Berkow, Steven JD; Virkstis, Katherine ND; Stewart, Jennifer BA; Aronson, Sarah AB; Donohue, Meghan AB
Author Affiliations: Executive Director (Dr Berkow), Senior Consultant (Dr Virkstis), Practice Manager (Ms Stewart), Consultant (Ms Aronson), Nursing Executive Center, The Advisory Board Company, Washington, District of Columbia; Master's in Public Health Candidate (Ms Donohue), Rollins School of Public Health, Emory University, Atlanta, Georgia.
Correspondence: Dr Virkstis, The Advisory Board Company,2445 M St NW, Washington, DC 20037 (firstname.lastname@example.org).
Three forces-dramatic decrease in length of stay,1 heightened patient acuity,2 and an expanding set of clinical protocols that busy frontline nurses must implement3-combine to create a perfect storm: frontline nurses must accomplish more in less time. In this time-compressed, seemingly task-oriented care environment, it is challenging for frontline nurses to think critically about the care they deliver. Yet there is widespread agreement among nursing leaders that critical thinking is a frontline nurse competency essential to providing safe and effective care.
Research from the Nursing Executive Center suggests there is ample room for improvement in the critical thinking skills of all frontline staff: both new graduates and tenured nurses.3 Furthermore, critical thinking can be learned at any point during a nurse's tenure.4 Indeed, all nurses must readily see a holistic picture of their patients' conditions to recognize emerging clinical patterns and know when to intervene earlier. But what action should nursing leaders take to ensure frontline staff members do not default to a "checkbox" approach and continue to see the larger picture?
The first step in helping nurses meaningfully improve their critical thinking skills is identifying and providing feedback on specific strengths and weaknesses. Yet, only a small fraction of all hospitals currently measure the performance of individual staff nurses on discrete critical-thinking competencies. Although many organizations include a broad review of critical thinking in annual performance appraisals, only about 10% of nursing leaders reported that they routinely conduct a detailed assessment of specific critical-thinking competencies.3 However, a handful of tools have been developed to assess critical-thinking skills of nurses and nonnurses alike. These include the Performance-Based Development System (PBDS), clinical narratives, Watson Glaser Critical Thinking Appraisal, California Critical Thinking Skills Test, California Critical-Thinking Disposition Inventory, Adult Medical Nursing Critical Thinking Test, Assessment of Critical Thinking in Perioperative Nurses, Enis-Weir Critical Thinking Test, Cornell Critical-Thinking Test, and the HESI Exam.5-7
For the minority of hospitals and health systems routinely conducting critical-thinking assessments for frontline nurses, 2 methodologies predominate: PBDS and clinical narratives.3 The PBDS is a scenario-based, online competency assessment completed by frontline nurses. The tool assesses critical-thinking skills, interpersonal relations, and technical skills based on frontline nurse responses to clinical vignettes. Because the tool is scenario-based with a free-text format for responses, it can capture how participants think through and respond to a variety of clinical situations.5 Hospitals deploying clinical narratives ask staff nurses to recount a recent clinical experience and reflect on the care they provided, articulate outstanding questions, and contemplate lessons learned. The narratives are then reviewed by a panel of tenured nurses who have been identified as expert critical thinkers. These individuals assess the narrative along Dr Patricia Benner's8 novice-to-expert continuum.
Among the roughly 90% of interviewed nurse executives not assessing discrete critical-thinking competencies, nearly all cited a lack of time and resources as the primary barrier. This finding prompted Nursing Executive Center researchers to develop a third option for assessing frontline nurse critical thinking: the Critical Thinking Diagnostic.
Data and Methods
Identifying 25 Core Critical-Thinking Competencies
In summer 2009, the Nursing Executive Center began to develop the 25 competencies included in the Critical Thinking Diagnostic (Table 1) using an iterative process. More than 100 industry leaders-including hospital-based nurse executives, directors, managers, nursing school deans, faculty members, and nursing education association representatives-were interviewed by telephone and in person during the course of this process. The instrument was repeatedly revised until all recommendations had been considered and typically incorporated. To be included in the Diagnostic, a competency had to be specific and actionable and reflect current hospital demands. Importantly, these 25 nursing competencies do not comprise a comprehensive list of attributes potentially supporting critical thinking in nursing practice. Instead, they are intended to reflect the core skills found at the heart of critical thinking, as identified by nursing industry experts. The competencies included in the final list were grouped into 5 broader skill categories: problem recognition, clinical decision making, prioritization, clinical implementation, and reflection.
Assessment Instrument Overview
The Critical Thinking Diagnostic assesses frontline nurse critical-thinking performance on 25 core critical-thinking competencies and is completed using a 6-point Likert scale. It is available to members of the Nursing Executive Center as a fully automated, online assessment tool, but it can also be conducted manually, via a paper format. The Diagnostic is designed to be completed by tenured nurses who have been identified as competent critical thinkers. During the development of the Critical Thinking Diagnostic, interviewed experts and other nursing leaders overwhelmingly agreed that the assessment should be completed by experienced nurses recognized as strong critical thinkers, such as educators, preceptors, and nurse managers, who are familiar with the practice of the frontline nurses they assess. Completion of the diagnostic requires approximately 15 minutes for each nurse assessed.
Implementing the Critical Thinking Diagnostic
The first step for nurse leaders implementing the Nursing Executive Center Critical Thinking Diagnostic is selecting a group of frontline staff to be assessed. This may include a single pilot unit, a cohort of nurses (such as new graduates), or all nurses working at the organization. After the group to be assessed is selected, designated assessors complete the Critical Thinking Diagnostic for these staff. Nurses being assessed also have an opportunity to complete a self-assessment. Once all assessments and self-assessments have been completed, nurse leaders can view the results of the Diagnostic on an individual, group, and housewide level on a reporting page.
To promote interrater consistency throughout the assessment process, Nursing Executive Center researchers devised a critical-thinking assessor training exercise. During the exercise, all designated assessors are asked to review a clinical scenario and use the Critical Thinking Diagnostic to assess the critical-thinking competencies of the nurse portrayed in the scenario. Participants are then prompted to share and discuss their assessments and underlying rationale as a group. At the session's conclusion, assessors should have a common assessment strategy, thereby minimizing variability among assessments.
Applying Critical Thinking Diagnostic Results
The results of the Critical Thinking Diagnostic enable nurse leaders to customize their strategy to elevate frontline nurse critical thinking skills in 2 important ways. First, leaders can identify the individuals with the most substantial critical-thinking development needs and the specific critical-thinking competencies representing these individuals' most pressing opportunities for improvement. Once specific improvement needs have been identified, nurse educators or coaches should complement any didactic training with individualized action plans that encompass interactive learning activities-such as role playing, structured peer feedback, targeted patient observation, and guided self-reflection. Second, nurse leaders can examine the results of the Critical Thinking Diagnostic to target the critical-thinking skills on which a particular cohort of nurses-or all nurses assessed-may be falling short. Based on this information, nurse leaders can effectively triage resources and make principled trade-offs to improve foundational critical-thinking competency areas, such as problem recognition, clinical decision making, prioritization, clinical implementation, and reflection.
Instrument Reliability and Validity
In May 2010, 5 hospitals volunteered to participate in a pilot project to test the Nursing Executive Center Critical Thinking Diagnostic, in which 128 staff nurses were assessed. The Cronbach α coefficients for each scale within the survey were.976 for all survey items,.910 for problem recognition,.882 for clinical decision making,.932 for prioritization,.919 for clinical implementation, and.922 for reflection (Table 2). A split-half reliability on the entire instrument yielded a 0.930 correlation between halves and 0.961 for the Guttman split-half coefficient. In addition, a regression analysis demonstrated that 4 of the independent variables yield an adjusted r2 = 0.762 when using the statement: "The nurse I am assessing has the critical thinking skills to enable him/her to deliver safe and effective patient care" as the dependent variable.
To help nurse leaders pinpoint critical-thinking strengths and developmental opportunities among staff nurses, the Critical Thinking Diagnostic calls for the opinion of staff who are already recognized as strong critical thinkers. This methodology is inherently subjective as no 2 individuals may have an identical perception of a frontline staff member's ability. Second, because assessments require the perspectives of individuals whom nurse leaders already regard as strong critical thinkers, institutions wishing to deploy the assessment must be able to identify and enlist a sufficient number of individuals who already possess the critical thinking skills required to complete the assessments.
Conducting an assessment of frontline nurse critical thinking is a necessary, yet frequently overlooked first step in improving this essential component of nurse performance. As a result, nursing leaders struggle to identify the specific competencies that frontline staff must improve to elevate overall critical thinking. Instead, critical-thinking skill development is often approached with a one-size-fits-all strategy, regardless of the specific aspects of critical thinking that challenge a nurse or group of nurses. However, once discrete, actionable, and measurable critical-thinking competencies are identified using a tool such as the Critical Thinking Diagnostic, educators can provide staff with targeted, self-directed development opportunities.
To help nursing leaders address specific critical-thinking skill gaps, the Nursing Executive Center developed the Critical Thinking Toolkit, a collection of 16 exercises designed to enhance bedside nursing performance by focusing on 5 core components of critical thinking: problem recognition, clinical decision-making, prioritization, clinical implementation, and reflection. Designed for nurses at every career stage, these exercises are highly interactive and include activities such as role playing, structured peer feedback, targeted patient observation, and guided self-reflection.
Finally, recognizing that many nursing organizations operate in resource-constrained environments, nurse leaders seeking to expand critical-thinking education to nurses of all levels of tenure will need to refine their critical-thinking investment to ensure viability. The Nursing Executive Center recommends triaging investment in critical thinking to maximize impact by targeting education on either a limited number of most pressing critical-thinking competencies or specific subgroups of frontline staff nurses who demonstrate the greatest critical-thinking improvement needs.
1. Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. 2007. Available at http://www.ahrq.gov/data/hcup/
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