities. All individuals have preconceived notions and biases that influence decisions in a variety of ways. For instance the Institute of Medicine (IOM, 2001) endorsed the use of c omputerized p hysician o rder e ntry (CPOE) as one solution to reduce medication errors. Furthermore, The Centers for Medicare and Medicaid Services has set forth meaningful use criteria for implementation of CPOE as well as electronic health records (EHR). Despite incentive payments for implementing EHR ( HFMA P & P Board, 2012 ), the financial costs involved, human-factor errors and work-flow issues can hamper successful implementation ( Campbell et al., 2006 ). 2.  Status-quo trap: Decision makers display a strong bias toward alternatives that perpetuate the status quo. In the face or rapid change in the environment, past practices that exhibit any sense of permanence provide managers with a feeling of security. 3.  Sunk-cost trap: Past decisions become sunk costs, and new choices are often made in a way that justifies past choices. This may result in becoming trapped by an escalation of commitment. Because of rapid, ongoing advances in medical technology, managers are frequently pressured to replace existing equipment before it is fully depreciated. If the new equipment provides a higher level of quality at a lower cost, the sunk cost of the existing equipment is irrelevant to the decision-making process. However, managers may delay purchasing new equipment and forgo subsequent savings because the equipment has yet to reach the end of its useful life. 4.  Confirming-evidence trap: Kahneman and colleagues (2011) noted that decision makers also fall into the trap of confirmation bias where contradictory data are ignored. This bias leads people to seek out information that supports an existing instinct or point of view while avoiding contradictory evidence. A typical example is favoring new technology over less glamorous alternatives. A decision maker may become so enamored by technological solutions (and slick vendor demonstrations) that he or she may unconsciously decide in favor of these systems even though strong evidence supports implementing less costly solutions first. 5.  Framing trap: The way a problem is initially framed profoundly influences the choices made. Different framing of the same problem can lead to different decision responses. A decision frame can be viewed as a window into the varied reasons a problem exists. As implied by the word frame , individuals may perceive problems only within the boundaries of their own frame. The human resources director may perceive a staffing shortage as a compensation problem, the chief financial officer as an insurance reimbursement issue, the director of education as a training issue, and the chief nursing officer as a work environment problem. Obviously all these issues may contribute, in part, to the problem; however, each person, in looking through his or her individual frame, sees only that portion with which he or she is most familiar ( Layman, 2011 ). 6.  Estimating and forecasting traps: People make estimates or forecasts about uncertain events, but their minds are not calibrated for making estimates in the face of uncertainty. The notion that experience is the parent of wisdom suggests that mature managers, over the course of their careers, learn from their mistakes. It is reasonable to assume that the knowledge gained from a manager’s failed projects would be applied to future decisions. Whether right or wrong, humans tend to take credit for successful projects and find ways to blame external factors on failed ones. Unfortunately, this form of overconfidence often results in overly optimistic projections in project planning. This optimism is usually buried in the analysis done before ranking alternatives and recommendations. Conversely, excessive cautiousness or prudence may also result in faulty decisions. This is called aversion bias ( Kahneman et al., 2011 ). Dramatic events may overly influence decisions because of recall and memory, exaggerating the probability of rare but catastrophic occurrences. It is important that managers objectively examine project planning assumptions in the decision-making process to ensure accurate projections. Because misperceptions, biases, and flaws in thinking can influence choices, actions related to awareness, testing, and mental discipline can be employed to ferret out errors in thinking before the stage of decision making ( Hammond et al., 1998 ). Data-driven decision making is important ( Dexter et al., 2011 ; Lamont, 2010 ; Mick, 2011 ). The electronic health record can be mined for valuable data, upon which fiscal, human resource, and patient care decisions can be made. However, the data derived can be overwhelming and cause decision makers to make less than optimal decisions. Shared decision making can help ameliorate decision traps ( Kahneman et al., 2011 ) because dissent within the group may help those accountable for the decision to prevent errors that are “motivated by self-interest” (p. 54). More alternatives can be generated by a group and more data can be gathered upon which to base the decision, rather than just using data that is more readily apparent. DECISION-MAKING SITUATIONS The situations in which decisions are made may be personal, clinical, or organizational ( Figure 4-3 ). Personal decision making is a familiar part of everyday life. Personal decisions range from multiple small daily choices to time management and career or life choices. FIGURE 4-3 Decision-making situations. Clinical decision making in nursing relates to quality of care and competency issues. According to Tanner (2006) , decision making in the clinical arena is called clinical judgment . In nursing, as with all health professions, clinical judgments should be patient-centered, use available evidence from research and other sources, and use available informatics tools (IOM, 2003). These crucial judgments should take place within the context of interprofessional collaboration. Within a hospital or other health care agency, a social network forms that is interprofessional ( Tan et al., 2005 ). This social network has to collaborate for positive change within the organization and to make clinical decisions of the highest quality. Nurses manage care and make decisions under conditions of certainty, uncertainty, and risk. For example, if research has shown that, under prescribed conditions, the selection of a specific nursing intervention is highly likely to produce a certain outcome, then the nurse in that situation faces a condition of relative certainty. An example would be the prevention of decubitus ulcers by frequent repositioning. If little knowledge is available or if the specific situation is more complex or variant from the usual, then the nurse faces uncertainty. Risk situations occur when a threat of harm to patients exists. Conditions of risk occur commonly relative to the administration of medications, crisis events, infection control, invasive procedures, and the use of technology in nursing practice. Furthermore, these conditions also apply to the administration of nursing care delivery, in which decision making is a critical function. Conditions of uncertainty and complexity are common in nursing care management. Over time, the complexity of health care processes has increased as a natural outgrowth of innovation and new technology. With computerized integration of billing, physician ordering, results of diagnostic tests, information about medications and their actions and side effects, and critical pathways and computerized charting, complexity increases more. Trying to integrate so many data points in care delivery can overwhelm the care provider who is making clinical judgments. As a result, subtle failures in any part of the information system can go unnoticed and have catastrophic outcomes. For example, if the computer system in the emergency room cannot “talk” to the system in the operating room, then errors in care management, such as giving cephalexin to patient who has an allergy can occur. If a provider fails to input critical information, such as a medication that a patient is taking, a fatal drug interaction could occur when another provider prescribes a new medication. Ready access to the Internet and online library sources can further create complexity in the decision-making process as care providers have access to more information upon which to make decisions. Readily accessible information related to evidence-based practice and information gleaned from human resources records and clinical systems can overwhelm nurse managers and leaders. Nurse leaders are coming to understand that innovation and new technology are the driving forces behind the discovery of new knowledge and improvements in patient care. Overlapping, unclear, and changing roles for nurses as a result of new technology and services create complex decision-making situations and impact the quality of care delivered (IOM, 2003). In addition, workflow interruptions can inhibit critical thinking, particularly in a chaotic environment ( Cornell et al., 2011 ; Sitterding et al., 2012 ). ADMINISTRATIVE AND ORGANIZATIONAL DECISION MAKING According to Choo (2006) , organizations use information to “make decisions that commit resources and capabilities to purposeful action” (p. 1). Nurse managers, for example, make staffing decisions and thus commit financial resources for the purpose of delivering patient care. Hospital administrators may decide to add additional services to keep up with external forces. These decisions subsequently have financial implications related to reimbursement, staffing, and the like. Etzioni (1989) noted that the traditional model for business decisions was rationalism. However, he further asserted that as information flow became more complex and faster-paced, a new decision-making model based on the use of partial information that has not been fully analyzed had begun to evolve. He called this model “humble decision making.” This approach arises in response to the need to make a decision when the amount of data exceeds the time available to analyze it. For instance, predicting the outcome of clinical and administrative decisions in health care is problematic because such processes are collectively defined as c omplex a daptive s ystems (CASs). A CAS is characterized by groups of individuals who act in unpredictable, nonlinear (not cause and effect) ways, such that one person’s actions affect all the others ( Holden, 2005 ). In CASs, humans do behave in unpredictable ways ( Tan et al., 2005 ). Critical thinking can help all health care personnel to examine these complex systems, wherein groups solve problems through complex, continually altering interactions between the environment and all involved in the decision making ( Fioratou et al., 2011 ). Situations within the environment constantly change and decision makers need to reframe their thinking as they broaden their awareness of the context of their decisions ( Sharma & Ivancevic, 2010 ). Having situation awareness is a must ( Fioratou et al., 2011 ; Sitterding et al., 2012 ). Decision makers need to make every effort to forecast unanticipated consequences of their decisions. For example if staffing is cut, what adverse events might occur (Kane et al., 2007)? Decision making is also influenced by the manager’s leadership style. A democratic/collaborative style of leadership and decision making works best in a complex adaptive system, such as a hospital, which is characterized by a large array of social relationships that can have an economic impact on an organization. Staff nurses who are not engaged in shared decision making may experience less job satisfaction and subsequently may leave an organization, leading to loss of expertise in patient care ( Gromley, 2011 ). However, the full array of leadership styles may at some time be used in the decision-making process. Vroom and Yetton (1973) proposed a classic managerial decision-making model that identified five managerial decision styles on a continuum from minimal subordinate involvement to delegation. Their model uses a contingency approach, which assumes that situational variables and personal attributes of the leader influence leader behavior and thus can affect organizational effectiveness. To diagnose the situation, the decision maker examines the following seven problem attributes: 1.  The importance of the quality of the decision 2.  Whether there is sufficient information/expertise 3.  The amount of structure to the problem 4.  The extent to which acceptance/commitment of followers is critical to implementation 5.  The probability that an autocratic decision will be accepted 6.  The motivation of followers to achieve organizational goals 7.  The extent to which conflict over preferred solutions is likely

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Decision making in nursing: an analytical approach

• PMID: 263800
• DOI: 10.1097/00005110-197811000-00017

Decision making is a basic function of all nurse leaders. Because of the complex nature of many decision situations faced by nurses, problem solving and decision making in nursing are as much an art as a science. The Vroom and Yetton model of decision making is an appropriate tool through which nurses involved in patient care management can examine their decision making and improve their decision behavior. Use of this model is suggested as an approach to teaching decision making at the undergraduate and graduate level of nursing education. Case material has been presented to help readers identify their favored methods of decision making and to point out possible deficiencies in these methods.

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• Rational decision making: managing uncertainty. Lancaster W, Lancaster J. Lancaster W, et al. J Nurs Adm. 1982 Sep;12(9):23-8. J Nurs Adm. 1982. PMID: 6921234 No abstract available.
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Research Article

Problem-solving ability and future time perspective among the Chinese nursing interns: The mediating role of future work self

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

* E-mail: [email protected] (JP); [email protected] (YW); [email protected] (LY); [email protected] (ZW)

Affiliation Nursing Department, Affiliated Hengyang Hospital of Hunan Normal University & Hengyang Central Hospital, Hengyang, Hunan Province, China

Roles Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Writing – original draft

Affiliation Nursing Department, Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Tianjin, China

Roles Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

Affiliation Children Respiratory Zone 2, Chenzhou No.1 People’s Hospital, Chenzhou, Hunan Province, China

Roles Formal analysis, Investigation, Validation, Writing – original draft

Affiliation School of Nursing, Guizhou Medical University, Guiyang, Guizhou Province, China

Roles Data curation, Funding acquisition, Project administration, Writing – review & editing

Roles Funding acquisition, Investigation, Methodology, Project administration

Roles Formal analysis, Investigation, Resources, Visualization

Affiliation School of Nursing, Tianjin University of Traditional Chinese Medicine, Tianjin, China

Roles Data curation, Investigation, Resources

Roles Conceptualization, Funding acquisition, Investigation, Methodology, Writing – original draft, Writing – review & editing

Affiliation Nephrology Department / Rheumatology and Immunology Department, The Second Affiliated Hospital of University of South China, Hengyang, Hunan Province, China

Roles Conceptualization, Resources, Validation

Roles Methodology, Project administration, Visualization, Writing – review & editing

Roles Conceptualization, Formal analysis, Investigation, Methodology

Affiliation Medical Laboratory, Affiliated Hengyang Hospital of Hunan Normal University & Hengyang Central Hospital, Hengyang, Hunan Province, China

Roles Methodology, Resources, Validation, Writing – original draft

Affiliation Operating Room, The Second Affiliated Hospital of University of South China, Hengyang, Hunan Province, China

Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft

Affiliation Gynecology Department, Chenzhou No.1 People’s Hospital, Chenzhou, Hunan Province, China

• Zhangyi Wang, 
• Yue Zhu, 
• Xiaoping Zhan, 
• Tingrui Wang, 
• Xiaochun Tang, 
• Liping Li, 
• Tao Su, 
• Huifang Zhou, 
• Li Liu, 

• Published: August 8, 2024
• https://doi.org/10.1371/journal.pone.0308669
• Peer Review
• Reader Comments

The significance of problem-solving ability has been confirmed in numerous studies worldwide, highlighting its role in enhancing the skills of nursing interns and reducing psychological pressure. However, existing research indicates that the problem-solving ability of nursing interns urgently needs to be further improved. Limited research has been conducted on the problem-solving ability of nursing interns, and the correlations among problem-solving ability, future time perspective, and future work self of Chinese nursing interns are unclear.

To investigate problem-solving ability, future time perspective, and future work self among the Chinese nursing interns, and to examine the relationships among these variables. Additionally, the study aims to explore the mediating role of future work self between problem-solving ability and future time perspective.

A cross-sectional and correlational design was employed, adhering to the quality reporting conformed to the STROBE Checklist. From May 8, 2023, to February 15, 2024, 1,251 nursing interns were recruited from 15 tertiary grade-A hospitals across six cities in China. The Demographic Characteristics Questionnaire, Social Problem-Solving Inventory, Future Time Perspective Inventory, and Future Work Self Scale were used. The data was analyzed using descriptive statistics, univariate, correlation, and process plug-in mediation effect analyses.

The total scores for problem-solving ability, future time perspective, and future work self were 64.39 ± 18.55, 45.08 ± 11.37, and 16.92 ± 5.28, respectively. Problem-solving ability was positively correlated with future time perspective ( r = 0.638, p < 0.001) and future work self ( r = 0.625, p < 0.001). Additionally, future work self partially mediated mediating role between problem-solving ability and future time perspective, accounting for 39.7% of the total effect.

The problem-solving ability, future time perspective, and future work self among the Chinese nursing interns were relatively moderate, indicating a need for improvement. It is suggested that nursing managers and educators should actively implement career management and planning programs. By enhancing the future time perspective and future work self of nursing interns, their problem-solving ability can be improved. This, in turn, will facilitate their adaptation to clinical work, enhance the quality of nursing care, and promote the development of their nursing profession.

Citation: Wang Z, Zhu Y, Zhan X, Wang T, Tang X, Li L, et al. (2024) Problem-solving ability and future time perspective among the Chinese nursing interns: The mediating role of future work self. PLoS ONE 19(8): e0308669. https://doi.org/10.1371/journal.pone.0308669

Editor: Mukhtiar Baig, King Abdulaziz University Faculty of Medicine, SAUDI ARABIA

Received: May 6, 2024; Accepted: July 24, 2024; Published: August 8, 2024

Copyright: © 2024 Wang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting information files.

Funding: This study was supported by the Tianjin Research Innovation Project for Postgraduate Students (CN) [grant numbers: 2021YJSS171], the Health Research Project of Hunan Provincial Health Commission (CN) [grant numbers: W20243278], the Tianjin University of Traditional Chinese Medicine Science and Technology Innovation Fund Project for College Students (CN) [grant numbers: ZX01], and the Hengyang Science and Technology Plan Project (CN) [grant numbers: 202222035776]. The funders of Zhangyi Wang, Liping Li, Yue Zhu, and Xiaochun Tang had role in study design, data collection and analysis, decision to publish, and preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

1. Introduction

With the development of modern medicine and the prevalence of a holistic nursing service model encompassing mind-body-social-spirit aspects, patients’ demands for nursing care are increasing. This requires nurses to possess higher comprehensive quality, theoretical knowledge, and clinical practice skills, such as problem-solving, scientific research, and teaching skills, as well as a solid educational background. Consequently, nurses’ roles and responsibilities are becoming more challenging [ 1 ]. Nursing students, as the reserve force of the nursing profession, often lack rational thinking and decision-making abilities when identifying patients’ various health problems. This deficiency is due to their changing environment and role, unskilled nursing techniques, and limited clinical experience. These factors easily lead to anxiety and psychological pressure, affecting their professional adaptation and development. At this time, nursing students are about to transition from being students to new nurses. Due to their inadequate problem-solving abilities, they may encounter various issues when facing complex and dynamic work pressures and transformation challenges. This situation is not conducive to stabilizing nursing talent and improving nursing quality [ 2 – 4 ].

Problem-solving ability is defined as the capacity to identify complex problems, develop effective and targeted solutions, implement them, and address the root causes of these problems. It is one of the essential competencies in a nurse’s career [ 5 , 6 ]. This ability helps individuals to identify problems and find solutions, and those with strong problem-solving abilities actively seek out resources to solve problems and adapt to unexpected situations [ 7 ]. In the nursing profession, problem-solving ability significantly impacts nurses’ performance, the quality of care, and patient health outcomes [ 7 ]. Nurses with high problem-solving abilities are more likely to establish harmonious and cordial interpersonal relationships in the work environment and better handle patients’ problems [ 5 ]. Furthermore, problem-solving ability helps to improve various abilities of nursing interns and reduce psychological stress [ 8 ]. However, several studies have shown that the problem-solving abilities of Chinese nursing students, especially nursing interns, are not at an optimal level and require significant improvement [ 9 – 11 ]. Therefore, nursing interns must develop problem-solving skills to improve their actual clinical ability, This will promote the personal development of nursing interns and improve the quality of nursing services and patient satisfaction.

However, existing research mainly focuses on the current state of problem-solving abilities among nursing students and newly recruited nurses, along with analyses of general demographic characteristics. There is a notable lack of research on the problem-solving abilities of nursing interns and the exploration of related correlational and mediating roles in China. Therefore, it is essential to investigate the problem-solving abilities of Chinese nursing interns and explore the relationships and mediating roles between these abilities and other related variables.

1.1. Literature review

Future time perspective can positively predict problem-solving ability..

Future time perspective refers to an individual’s self-perception, emotional experience, and direction of action regarding their potential for development, ultimately driving the individual to behave in ways that align with their future short- or long-term goals [ 12 ]. This perspective helps nursing interns better face the future, plan for it, and act accordingly, significantly impacting their future. Nursing interns who are more concerned about their future development are likely to have clearer plans and are more proactive in shaping their future. Such individuals are less afraid of difficulties, more rational and methodical, and more committed to achieving their goals. This approach leads to continuous improvement in their problem-solving abilities and motivation at work. However, research has shown that the future time perspective of Chinese nursing interns is currently at a poor level and needs to be further improved [ 13 ].

Future work self is a positive predictor of problem-solving ability.

Strauss et al. [ 14 ] first introduced the concept of the future work self, which is the degree to which an individual’s self-perception can imagine their future work with clarity. It was found that future work self can help individuals to better set career goals and clarify the behavioral paths they need to take [ 15 ]. According to self-regulation theory, the clearer an individual is about themselves, the more effectively their self-regulatory system can drive them towards their goals, resulting in more practical actions [ 16 ]. A positive future work self serves as a motivating factor, pushing individuals to pursue better performance at work [ 14 ]. Individuals with good future work self will put in more effort to reach their goals, thereby bridging the gap between their current reality and their future self at work [ 17 ]. Therefore, nursing interns with greater clarity of their future work self are likely to have greater problem-solving abilities. However, research has shown that the future work self of Chinese nursing interns is at a poor level and needs to be further improved [ 17 ].

Future work self may play a mediating role between problem-solving ability and future time perspective.

Individuals with a strong future time perspective are more focused on the future, anticipate future needs, and envision and plan their future work, a cognitive process that promotes a clearer imagination of their future work self-image and helps them develop a well-defined future work self [ 14 ]. Furthermore, when individuals have a well-defined future work self, they are more positive about their current work and are more likely to improve their problem-solving ability [ 18 ]. Thus, future work self may play a mediating role between problem-solving ability and future time perspective.

In summary, future time perspective and future work self may have a positive predictive effect on the problem-solving ability of nursing interns, and future work self may play a mediating role between problem-solving ability and future time perspective. However, existing research has primarily focused on the effects of variables such as critical thinking, self-directed learning, and psychological resilience on problem-solving ability. There has been no research on the correlation between problem-solving ability, future time perspective, and future work self among Chinese nursing interns. Thus, the correlations between problem-solving ability, future time perspective, future work self, and their mediating roles in the Chinese nursing interns remain open for further research. Based on the literature review and the aforementioned theory, the conceptual framework of this study was constructed, as shown in Fig 1 .

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https://doi.org/10.1371/journal.pone.0308669.g001

2. Objectives

This study aimed to (1) investigate the problem-solving ability, future time perspective, and future work self among Chinese nursing interns; (2) examine the correlations between problem-solving ability, future time perspective, and future work self; (3) explore the mediating role of future work self between problem-solving ability and future time perspective; and (4) provide a theoretical basis for constructing the interventional measures to improve the problem-solving ability of the Chinese nursing interns.

3.1. Study design

This study used a descriptive cross-sectional design and was conducted in China. The quality reporting of the study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (see S1 File ), which outline the necessary information to include in reports of cross-sectional studies.

3.2. Participants and settings

Convenience sampling was used to recruit nursing interns from 15 tertiary grade-A hospitals across six cities in China: Tianjin and Shijiazhuang in the north, and Guiyang, Changsha, Chenzhou, and Hengyang in the south. The recruitment period was from May 8, 2023, to February 15, 2024. Respondents met the following inclusion criteria: (1) clinical internship nursing students in their post; (2) internship duration ≥ 1 month; and (3) voluntary participation with written informed consent obtained. Those who were on leave or a leave of absence and those with serious physical and psychological illnesses were excluded from this study.

G*Power 3.1 software was used to calculate the minimum sample size required for correlation analysis (α error probability was 0.05 and test validity was 80%). According to related research, the average correlation coefficient among problem-solving ability, future time perspective, and future work self is 0.16 [ 19 – 21 ], and the sample size was calculated using a t -test. In G*Power 3.1 software, the t -tests method was selected, and "Correlation: Point biserial model" was selected. The parameters were set to an effect size |ρ| = 0.16, α = 0.05, and β = 0.80, resulting in a calculated total sample size of 237, which was the minimum sample size for this study. Ultimately, 1,251 participants were included in this study.

3.3. Measurements

3.3.1. the demographic characteristics questionnaire..

The Demographic Characteristics Questionnaire was developed and used to investigate 14 demographic characteristics of Chinese nursing interns. These characteristics included gender, age, educational background, residence, character traits, whether the intern is an only child, and whether the intern holds a student cadre position, among others.

3.3.2. The Social Problem-Solving Inventory (SPSI).

The Social Problem-Solving Inventory (SPSI) was used to assess the problem-solving ability of nursing interns. The scale, compiled by Wang et al. [ 19 ], comprises 25 items across 5 dimensions: "Negative problem orientation" (5 items), "Rational problem-solving" (5 items), "Positive problem orientation" (5 items), "Avoidance style" (6 items), and "Impulsive/negligent style" (4 items). Responses are scored using a Likert scale ranging from 1 (not at all) to 5 (very), with total scores ranging from 5 to 125 points. Higher scores indicate higher problem-solving ability. The scale demonstrated high internal consistency, with a Cronbach’s α of 0.925 in Wang et al.’s study and 0.963 in the current study.

3.3.3. The Future Time Perspective Inventory (FTPI).

The Future Time Perspective Inventory (FTPI), developed by Song et al. [ 20 ], was used to assess the future time perspective of nursing interns. The scale comprises 5 dimensions and 20 items: "Long-term target orientation" (5 items), "Future intentions" (4 items), "Behavioral commitments" (4 items), "Future effectiveness" (3 items), and "Awareness of purpose" (4 items). Responses are scored using a Likert scale ranging from 1 (not at all) to 4 (fully). The total score ranges from 20–80 points, with higher scores indicating a better future time perspective. The scale demonstrated high internal consistency, with a Cronbach’s α of 0.935 in Song et al.’s study and 0.928 in the current study.

3.3.4. The Future Work Self Scale (FWSS).

The Future Work Self Scale (FWSS), developed by Guan et al. [ 21 ], was used to assess the future work self of nursing interns. The scale consists of 1 dimension and 4 items: "I can easily imagine my future," "This future is easy for me to imagine," "The mental image of this future is very clear," and "I am very clear about who and what I want to be in my future work." Responses are rated on a 7-point Likert scale, ranging from "strongly disagree" to "completely agree." The total score ranges from 4 to 28 points, with higher scores indicating a stronger future work self. The scale demonstrated high internal consistency, with a Cronbach’s α of 0.913 in Guan et al.’s study and 0.968 in the current study.

3.4. Data collection

Participants were recruited from 15 tertiary grade-A hospitals in six cities across China (Tianjin and Shijiazhuang in the north; Guiyang, Changsha, Chenzhou, and Hengyang in the south) from May 8, 2023, to February 15, 2024. The investigation was conducted with the hospitals’ prior approval, focusing on individual departments and with the assistance of the head nurse in each department for questionnaire distribution. Unified instructions were provided to explain the study’s purpose, significance, and confidentiality to participants, who were then surveyed face-to-face using an online questionnaire. Several quality control measures were implemented to ensure the validity of the questionnaires: (1) each participant could fill out the questionnaire only once, as controlled by system settings; (2) participants were required to answer all questions; (3) questionnaires completed in less than one minute were excluded; (4) questionnaires with obviously contradictory answers were excluded (e.g., a 19-year-old with a master’s degree, which is implausible for the nursing profession in China); (5) questionnaires with obviously inconsistent personal information were excluded. These measures resulted in the collection of 1,273 questionnaires, of which 1,251 were valid, yielding an effective recovery rate of 98.3%.

3.5. Statistical analysis

Two researchers recorded and analyzed the raw data using Epidata 3.1 and IBM SPSS 21.0. Descriptive statistics (numbers and percentage distributions) were used to describe the demographic characteristics. Measurement data following a normal distribution were described using mean ± standard deviation (M ± SD). Group comparisons were performed using two independent sample t-tests or one-way ANOVA for normally distributed data. For non-normally distributed measurement data, the median and interquartile ranges were used, and group comparisons were conducted using Mann–Whitney U or Kruskal–Wallis tests. Pearson’s correlation analysis was used to explore correlations between normally distributed variables, while Spearman correlation analysis was used for non-normally distributed variables. The PROCESS plug-in mediation effect analysis was used to investigate the mediating role of future work self between problem-solving ability and future time perspective, with statistical significance set at p < 0.05 (two-tailed).

3.6. Ethics approval and consent to participate

The study protocol was approved by the Medical Ethics Committee of Hengyang Central Hospital (2023-027-08). Written informed consent was obtained from each participant. All procedures were performed per the principles of the Declaration of Helsinki and relevant guidelines and regulations in China. After obtaining permission from hospital administrators, the researchers approached the participants with the help of the head nurses. The participants were given the right to refuse or withdraw from this study. The questionnaires were designed to ensure anonymity and confidentiality, with no identifying marks, names, or numbers linked to the participants. The data obtained were only used for academic research and not commercial purposes.

4.1. Demographic characteristics

A total of 1,273 Chinese nursing interns were recruited from 15 tertiary grade-A hospitals in six cities across China to participate in the survey. Notably, 22 nursing interns were excluded from the study because of their inconsistent answers, resulting in a final sample of 1,251 nursing interns. Among these participants, 204 (16.3%) were male and 1,047 (83.7%) were female. The age distribution was as follows: 1,030 (82.3%) were aged 19 to less than 22 years old, 189 (15.1%) were aged 22 to less than 24 years old, and 32 (2.6%) were aged 24 years or older. Other demographic characteristics and the results of the univariate analysis are presented in Table 1 .

https://doi.org/10.1371/journal.pone.0308669.t001

4.2. Scores of problem-solving ability, future time perspective, and future work self

The problem-solving ability score was 64.39 ± 18.55, and the average SPSI score was 2.58 ± 0.92. Among the dimensions of the SPSI, "Avoidance style" had the highest average score (2.77 ± 0.96), while "Negative problem orientation" had the lowest (2.21 ± 0.89). The average scores of "Rational problem-solving," "Positive problem orientation," and "Impulsive/negligent style" were 2.69 ± 0.93, 2.62 ± 0.95, and 2.53 ± 0.91, respectively.

The total score for the future time perspective was 45.08 ± 11.37, and the average FTPI score was 2.25 ± 0.63. Among the five dimensions of the FTPI, "Awareness of purpose" had the highest average score (2.42 ± 0.93), while "Future effectiveness" had the lowest (2.11 ± 0.58). The average scores for "Long-term target orientation," "Behavioral commitments," and "Future intentions" were 2.31 ± 0.65, 2.22 ± 0.70, and 2.16 ± 0.62, respectively.

The total score for future work self was 16.92 ± 5.28, and the average FWSS score was 4.23 ± 1.27. The SPSI, FTPI, and FWSS scores are presented in Table 2 .

https://doi.org/10.1371/journal.pone.0308669.t002

4.3. Relationships between problem-solving ability, future time perspective, and future work self

The total problem-solving ability score was positively correlated with the total future time perspective score ( r = 0.638, p < 0.01), with positive correlations observed across all dimensions ( r = 0.603–0.642, p < 0.01). Additionally, the total problem-solving ability score was positively correlated with the total score for future work self ( r = 0.625, p < 0.01), with positive correlations also observed across all dimensions ( r = 0.586–0.621, p < 0.01), as shown in Table 3 .

https://doi.org/10.1371/journal.pone.0308669.t003

4.4. Mediating effect of future work self between problem-solving ability and future time perspective

The total impact of future time perspective on problem-solving ability was 0.451 ( p < 0.01), with a 95% confidence interval (CI) of 0.225–0.512. The direct effect of future time perspective on problem-solving ability was 0.272 ( p < 0.01), with a 95% CI of 0.208–0.483. The indirect effect of future work self on problem-solving ability was calculated as 0.573×0.312 = 0.179, accounting for 39.7% of the total effect value of 0.451 ( p < 0.01). The bootstrapped CI ranged from 0.136 to 0.288, which, excluding 0, indicates that the difference was statistically significant ( p < 0.05), as shown in Table 4 and Fig 2 .

https://doi.org/10.1371/journal.pone.0308669.g002

https://doi.org/10.1371/journal.pone.0308669.t004

5. Discussion

5.1. status quo of the problem-solving ability, future time perspective, and future work self.

The total score for problem-solving ability among the 1,251 Chinese nursing interns was 64.39 ± 18.55. The average score was 2.58 ± 0.92, which is relatively low compared to the median score of 75.00, similar to the findings of Yalin et al. [ 10 ]. "Avoidance style" had the highest score, followed by "Rational problem solving", "Positive problem orientation", and "Impulsive/negligent". This finding indicates that while most nursing students view problems as challenges and follow the principles and strategies of effective problem-solving to solve them rationally and systematically, they tend to procrastinate, depend on others, be passive, inactive, panic, and become distracted, leading to incomplete problem resolution. The reasons for this may be that nursing interns face a change of environment and role after entering clinical practice, and their lack of clinical experience, inexperience in nursing practice, poor ability to deal with emergencies, and tensions in the nurse-patient relationship make them prone to adopt an avoidance style when solving problems [ 22 ]. As future leaders in nursing, the problem-solving ability of nursing interns is crucial for improving the quality of nursing care and promoting the development of the nursing profession [ 23 ]. Therefore, it is suggested that schools and clinical instructors focus on the cultivation of the problem-solving ability of nursing interns, actively conduct training programs on problem-solving ability, and promote the improvement of the clinical nursing ability of nursing interns using flipped classrooms, nursing check-ups, and nursing ability competition for nursing interns. Such initiatives can improve the problem-solving ability of nursing interns.

The total future time perspective score for the 1,251 Chinese nursing interns was 45.08 ± 11.37, with an average score of 2.25 ± 0.63, indicating an intermediate level. This score is lower than that reported by Liu et al. [ 24 ]. Among the dimensions, the highest score was for the "Awareness of purpose" dimension, indicating that nursing interns are concerned about their future development and have a clear understanding of their future. The lowest score was for the "Future effectiveness" dimension, indicating a lack of confidence among nursing interns in their ability to create a better future. This may be due to a lack of work experience, poor communication ability with patients, and a tendency to feel overwhelmed in the face of unexpected situations, as well as a lack of awareness of the values of the nursing profession and a general perception that nursing has a heavy workload and low social status. Future time perspective is a value belief that leads to the formation of future goals, which can facilitate continuous self-adjustment by nursing interns and lead to changes in their cognition and behavior [ 24 ]. Therefore, it is suggested that schools and hospital lead teachers emphasize the importance of professional values education. This can be achieved by discussing the meaning, importance, and development prospects of the nursing profession through additional professional quality elective courses and role model education. Such initiatives aim to enhance nursing interns’ confidence in the nursing profession and enable them to approach problems during their internships with a positive mindset.

The total score of future work self for the 1,251 Chinese nursing interns was 16.92 ± 5.28, with an average score of 4.23 ± 1.27, also at an intermediate level. This score is lower than the results reported by Fris et al. [ 25 ] study on medical students, indicating that nursing interns’ perceptions of their future work development and goals were not clear enough. The reasons for this may be that: (1) career planning education in higher education institutions in China is still in its infancy and fails to meet the needs of practicing nurses [ 26 ] and (2) nursing students tend to feel confused about their future career development due to heavy tasks and high learning pressure during their internship. Research has shown that future work self can motivate individuals to engage in more proactive career behaviors [ 14 ]. Therefore, it is suggested that schools and hospital instructors focus on cultivating the career planning abilities of nursing interns. This can be accomplished by offering career planning courses and organizing activities such as presentations of outstanding nurses’ achievements and Satya group counseling sessions to improve nursing interns’ future work self and career clarity.

5.2. Positive correlations between problem-solving ability, future time perspective, and future work self

A positive correlation was observed between the problem-solving ability of nursing interns and their future time perspective ( r = 0.638, p < 0.01), i.e. the higher the level of future time perspective, the stronger the problem-solving ability of nursing interns, which is consistent with the study of Mulyono et al. [ 13 ]. Future time perspective refers to an individual’s self-perception, emotional experience, and direction of action regarding potential possibilities for development, and ultimately drives the individual to act in ways that align with their short- and long-term goals [ 12 ]. It has been argued that more future-oriented individuals tend to have greater problem-solving abilities, as future time perspective can facilitate the development of creative problem-solving skills [ 27 ]. According to cognitive-motivational theory, future time perspective originates from motivational goals and is shaped by a cognitive outlook that allows individuals to predict the future over a longer period. This perspective enables individuals to plan motivational goals and tasks that guide current behavior, ultimately facilitating the achievement of future goals [ 28 ]. Therefore, a high level of future time perspective can motivate nursing interns to grow and progress academically, thereby improving their problem-solving ability. For this reason, it is recommended that nursing educators and managers focus on the development of future time perspective in nursing interns and improve their future time perspective through professional values education, psychological counseling, and training in nurse-patient communication ability, thereby improving their problem-solving ability.

Additionally, the study found that the problem-solving ability of nursing interns was positively correlated with their future work self ( r = 0.625, p < 0.01). Future work self refers to the degree to which an individual’s future work self is clear and easy to imagine [ 14 ]. Future work self is a motivational resource, encouraging self-improvement and proactive investment in current resources to gain other valuable resources [ 14 ]. According to resource conservation theory, individuals are more likely to invest their resources in activities that bring a return on resources, and problem-solving ability significantly impacts the psychological quality and overall capability of nursing interns, bringing them more resources [ 29 ]. As a result, nursing interns with high levels of future work self are more likely to take steps to improve their problem-solving ability to access more resources. For this reason, it is recommended that nurse educators and administrators strengthen career planning education for student nurses and provide opportunities such as mock interviews to increase their confidence in their future work and thus improve their problem-solving ability.

5.3. Mediating role of future work self between problem-solving ability and future time perspective

The results demonstrated that future work self partially mediates mediating role between problem-solving ability and future time perspective, with a mediating effect of 39.7% ( p < 0.01). This suggests that future time perspective not only improves the problem-solving ability of nursing interns but also improves problem-solving ability by increasing future work self. The study showed that individuals with a strong future time perspective tend to be more focused on the future, anticipate future needs, and envision and plan future work for themselves, leading to the development of a clear future work self [ 14 ]. According to the theory of planned behavior, when nursing interns have a clear future work self, they believe that their current efforts will help them achieve their future work goals. Consequently, they maintain a positive, optimistic, and forward-looking attitude toward their current work and feel more perceptual control over their tasks. Driven by these positive attitudes and perceptual control, nursing interns are likely to be enthusiastic, energetic, and willing to share their knowledge at work. This environment fosters their creative problem-solving abilities [ 18 ]. Based on these findings, it is recommended that nursing educators and managers focus on the impact of future time perspective and future work self on interns’ problem-solving ability and construct intervention programs to improve nursing interns’ problem-solving ability by increasing their future time perspective and future work self.

5.4. Strengths and limitations

This study is innovative for several reasons. Firstly, there is limited research on the problem-solving ability of Chinese nursing interns. Secondly, existing research on problem-solving ability has primarily focused on variables such as critical thinking, psychological flexibility, and self-efficacy. This study, however, explores the impact of future time perspective and future work self on the problem-solving ability of nursing interns from the perspective of career planning, which is precisely applicable to nursing interns who are about to enter clinical practice. Additionally, the study suggests that nursing managers and educators should emphasize the development of nursing interns’ career planning abilities, and its findings have significant implications for improving the problem-solving abilities of nursing interns.

However, there were some limitations to this study. First, it used a convenience sampling method, enrolling only 1,251 Chinese nursing interns from 15 tertiary grade-A hospitals in six cities across China (Tianjin and Shijiazhuang in the north; Guiyang, Changsha, Chenzhou, and Hengyang in the south). This may result in unrepresentative samples and potentially biased, non-generalizable, or limited findings. Future research should employ random, multi-center sampling with a larger sample size to address this limitation. Second, the study’s cross-sectional design may restrict the ability to establish causal relationships. Further longitudinal research is needed to better understand the mechanisms underlying the relationships identified in this study. Third, the study relied solely on an online questionnaire, which might have disadvantages in terms of the accuracy of responses and on-site quality control. Future studies should combine online and offline surveys to reduce potential biases. Lastly, the study did not employ multiple linear regression analysis to examine the factors influencing problem-solving ability, future time perspective, and future work self. Future research should include a larger number of nursing interns from diverse regions and investigate the factors that influence problem-solving ability more rigorously.

6. Conclusion

This study found that the problem-solving ability, future time perspective, and future work self among 1,251 Chinese nursing interns were relatively moderate and needed improvement. In addition, there were significant and positive correlations between problem-solving ability, future time perspective, and future work self. Future work self played a mediating role in the change in problem-solving ability and future time perspective. Based on these findings, it is suggested that nursing managers and educators should actively carry out career management and planning. By improving the future time perspective and future work self of nursing interns, their problem-solving abilities can be enhanced. This will facilitate their adaptation to clinical work, improve the quality of nursing care, and promote the development of nursing careers.

Supporting information

S1 file. strobe checklist..

https://doi.org/10.1371/journal.pone.0308669.s001

S2 File. Dataset used for the study.

https://doi.org/10.1371/journal.pone.0308669.s002

S1 Appendix. Questionnaires for the study.

https://doi.org/10.1371/journal.pone.0308669.s003

Acknowledgments

All researchers would like to express our gratitude to all the participants for taking their precious time to participate in this study, and also thank the hospital managers and nursing administrators for their strong support and help to this study. Furthermore, we would like to thank KetengEdit ( www.ketengedit.com ) for its linguistic assistance during the preparation of this manuscript.

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• v.6(4); Oct-Dec 2016

Effect of training problem-solving skill on decision-making and critical thinking of personnel at medical emergencies

Mohammad heidari.

Department of Nursing, School of Nursing and Midwifery, Shahrekord University of Medical Sciences, Shahrekord, Iran

Sara Shahbazi

1 Department of Nursing, Borujen Nursing Faculty, Shahrekord University of Medical Sciences, Shahrekord, Iran

Background:

The aim of this study was to determine the effect of problem-solving training on decision-making skill and critical thinking in emergency medical personnel.

Materials and Methods:

This study is an experimental study that performed in 95 emergency medical personnel in two groups of control (48) and experimental (47). Then, a short problem-solving course based on 8 sessions of 2 h during the term, was performed for the experimental group. Of data gathering was used demographic and researcher made decision-making and California critical thinking skills questionnaires. Data were analyzed using SPSS software.

The finding revealed that decision-making and critical thinking score in emergency medical personnel are low and problem-solving course, positively affected the personnel’ decision-making skill and critical thinking after the educational program ( P < 0.05).

Conclusions:

Therefore, this kind of education on problem-solving in various emergency medicine domains such as education, research, and management, is recommended.

INTRODUCTION

Having strong coping skills to reduce stress and satisfaction on the decision-making process to be creative and also having problem-solving skill is necessary in life.[ 1 ] In this way, learning should be defined “meaningful” and problem-solving skill is one of these ways.[ 2 ]

Unfortunately, traditional teaching method in universities transfers a mixture of information and concepts to individuals but leaves them alone in analyzing, prioritizing, and reorganizing emerging knowledge which requires critical thinking and will lead to effective and meaningful learning.[ 3 ] Critical thinking is considered is an essential part of clinical decision-making and professional competence of nursing staff and medical emergencies. Emphasize the need for this skill in these jobs is due to rapid change in the healthcare field and complexities of this current system,[ 4 , 5 ] which face staff working in health–care services with the special situation to render safe, decent, and high–quality services. In general, health–care staff has to use critical thinking in taking important and vital decisions inevitable.[ 6 ]

Education experts agree that critical thinking should be an integral part of any education in every level, because, it is thinking that will lead to make a decision the best possible solution with analyzing, assessing, selecting, and application and this is what is needed in the contemporary world of today.[ 5 ] Interest in the abilities of critical thinking in educational circles is not a new phenomenon, and its origin dates back to Plato's Academy.[ 7 ]

Accordingly, this skill is considered as a priority in training medical specialties.[ 8 ] However, using and expanding it by staff of medical emergencies is a necessity,[ 9 ] which causes delineating comprehensive and purposeful care plan and also increasing the probability of success in the management of victims and the scene.[ 10 , 11 ]

Furthermore, increase the number and scale of natural disasters over the past decade has caused that staff of medical emergencies, working in the field of healthcare and treatment cares in current situation, face with very complicated problems comprehensively as a result of advanced technology, ethical and cultural factors. In this regard, it is necessary that traditional methods should be replaced with decentralized emergency management systems to meet demands and attain considerable success in severe events and catastrophic disasters. Some of these techniques use decision-making skills, creative thinking, and problem-solving skill in today's world.[ 12 , 13 ]

Critical thinking skills in medical education are considered as the ultimate goal of learning and staff and personnel, who think creatively and critically, less commit false judgment and conclusion, rather, they try to concentrate on topics that are relevant to the clinical area and adopt proper decision in this respect, the issue of which can reduce gap between theoretical and clinical education to a great extent.[ 14 ]

However, making a decision is considered the most important and risky part of health–care professions. Therefore, knowing the decision making and applying useful strategies for creating this skill is essential for health–care personnel, particularly, the staff working in medical emergencies.[ 15 ] Triage is just one of complicated decision-making examples which include considering patient and other factors of the treatment system.[ 16 ]

Therefore, knowing decision-making and applying fruitful strategies for the creation of this skill is essential for healthcare workers, especially those working in medical emergencies.[ 17 ] Considering the job sensitivity of medical emergencies’ staff and significance of decision-making power and ability of solving problem in them,[ 18 ] as well as selecting and adopting accurate decision at the time of triage of patients, they (health-care workers) are in dire need of skill more than anything else to adopt proper decision.

On the other hand, moreover all these problems, staff working in medical emergencies will face unique problems which are specific to their job environment such as working with multiple staff and people in treatment team of patients and crisis–hit families, happy and sad moments, life and death, accidents and disaster.[ 19 , 20 , 21 , 22 ]

Therefore, with due observance to the said issues, the effect of training problem-solving skills on decision-making power and critical thinking of staff working in medical emergencies is the main aim of this study.

MATERIALS AND METHODS

This is an experimental study with two pre- and post–test stages, in which, effect of teaching problem-solving skill (independent variable) has been studied on decision-making skill and critical thinking of 95 staff working in medical emergencies (dependent variable). This 95 staff was divided into two groups: Experimental ( n = 47) and control ( n = 48). A sample of this study includes all staff working in medical emergencies as many as 95 persons who showed their interest to participate in this study. Purposive sampling method and size in this study were similar to the total population. In Iran, prehospital emergency medical handled by the graduate of an emergency medical technician and a bachelor and only men is graduates in this field. Moreover, there are a number of general physicians in the central dispatch who provide medical consultation for people who call emergency medical services (EMS) and also give medical advice to the technicians who treat victims at the crash scene or on the way to the hospital.[ 23 ]

Then, all personnel filled out a demographic variables’ questionnaire. In this questionnaire, it was tried to control factors affecting decision-making power and critical thinking (such as age, marital status, working experience, education, number of children, mental illness and consumption of psychotropic drugs and experience of participating in classes (emotional intelligence, stress management, yoga, problem-solving and decision-making within 6 months) in each two groups. In this regard, any significant difference was not observed between research units in both groups ( P > 0.05). decision-making and critical thinking skill of personnel was evaluated before and after the intervention.

Decision-making skill was evaluated in twenty questions using decision-making questionnaire. According to Likert Scale, each question was scored in four levels from 0.25 to 1. The minimum and maximum score in this questionnaire stood at 5 and 20, respectively. In other words, the lowest score in this questionnaire was calculated 5, whereas the highest score stood at 20. Translation and preparation stages of questionnaire were conducted.

In the same direction, face and content validity of the questionnaire was approved by five professors. The reliability of this test was obtained at 0.87 and approved using retest method in a 2-week time interval for 30 persons.

California critical thinking skills’ test is not a test only, rather, it includes various editions for measuring critical thinking skills in children, young adults, students in various academic levels and also various health, law and business professions, etc.

Questions of the questionnaire are divided into two forms. In one classification, three cognitive critical thinking skills including analyzing, evaluating, and inference are measured while in the second category, two cognitive skills of inductive reasoning and deductive reasoning are evaluated. In fact, all forms and various editions of this test are measured the five mentioned cognitive skills.[ 24 ]

The questionnaire used in this study consists of 34 four or five option questions with only one option is correct. The timeframe for completing this questionnaire was set about 45 min. Some questions should be answered with thinking and inferring a series of assumptions while some others should be answered with well–grounded assessment of a conclusion.

This questionnaire is appropriate for evaluating students’ critical thinking and also for assessment of those people who are in dire need of solving problem and making a decision.[ 25 ] Scores of questionnaire assess general skills of critical thinking. The range of test scores is between 0 and 34.[ 26 ]

In a study conducted by Khalili et al . on 405 students in Nursing at Tehran, Iran and Shahid Beheshti Universities of Medical Sciences, Persian translation of this form was studied in terms of validity and reliability. The reliability coefficient obtained in the above study, using KR-20 (62%), had a high correlation with the reliability coefficient obtained in the standardization process of this test conducted in the US (68%-70%).

Furthermore, construct validity, which has been translated as the most important validity type in tests, indicates correlation between the structure of this test and its basic theory.[ 27 ]

To control data transfer between personnel of test and control groups, personnel of the experimental group were requested not to talk with the control group at the time of research with regard to the conducted interventions.

Then, training a course of problem-solving skill was held in eight 2-h sessions during 8 weeks in the presence of personnel of experimental group, using group discussion methods, brainstorming and discussion in small four–member groups with the guidance of a pertinent professor, taking advantage of social problem-solving model as practiced by D–zurilla and gold fried. The stages of this model include:

Stage 1: General orientation

• The ability to identify problem
• Acknowledging the problem as a changeable potentially natural phenomenon
• Believed to be effective in dealing with the problem-solving framework
• High self–efficiency expectations to implement stages of model
• Accustomed to stop, think, and then making effort to solve a problem.

Stage 2: Defining and formulating the problem

• Collection of all information available
• Separation of facts is of the assumptions which require investigation
• Analysis of the problem
• Specifying the actual objectives.

Stage 3: Production of alternative solutions

• To determine wide range of possible solutions
• Ability to choose the most effective response to replies.

Stage 4: Decision-making

• Predict probable consequences of each action
• Paying due attention to the usefulness of these consequences.

Stage 5: Implementation of solution

• Execute the selected method.

Stage 6: Review

• Observing the results of execution
• Evaluation.[ 19 ]

All sessions of the training course were designed in tandem with this pattern, and one stage of this pattern was executed in each session.

In each session, so the presence of all members of the experimental group, the instructor explained the objectives of the meeting and the participants requested that their experiences in dealing with different problems on the job fit the theme of the meeting, express. Then, discuss a case study, and participation in meeting goals, training was provided to them.

To analyze data, descriptive and inferential statistics were used. In this study, data were analyzed using SPSS statistical software version 16.0 (SPSS Inc. Released 2009. PASW Statistics for Windows, Version 16.0. Chicago: SPSS Inc.) In addition, statistical t -test, Chi–square test, and paired t -test were used.

This study was conducted on 95 personnel of medical emergencies. 100% of participants in this study were men, and all were employed in prehospital emergency centers in Isfahan Province. It should be noted that only men are presently admitted to medical emergencies’ course. The age range of participants was between 23 and 51 years, and their mean age stood at 32.15 ± 5.21.

Of total participants, 29 (30.52%) and 66 (69.47%) persons were single and married, respectively. The minimum and maximum job experience of participants in this study stood at 1 and 29 years, respectively. The mean work experience of all participants stood at 33.6 ± 5.42. Of total participants in this study, 10 participants (10.52%) held a diploma degree, 32 participants (33.68%) with associate's degree, 50 participants (52.63%) with Bachelor's degree and three participants (3.15%) with Master's degree. Of total participants, 48 persons (50.52%) graduated in nursing, 25 persons (26.31%) in medical emergencies, nine persons (9.47%) in anesthesiology, five persons (5.26%) in operating room, and eight persons (8.42%) graduated in other fields of study.

In terms of employment status, 20 of participants (2.10%) were official crew members, whereas 54 participants (56.84%) had been employed in contracting basis, 11 of participants (11.57%) employed in contractual basis, whereas 10 participants (10.52%) had been employed as corporate manpower.

It should be noted that 60 participants (63.15%) were employed in urban emergency bases while 35 of them (36.84%) had been employed in road emergency centers.

Before intervention, mean and standard deviation of decision-making scores in experimental and control groups stood at (12.85 ± 2.57) and (11.79 ± 2.12), respectively, while total score of critical thinking in test and control groups stood at (10.42 ± 1.85) and (10.61 ± 2.12), respectively.

Given the above issue, independent t -test did not show a significant statistical difference between these means. Furthermore, Chi–square statistical test showed that there is not any significant difference between two groups of “experimental” and “control” statistically in terms of demographic variables. None of the groups, that is, “experimental” and “control” showed experience of participating in the following classes such as “yoga,” “problem solving,” “emotional intelligence,” and “stress control and management.”

The average decision-making score in whole samples before intervention stood at 11.84 ± 1.38 while critical thinking score stood at 11.03 ± 1.09, the rate of which is not acceptable.

The mean decision-making score before intervention showed no a significant difference between the two groups statistically ( P > 0.05), but the mean between two groups showed the significant difference after intervention ( P < 0.05) [ Table 1 ]. The mean score of critical thinking did not show any significant difference between the two groups before the intervention ( P > 0.05), but this mean showed a significant difference between the two groups after intervention ( P < 0.05) [ Table 2 ].

Comparing mean change of decision-making skill score before and after intervention

Comparing mean change of critical thinking scores’ difference before and after intervention

Tables ​ Tables3 3 and ​ and4 4 indicate that mean decision-making and critical thinking scores before and after intervention in “experimental” group showed a significant difference ( P < 0.05) and has increased, but it did not show any significant difference in “control” group ( P > 0.05).

Comparing mean difference of decision-making skill scores before and after intervention

Comparing mean difference of critical thinking scores before and after intervention

Any significant relationship was not observed between demographic variables with critical thinking and decision-making power ( P > 0.05).

The results of this study show the weakness of decision-making and critical thinking skill in personnel of medical emergencies and an increase of this skill with training problem-solving skill. Unfortunately, a study has not thus far been conducted with regard to the determination of decision-making skill among personnel of medical emergencies.

In a study which was conducted by Gunnarsson and Stomberg in Sweden, he examined factors affecting decision making among EMS personnel in emergency centers. In his study, he reported that various factors affect decision-making power of these personnel which includes as follows: Factors related to patient, factors related to the environment, factors related to colleagues, factors related to patients’ privacy issues, performance of team leader, staff technical know–how and knowledge and moral contradictions, etc.[ 28 ] It should be noted that these issues make decision making very difficult for these people and sometimes, would lead to unsuccessful decisions.[ 26 ]

In a study conducted by Franklin et al ., they examined the way of decision-making among staff of medical emergency and reported that method of staff's decision-making has high relationship with the mental processes, cognitive abilities, degree of sensitiveness of decision, power of cognition (judgment), solving problem, and organizational situation of their workplace. Therefore, quality decision-making training courses should be organized at higher levels by adopting better decisions. Hence, to make better decision, staff must make an educated decision at higher levels, and education in healthcare environment merely should go step further. Generally speaking, high–level training courses should be disseminated in this regard.[ 29 ]

Furthermore, results of study conducted by Dy and Purnell showed that a variety of factors effect on the complexity of decision-making process among personnel in healthcare and treatment system, the most important of which include as follows: ability and talent of individuals, level of culture, ability of patient, level of knowledge and information, method of establishing relationship, ability of solving problem, etc. To adopt the best decision, personnel should strengthen and improve the aforesaid skills among themselves.[ 30 ]

Pitt et al . also reported that promoting critical thinking skills can increase professional competency and qualifications of nurses to a great extent, the issue of which as of paramount importance for personnel working in special emergency wards.[ 31 ]

Thaiposri and Wannapiroon also studied the impact of conceptual methods in promoting critical thinking skill and enumerated problem-solving method as one of methods of strengthening and improving critical thinking skill which is a solid evidence of the said claim.[ 32 ]

Popil also showed that the critical thinking skill can be promoted using challenge methods such as case study.[ 9 ] The results a study conducted by Roberts et al . and Heidari and Ebrahimi emphasizing on decision-making skill, confirm these results.[ 33 , 34 ]

With due observance to the results of this study and given the significance which is considered for empowering associate's degree personnel of medical emergencies in terms of problem-solving skills, it can be concluded that these skills are weak among them. Hence, to attain the best decisions, providers should receive on-the-job training to foster strong problem-solving and decision-making skills that can be utilized in the field and on the front lines of Iranian emergency medicine.

CONCLUSIONS

Finally, despite the significance of decision making and its influence on the way of managing and caring victims, the results of studies conducted in Iran show the insufficient skill of personnel in decision-making and critical thinking process.

Considering the job sensitivity of staff working in medical emergencies and significance of decision-making power and ability of critical thinking in them, it can be said that giant stride can be taken in line with promoting scientific and job level of associate's degree personnel working in medical emergencies.

In general, status of this scientific course can be promoted to a great extent. Considering that this study has been conducted among students in medical emergencies, generalization of results of this study to other students is impossible, so that this study is recommended to be conducted in other academic courses with high number of students.

In other words, results of this study cannot be generalized to other students. For this reason, this study is recommended to be conducted for students of other academic courses.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.