importance of critical thinking in the nursing profession

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.

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?

Critical Thinking in Nursing

• First Online: 02 January 2023

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• Şefika Dilek Güven 3  

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Critical thinking is an integral part of nursing, especially in terms of professionalization and independent clinical decision-making. It is necessary to think critically to provide adequate, creative, and effective nursing care when making the right decisions for practices and care in the clinical setting and solving various ethical issues encountered. Nurses should develop their critical thinking skills so that they can analyze the problems of the current century, keep up with new developments and changes, cope with nursing problems they encounter, identify more complex patient care needs, provide more systematic care, give the most appropriate patient care in line with the education they have received, and make clinical decisions. The present chapter briefly examines critical thinking, how it relates to nursing, and which skills nurses need to develop as critical thinkers.

Graphical Abstract/Art Performance

Critical thinking in nursing.

This painting shows a nurse and how she is thinking critically. On the right side are the stages of critical thinking and on the left side, there are challenges that a nurse might face. The entire background is also painted in several colors to represent a kind of intellectual puzzle. It is made using colored pencils and markers.

(Adapted with permission from the Association of Science and Art (ASA), Universal Scientific Education and Research Network (USERN); Painting by Mahshad Naserpour).

Unless the individuals of a nation thinkers, the masses can be drawn in any direction. Mustafa Kemal Atatürk

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Güven, Ş.D. (2023). Critical Thinking in Nursing. In: Rezaei, N. (eds) Brain, Decision Making and Mental Health. Integrated Science, vol 12. Springer, Cham. https://doi.org/10.1007/978-3-031-15959-6_10

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Critical thinking in nursing clinical practice, education and research: From attitudes to virtue

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• 1 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, Consolidated Research Group Quantitative Psychology (2017-SGR-269), University of Barcelona, Barcelona, Spain.
• 2 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, Consolidated Research Group on Gender, Identity and Diversity (2017-SGR-1091), University of Barcelona, Barcelona, Spain.
• 3 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, University of Barcelona, Barcelona, Spain.
• 4 Multidisciplinary Nursing Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Hospital, Barcelona, Spain.
• PMID: 33029860
• DOI: 10.1111/nup.12332

Critical thinking is a complex, dynamic process formed by attitudes and strategic skills, with the aim of achieving a specific goal or objective. The attitudes, including the critical thinking attitudes, constitute an important part of the idea of good care, of the good professional. It could be said that they become a virtue of the nursing profession. In this context, the ethics of virtue is a theoretical framework that becomes essential for analyse the critical thinking concept in nursing care and nursing science. Because the ethics of virtue consider how cultivating virtues are necessary to understand and justify the decisions and guide the actions. Based on selective analysis of the descriptive and empirical literature that addresses conceptual review of critical thinking, we conducted an analysis of this topic in the settings of clinical practice, training and research from the virtue ethical framework. Following JBI critical appraisal checklist for text and opinion papers, we argue the need for critical thinking as an essential element for true excellence in care and that it should be encouraged among professionals. The importance of developing critical thinking skills in education is well substantiated; however, greater efforts are required to implement educational strategies directed at developing critical thinking in students and professionals undergoing training, along with measures that demonstrate their success. Lastly, we show that critical thinking constitutes a fundamental component in the research process, and can improve research competencies in nursing. We conclude that future research and actions must go further in the search for new evidence and open new horizons, to ensure a positive effect on clinical practice, patient health, student education and the growth of nursing science.

Keywords: critical thinking; critical thinking attitudes; nurse education; nursing care; nursing research.

© 2020 John Wiley & Sons Ltd.

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Nurses are critical thinkers

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The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice. Nurses’ ability to recognize and respond to signs of patient deterioration in a timely manner plays a pivotal role in patient outcomes (Purling & King 2012). Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events (Tomlinson, 2015). The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement. Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010). At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction.

The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.

As lifelong learners, nurses are constantly accumulating more knowledge, expertise, and experience, and it’s a rare nurse indeed who chooses to not apply his or her mind towards the goal of constant learning and professional growth. Institute of Medicine (IOM) report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice. American Nurses Association (ANA), Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice (p.26)

Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier

The future of nursing: Leading change, advancing health, (2010). https://campaignforaction.org/resource/future-nursing-iom-report

Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today. 30(6), 515-520.

NMC (2010) New Standards for Pre-Registration Nursing. London: Nursing and Midwifery Council.

Purling A. & King L. (2012). A literature review: graduate nurses’ preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23–24), 3451–3465

Thompson, C., Aitken, l., Doran, D., Dowing, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50 (12), 1720 - 1726 Tomlinson, J. (2015). Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Medical Education, 15(103)

Competing interests: No competing interests

The Importance of Critical Thinking in Nursing

An American Association of Nurse Practitioners (AANP) survey found that a majority of nurse practitioners saw three or more patients per hour. Nurse practitioners see patients of all ages with a broad spectrum of potential ailments. Critical thinking skills in nursing improve patient outcomes by enabling evidence-based decision-making. 

Nurse practitioners gather considerable amounts of patient data through evaluations, tests and conversations. Each patient's information can be interpreted and analyzed to determine the best courses of action for their health. A growing emphasis on critical thinking in nursing stems from the increasing importance of nurse practitioners in primary care.

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Growing need for critical thinking in nursing.

There is a significant shortage of primary care services throughout the United States. GoodRx identified 80% of counties as "health care deserts" or locations without easy access to necessary services. This data includes the following categories relevant to family nurse practitioners:

• 9% of counties lack enough primary care providers to serve the local population
• Residents in 20% of counties are at least 30 minutes away from hospitals
• Residents in 45% of counties are at least 20 minutes away from community health centers

"Health care deserts" are worsening because of a shortage of primary care physicians. The Association of American Medical Colleges ( AAMC ) estimates up to 48,000 more primary care providers are needed to meet patient care needs by 2034. This shortfall translates to a lack of preventive care and increased reliance on emergency care facilities.

The U.S. Bureau of Labor Statistics ( BLS ) projects a 52% growth in nurse practitioner roles by 2030. This growth is fueled not only by "health care deserts" but an aging population and public health threats like COVID-19. Critical thinking by nurse practitioners can overcome these challenges even with limited resources and stressful situations.

The Critical Thinking Process

The first step in incorporating critical thinking into patient care is understanding the critical thinking process. The National League for Nursing Accreditation Commission ( NLNAC ) defines critical thinking as:

"the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief based."

Critical thinking in nursing does not move in a straight line because each patient is unique. There isn't a one-size-fits-all diagnosis for patients because there isn't a single type of patient. Nurse practitioners can apply the following steps in the Clinical Reasoning Cycle as they evaluate patient care decisions.

Consider the Situation

First impressions of new patients can distract from effective evaluations. Personal experiences and assumptions may lead to hasty conclusions about patient needs. The first step to critical thinking in nursing involves a dispassionate consideration of the facts.

Nurse practitioners often have the basic facts about their patients' conditions before stepping into exam rooms. A simple repetition of the patient's age and reported illness counters assumptions that can negatively impact patient care.

Collect Information

Critical thinking requires the synthesis of existing and new information for effective analysis. Nurse practitioners can pull useful details from patient charts and histories when they are available. An evaluation of visual appearance, speech, blood pressure and other metrics builds on this previous work.

Skilled practitioners automatically apply their knowledge of physiology, pharmacology and other areas during the collection process. They also keep best practices, cultural competence and ethics in mind while working with patients. This recall makes it easier to process information during diagnosis.

Process Information

There is a multi-step process for turning raw information into useful insights for patient care. Nurse practitioners effectively process patient data by:

• Analyzing information within the context of normal and abnormal ranges
• Separating relevant and irrelevant data while finding information gaps
• Focus on relationships between symptoms and cues
• Deduce potential causes of health problems
• Compare similar situations between current and past patients
• Predict potential outcomes and complications from treatment

Nurse practitioners are ready to diagnose patient conditions following this process. Depending on symptoms, they'll have considered and eliminated multiple diagnoses based on careful consideration of the facts. This step also takes into consideration risks for other health issues without treatment.

Set Goals and Act

A patient's course of treatment should follow the SMART model for goal-setting. The best treatment plans are Specific, Measurable, Achievable, Realistic and Timely to support the measurement of their efficacy. This model creates a repeatable process that is effective across patient demographics and conditions.

Critical thinking in nursing produces clear goals that are essential to patient adherence to treatment. Treatment plans may include prescribed medications, therapies and visits with specialists. Nurse practitioners collaborate with their patients and colleagues on supportive frameworks for effective treatment.

Evaluate and Reflect

Follow-up appointments provide opportunities for evaluation of treatment plans. Nurse practitioners compare past and present metrics when determining improvements in patient conditions. A useful method for evaluating success is whether the following rights of clinical reasoning were applied:

• Right patient
• Right action
• Right reason

Frequent reflection on this process is essential for improvement as a nurse practitioner. Self-directed explorations of what should have been done and what could have happened in each case sharpen critical thinking skills. An understanding of what was learned in each case creates points of comparison for future patients.

Improving Your Critical Thinking

Critical thinking in nursing improves through thoughtful deliberation and frequent use. Nurse practitioners should speak with their colleagues and mentors about their applications of critical thinking. Frequent collaboration on patient care also places the focus on evidence-based care rather than personal assumptions.

Updated knowledge of nursing resources and tools makes it easier to implement critical thinking in nursing. Medical journals and continuing education courses reinforce what nurse practitioners have learned throughout their careers. Carson-Newman University provides a strong foundation for improved critical thinking through its Online MSN-FNP.

Preparing for Clinical Decisions at Carson-Newman

Carson-Newman's innovative program prepares BSN & MSN-educated nurses for future roles as family nurse practitioners (FNPs). The in-person requirements for this 100% online degree are clinical placements and a three-day campus residency. Students can complete the Online MSN-FNP in as little as 32 months.

Every course in the program is taught by an experienced nurse educator who also practices in their community. Carson-Newman reinforces the importance of critical thinking in nursing with courses on topics including:

• Advanced Health Assessment
• Advanced Pathophysiology
• Advanced Primary Care Nursing for Adults

FNP students receive full support from Carson-Newman to identify clinical placements in their communities. They also receive one-on-one guidance from Student Success Advisors throughout their time at the University. This commitment to nursing education helped Carson-Newman reach the top third of graduate nursing programs in U.S. News & World Report's rankings.

Contact an enrollment advisor today to learn how Carson-Newman can prepare you for a role as an FNP.

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Why Critical Thinking Skills in Nursing Matter (And What You Can Do to Develop Them)

By Hannah Meinke on 07/05/2021

The nursing profession tends to attract those who have natural nurturing abilities, a desire to help others, and a knack for science or anatomy. But there is another important skill that successful nurses share, and it's often overlooked: the ability to think critically.

Identifying a problem, determining the best solution and choosing the most effective method to solve the program are all parts of the critical thinking process. After executing the plan, critical thinkers reflect on the situation to figure out if it was effective and if it could have been done better. As you can see, critical thinking is a transferable skill that can be leveraged in several facets of your life.

But why is it so important for nurses to use? We spoke with several experts to learn why critical thinking skills in nursing are so crucial to the field, the patients and the success of a nurse. Keep reading to learn why and to see how you can improve this skill.

Why are critical thinking skills in nursing important?

You learn all sorts of practical skills in nursing school, like flawlessly dressing a wound, taking vitals like a pro or starting an IV without flinching. But without the ability to think clearly and make rational decisions, those skills alone won’t get you very far—you need to think critically as well.

“Nurses are faced with decision-making situations in patient care, and each decision they make impacts patient outcomes. Nursing critical thinking skills drive the decision-making process and impact the quality of care provided,” says Georgia Vest, DNP, RN and senior dean of nursing at the Rasmussen University School of Nursing.

For example, nurses often have to make triage decisions in the emergency room. With an overflow of patients and limited staff, they must evaluate which patients should be treated first. While they rely on their training to measure vital signs and level of consciousness, they must use critical thinking to analyze the consequences of delaying treatment in each case.

No matter which department they work in, nurses use critical thinking in their everyday routines. When you’re faced with decisions that could ultimately mean life or death, the ability to analyze a situation and come to a solution separates the good nurses from the great ones.

How are critical thinking skills acquired in nursing school?

Nursing school offers a multitude of material to master and upholds high expectations for your performance. But in order to learn in a way that will actually equip you to become an excellent nurse, you have to go beyond just memorizing terms. You need to apply an analytical mindset to understanding course material.

One way for students to begin implementing critical thinking is by applying the nursing process to their line of thought, according to Vest. The process includes five steps: assessment, diagnosis, outcomes/planning, implementation and evaluation.

“One of the fundamental principles for developing critical thinking is the nursing process,” Vest says. “It needs to be a lived experience in the learning environment.”

Nursing students often find that there are multiple correct solutions to a problem. The key to nursing is to select the “the most correct” solution—one that will be the most efficient and best fit for that particular situation. Using the nursing process, students can narrow down their options to select the best one.

When answering questions in class or on exams, challenge yourself to go beyond simply selecting an answer. Start to think about why that answer is correct and what the possible consequences might be. Simply memorizing the material won’t translate well into a real-life nursing setting.

How can you develop your critical thinking skills as a nurse?

As you know, learning doesn’t stop with graduation from nursing school. Good nurses continue to soak up knowledge and continually improve throughout their careers. Likewise, they can continue to build their critical thinking skills in the workplace with each shift.

“To improve your critical thinking, pick the brains of the experienced nurses around you to help you get the mindset,” suggests Eileen Sollars, RN ADN, AAS. Understanding how a seasoned nurse came to a conclusion will provide you with insights you may not have considered and help you develop your own approach.

The chain of command can also help nurses develop critical thinking skills in the workplace.

“Another aid in the development of critical thinking I cannot stress enough is the utilization of the chain of command,” Vest says. “In the chain of command, the nurse always reports up to the nurse manager and down to the patient care aide. Peers and fellow healthcare professionals are not in the chain of command. Clear understanding and proper utilization of the chain of command is essential in the workplace.”

How are critical thinking skills applied in nursing?

“Nurses use critical thinking in every single shift,” Sollars says. “Critical thinking in nursing is a paramount skill necessary in the care of your patients. Nowadays there is more emphasis on machines and technical aspects of nursing, but critical thinking plays an important role. You need it to understand and anticipate changes in your patient's condition.”

As a nurse, you will inevitably encounter a situation in which there are multiple solutions or treatments, and you'll be tasked with determining the solution that will provide the best possible outcome for your patient. You must be able to quickly and confidently assess situations and make the best care decision in each unique scenario. It is in situations like these that your critical thinking skills will direct your decision-making.

Do critical thinking skills matter more for nursing leadership and management positions?

While critical thinking skills are essential at every level of nursing, leadership and management positions require a new level of this ability.

When it comes to managing other nurses, working with hospital administration, and dealing with budgets, schedules or policies, critical thinking can make the difference between a smooth-running or struggling department. At the leadership level, nurses need to see the big picture and understand how each part works together.

A nurse manager , for example, might have to deal with being short-staffed. This could require coaching nurses on how to prioritize their workload, organize their tasks and rely on strategies to keep from burning out. A lead nurse with strong critical thinking skills knows how to fully understand the problem and all its implications.

• How will patient care be affected by having fewer staff?
• What kind of strain will be on the nurses?

Their solutions will take into account all their resources and possible roadblocks.

• What work can be delegated to nursing aids?
• Are there any nurses willing to come in on their day off?
• Are nurses from other departments available to provide coverage?

They’ll weigh the pros and cons of each solution and choose those with the greatest potential.

• Will calling in an off-duty nurse contribute to burnout?
• Was this situation a one-off occurrence or something that could require an additional hire in the long term?

Finally, they will look back on the issue and evaluate what worked and what didn’t. With critical thinking skills like this, a lead nurse can affect their entire staff, patient population and department for the better.

Beyond thinking

You’re now well aware of the importance of critical thinking skills in nursing. Even if you already use critical thinking skills every day, you can still work toward strengthening that skill. The more you practice it, the better you will become and the more naturally it will come to you.

If you’re interested in critical thinking because you’d like to move up in your current nursing job, consider how a Bachelor of Science in Nursing (BSN) could help you develop the necessary leadership skills.

EDITOR’S NOTE: This article was originally published in July 2012. It has since been updated to include information relevant to 2021.

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What is Critical Thinking in Nursing? (Explained W/ Examples)

Last updated on August 23rd, 2023

Critical thinking is a foundational skill applicable across various domains, including education, problem-solving, decision-making, and professional fields such as science, business, healthcare, and more.

It plays a crucial role in promoting logical and rational thinking, fostering informed decision-making, and enabling individuals to navigate complex and rapidly changing environments.

In this article, we will look at what is critical thinking in nursing practice, its importance, and how it enables nurses to excel in their roles while also positively impacting patient outcomes.

What is Critical Thinking?

Critical thinking is a cognitive process that involves analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

It’s a mental activity that goes beyond simple memorization or acceptance of information at face value.

Critical thinking involves careful, reflective, and logical thinking to understand complex problems, consider various perspectives, and arrive at well-reasoned conclusions or solutions.

Key aspects of critical thinking include:

• Analysis: Critical thinking begins with the thorough examination of information, ideas, or situations. It involves breaking down complex concepts into smaller parts to better understand their components and relationships.
• Evaluation: Critical thinkers assess the quality and reliability of information or arguments. They weigh evidence, identify strengths and weaknesses, and determine the credibility of sources.
• Synthesis: Critical thinking involves combining different pieces of information or ideas to create a new understanding or perspective. This involves connecting the dots between various sources and integrating them into a coherent whole.
• Inference: Critical thinkers draw logical and well-supported conclusions based on the information and evidence available. They use reasoning to make educated guesses about situations where complete information might be lacking.
• Problem-Solving: Critical thinking is essential in solving complex problems. It allows individuals to identify and define problems, generate potential solutions, evaluate the pros and cons of each solution, and choose the most appropriate course of action.
• Creativity: Critical thinking involves thinking outside the box and considering alternative viewpoints or approaches. It encourages the exploration of new ideas and solutions beyond conventional thinking.
• Reflection: Critical thinkers engage in self-assessment and reflection on their thought processes. They consider their own biases, assumptions, and potential errors in reasoning, aiming to improve their thinking skills over time.
• Open-Mindedness: Critical thinkers approach ideas and information with an open mind, willing to consider different viewpoints and perspectives even if they challenge their own beliefs.
• Effective Communication: Critical thinkers can articulate their thoughts and reasoning clearly and persuasively to others. They can express complex ideas in a coherent and understandable manner.
• Continuous Learning: Critical thinking encourages a commitment to ongoing learning and intellectual growth. It involves seeking out new knowledge, refining thinking skills, and staying receptive to new information.

Definition of Critical Thinking

Critical thinking is an intellectual process of analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

What is Critical Thinking in Nursing?

Critical thinking in nursing is a vital cognitive skill that involves analyzing, evaluating, and making reasoned decisions about patient care.

It’s an essential aspect of a nurse’s professional practice as it enables them to provide safe and effective care to patients.

Critical thinking involves a careful and deliberate thought process to gather and assess information, consider alternative solutions, and make informed decisions based on evidence and sound judgment.

This skill helps nurses to:

• Assess Information: Critical thinking allows nurses to thoroughly assess patient information, including medical history, symptoms, and test results. By analyzing this data, nurses can identify patterns, discrepancies, and potential issues that may require further investigation.
• Diagnose: Nurses use critical thinking to analyze patient data and collaboratively work with other healthcare professionals to formulate accurate nursing diagnoses. This is crucial for developing appropriate care plans that address the unique needs of each patient.
• Plan and Implement Care: Once a nursing diagnosis is established, critical thinking helps nurses develop effective care plans. They consider various interventions and treatment options, considering the patient’s preferences, medical history, and evidence-based practices.
• Evaluate Outcomes: After implementing interventions, critical thinking enables nurses to evaluate the outcomes of their actions. If the desired outcomes are not achieved, nurses can adapt their approach and make necessary changes to the care plan.
• Prioritize Care: In busy healthcare environments, nurses often face situations where they must prioritize patient care. Critical thinking helps them determine which patients require immediate attention and which interventions are most essential.
• Communicate Effectively: Critical thinking skills allow nurses to communicate clearly and confidently with patients, their families, and other members of the healthcare team. They can explain complex medical information and treatment plans in a way that is easily understood by all parties involved.
• Identify Problems: Nurses use critical thinking to identify potential complications or problems in a patient’s condition. This early recognition can lead to timely interventions and prevent further deterioration.
• Collaborate: Healthcare is a collaborative effort involving various professionals. Critical thinking enables nurses to actively participate in interdisciplinary discussions, share their insights, and contribute to holistic patient care.
• Ethical Decision-Making: Critical thinking helps nurses navigate ethical dilemmas that can arise in patient care. They can analyze different perspectives, consider ethical principles, and make morally sound decisions.
• Continual Learning: Critical thinking encourages nurses to seek out new knowledge, stay up-to-date with the latest research and medical advancements, and incorporate evidence-based practices into their care.

In summary, critical thinking is an integral skill for nurses, allowing them to provide high-quality, patient-centered care by analyzing information, making informed decisions, and adapting their approaches as needed.

It’s a dynamic process that enhances clinical reasoning , problem-solving, and overall patient outcomes.

What are the Levels of Critical Thinking in Nursing?

The development of critical thinking in nursing practice involves progressing through three levels: basic, complex, and commitment.

The Kataoka-Yahiro and Saylor model outlines this progression.

1. Basic Critical Thinking:

At this level, learners trust experts for solutions. Thinking is based on rules and principles. For instance, nursing students may strictly follow a procedure manual without personalization, as they lack experience. Answers are seen as right or wrong, and the opinions of experts are accepted.

2. Complex Critical Thinking:

Learners start to analyze choices independently and think creatively. They recognize conflicting solutions and weigh benefits and risks. Thinking becomes innovative, with a willingness to consider various approaches in complex situations.

3. Commitment:

At this level, individuals anticipate decision points without external help and take responsibility for their choices. They choose actions or beliefs based on available alternatives, considering consequences and accountability.

As nurses gain knowledge and experience, their critical thinking evolves from relying on experts to independent analysis and decision-making, ultimately leading to committed and accountable choices in patient care.

Why Critical Thinking is Important in Nursing?

Critical thinking is important in nursing for several crucial reasons:

Patient Safety:

Nursing decisions directly impact patient well-being. Critical thinking helps nurses identify potential risks, make informed choices, and prevent errors.

Clinical Judgment:

Nursing decisions often involve evaluating information from various sources, such as patient history, lab results, and medical literature.

Critical thinking assists nurses in critically appraising this information, distinguishing credible sources, and making rational judgments that align with evidence-based practices.

Enhances Decision-Making:

In nursing, critical thinking allows nurses to gather relevant patient information, assess it objectively, and weigh different options based on evidence and analysis.

This process empowers them to make informed decisions about patient care, treatment plans, and interventions, ultimately leading to better outcomes.

Promotes Problem-Solving:

Nurses encounter complex patient issues that require effective problem-solving.

Critical thinking equips them to break down problems into manageable parts, analyze root causes, and explore creative solutions that consider the unique needs of each patient.

Drives Creativity:

Nursing care is not always straightforward. Critical thinking encourages nurses to think creatively and explore innovative approaches to challenges, especially when standard protocols might not suffice for unique patient situations.

Fosters Effective Communication:

Communication is central to nursing. Critical thinking enables nurses to clearly express their thoughts, provide logical explanations for their decisions, and engage in meaningful dialogues with patients, families, and other healthcare professionals.

Aids Learning:

Nursing is a field of continuous learning. Critical thinking encourages nurses to engage in ongoing self-directed education, seeking out new knowledge, embracing new techniques, and staying current with the latest research and developments.

Improves Relationships:

Open-mindedness and empathy are essential in nursing relationships.

Critical thinking encourages nurses to consider diverse viewpoints, understand patients’ perspectives, and communicate compassionately, leading to stronger therapeutic relationships.

Empowers Independence:

Nursing often requires autonomous decision-making. Critical thinking empowers nurses to analyze situations independently, make judgments without undue influence, and take responsibility for their actions.

Facilitates Adaptability:

Healthcare environments are ever-changing. Critical thinking equips nurses with the ability to quickly assess new information, adjust care plans, and navigate unexpected situations while maintaining patient safety and well-being.

Strengthens Critical Analysis:

In the era of vast information, nurses must discern reliable data from misinformation.

Critical thinking helps them scrutinize sources, question assumptions, and make well-founded choices based on credible information.

How to Apply Critical Thinking in Nursing? (With Examples)

Here are some examples of how nurses can apply critical thinking.

Assess Patient Data:

Critical Thinking Action: Carefully review patient history, symptoms, and test results.

Example: A nurse notices a change in a diabetic patient’s blood sugar levels. Instead of just administering insulin, the nurse considers recent dietary changes, activity levels, and possible medication interactions before adjusting the treatment plan.

Diagnose Patient Needs:

Critical Thinking Action: Analyze patient data to identify potential nursing diagnoses.

Example: After reviewing a patient’s lab results, vital signs, and observations, a nurse identifies “ Risk for Impaired Skin Integrity ” due to the patient’s limited mobility.

Plan and Implement Care:

Critical Thinking Action: Develop a care plan based on patient needs and evidence-based practices.

Example: For a patient at risk of falls, the nurse plans interventions such as hourly rounding, non-slip footwear, and bed alarms to ensure patient safety.

Evaluate Interventions:

Critical Thinking Action: Assess the effectiveness of interventions and modify the care plan as needed.

Example: After administering pain medication, the nurse evaluates its impact on the patient’s comfort level and considers adjusting the dosage or trying an alternative pain management approach.

Prioritize Care:

Critical Thinking Action: Determine the order of interventions based on patient acuity and needs.

Example: In a busy emergency department, the nurse triages patients by considering the severity of their conditions, ensuring that critical cases receive immediate attention.

Collaborate with the Healthcare Team:

Critical Thinking Action: Participate in interdisciplinary discussions and share insights.

Example: During rounds, a nurse provides input on a patient’s response to treatment, which prompts the team to adjust the care plan for better outcomes.

Ethical Decision-Making:

Critical Thinking Action: Analyze ethical dilemmas and make morally sound choices.

Example: When a terminally ill patient expresses a desire to stop treatment, the nurse engages in ethical discussions, respecting the patient’s autonomy and ensuring proper end-of-life care.

Patient Education:

Critical Thinking Action: Tailor patient education to individual needs and comprehension levels.

Example: A nurse uses visual aids and simplified language to explain medication administration to a patient with limited literacy skills.

Adapt to Changes:

Critical Thinking Action: Quickly adjust care plans when patient conditions change.

Example: During post-operative recovery, a nurse notices signs of infection and promptly informs the healthcare team to initiate appropriate treatment adjustments.

Critical Analysis of Information:

Critical Thinking Action: Evaluate information sources for reliability and relevance.

Example: When presented with conflicting research studies, a nurse critically examines the methodologies and sample sizes to determine which study is more credible.

Making Sense of Critical Thinking Skills

What is the purpose of critical thinking in nursing.

The purpose of critical thinking in nursing is to enable nurses to effectively analyze, interpret, and evaluate patient information, make informed clinical judgments, develop appropriate care plans, prioritize interventions, and adapt their approaches as needed, thereby ensuring safe, evidence-based, and patient-centered care.

Why critical thinking is important in nursing?

Critical thinking is important in nursing because it promotes safe decision-making, accurate clinical judgment, problem-solving, evidence-based practice, holistic patient care, ethical reasoning, collaboration, and adapting to dynamic healthcare environments.

Critical thinking skill also enhances patient safety, improves outcomes, and supports nurses’ professional growth.

How is critical thinking used in the nursing process?

Critical thinking is integral to the nursing process as it guides nurses through the systematic approach of assessing, diagnosing, planning, implementing, and evaluating patient care. It involves:

• Assessment: Critical thinking enables nurses to gather and interpret patient data accurately, recognizing relevant patterns and cues.
• Diagnosis: Nurses use critical thinking to analyze patient data, identify nursing diagnoses, and differentiate actual issues from potential complications.
• Planning: Critical thinking helps nurses develop tailored care plans, selecting appropriate interventions based on patient needs and evidence.
• Implementation: Nurses make informed decisions during interventions, considering patient responses and adjusting plans as needed.
• Evaluation: Critical thinking supports the assessment of patient outcomes, determining the effectiveness of intervention, and adapting care accordingly.

Throughout the nursing process , critical thinking ensures comprehensive, patient-centered care and fosters continuous improvement in clinical judgment and decision-making.

What is an example of the critical thinking attitude of independent thinking in nursing practice?

An example of the critical thinking attitude of independent thinking in nursing practice could be:

A nurse is caring for a patient with a complex medical history who is experiencing a new set of symptoms. The nurse carefully reviews the patient’s history, recent test results, and medication list.

While discussing the case with the healthcare team, the nurse realizes that the current treatment plan might not be addressing all aspects of the patient’s condition.

Instead of simply following the established protocol, the nurse independently considers alternative approaches based on their assessment.

The nurse proposes a modification to the treatment plan, citing the rationale and evidence supporting the change.

This demonstrates independent thinking by critically evaluating the situation, challenging assumptions, and advocating for a more personalized and effective patient care approach.

How to use Costa’s level of questioning for critical thinking in nursing?

Costa’s levels of questioning can be applied in nursing to facilitate critical thinking and stimulate a deeper understanding of patient situations. The levels of questioning are as follows:

• 15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)
• Nursing Concept Map (FREE Template)
• Clinical Reasoning In Nursing (Explained W/ Example)
• 8 Stages Of The Clinical Reasoning Cycle
• How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples
• What is the “5 Whys” Technique?
• What Are Socratic Questions?

Critical thinking in nursing is the foundation that underpins safe, effective, and patient-centered care.

Critical thinking skills empower nurses to navigate the complexities of their profession while consistently providing high-quality care to diverse patient populations.

Reading Recommendation

Potter, P.A., Perry, A.G., Stockert, P. and Hall, A. (2013) Fundamentals of Nursing

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Why Critical Thinking Is Important in Nursing

Most nursing professionals have natural nurturing abilities, a desire to give others support, and an appreciation for science and anatomy. Successful nurses also possess a skill that is often overlooked: they can think critically.

A critical thinker will identify the problem, determine the best solution, and choose the most effective method. Critical thinkers evaluate the execution of a plan to see if it was effective and if it could have been done better. 

The ability to think critically has multiple applications in your life, as you can see. But Why is critical thinking important in nursing? Learn why and how you can improve this skill by reading on.

Why Are Critical Thinking Skills in Nursing Important?

Critical thinking is an essential skill for nursing students to have. It’s not something that it can teach in a classroom, and it must be developed over time through experience and practice. 

Critical thinking is the process of applying logic and reason to make decisions or solve problems. The ability to think critically will help you make better decisions on your own and collaborate with others when solving problems – both are essential skills for nurses.

Nursing has always been a profession that relies on critical thinking. Nurses are constantly faced with new situations and problems, which they need to think critically about to solve. 

Critical thinking is essential for nurses because it helps them make decisions based on the available information and their past experiences and knowledge of the field. It also allows nurses to plan before making any changes to be most effective as possible.

It is an essential skill for nurses to have to provide the best care possible. Critical thinkers can comprehend a problem and think about how they can solve it, rather than reactively or automatically.

Critical thinking is a crucial skill for doctors, nurses, and other health care providers.

How can you develop your critical thinking skills?

As you know, learning doesn’t end when you graduate from nursing school. You must continue to grow as a professional and develop your critical thinking skills.

Critical thinkers are better problem solvers than others in the same situation because they examine all the facts before coming up with solutions. They can also take many different perspectives into account when solving problems.

It’s easy for people to come to conclusions too quickly, but those who think critically will avoid this trap by first looking at every possible angle.

When faced with difficult decisions, these nurses won’t just rely on their gut feelings or what seems right according to society’s norms; instead, they’ll analyze all available information carefully until they develop the best solution.

Critical thinking is also crucial because it helps nurses avoid making mistakes in their work by providing them with a way to examine each situation and identify any potential risks or problems that may arise from subsequent actions before they take place.

It’s not enough for you to have empathy if your compassion isn’t backed up by critical thought and understanding of how certain decisions might affect others in various circumstances, so keep learning ways to become more thoughtful about the world around you.

The skills involved in being a good nurse are many and varied, but one thing all nurses need, regardless of what specialty they choose, is critical solid thinking abilities.

Reasons Critical Thinking In Nursing Is Important

Nurses’ experiences often include making life-altering decisions, establishing authority in stressful situations, and helping patients and their loved ones cope with some of the most stressful and emotional times of their lives.  Critical thinking is an essential aspect of nursing.

Following are the reasons:

• Nurses’ critical thinking has a significant impact on patient care 
• Recognizing changes in patient status is essential 
• It’s essential to an honest and open exchange of ideas 
• It enables you to ensure patient safety 
• Nurses can find quick fixes with it 
• Improvements can be made through critical thinking 
• It Contributes to Rational Decision Making

Further critical thinking is essential to nursing because nurses can establish authority in a stressful situation, such as issuing orders or administering care when needed.

This can be difficult because it may require balancing medical expertise with empathy and compassion towards patients’ feelings, leading them to question your judgment at some point in time.

Another reason this skill set is crucial involves making decisions that will have life-changing effects on a patient’s health and well-being.

These are often irreversible choices that only you know how much weight they carry within the context of each situation, so you need to make sure all factors are carefully considered before deciding what action must be taken next without hesitation.

Skills that Critical Thinkers Need

When it comes to critical thinking, some skills are more important than others. Using a framework known as the Nursing Process, some of these skills are applied to patient care. The most important skills are:

Interpretation: Understanding and explaining a specific event or piece of information.

Analysis: Studying data based on subjective and objective information to determine the best course of action.

Evaluation: Here, you assess the information you received. Is the information accurate, reliable, and credible? The ability to determine if outcomes have been fully achieved requires this skill as well.

The nurse can then use clinical reasoning to determine what the problem is based on those three skills. 

The decisions need to be based on sound reasoning:

Provide a clear, concise explanation of your conclusions. Nurses should provide a rationale for their answers.

Self-regulation – You need to be aware of your thought processes. As a result, you must reflect on the process that led to your conclusion. In this process, you should self-correct as necessary. Keep an eye out for bias and incorrect assumptions.

Critical Thinking Pitfalls

It can fall by the wayside when it’s not seen as necessary or when there are more pressing issues.

• Critical thinking is important in nursing because it can fall by the wayside when it’s not seen as an essential or more pressing issue.
• It can be difficult to think critically about complex, ambiguous situations with a shortage of information and time in healthcare settings.
• If we don’t use critical thinking skills, problems might go undetected or unresolved, leading to further complications down the road.

Sometimes nurses can’t differentiate between a less acute clinical problem and one that needs immediate attention. When a large amount of complex data must be processed in a time-critical manner, errors can also occur.

Conclusion:

Nurses cannot overstate the importance of critical thinking. The clinical presentations of patients are diverse. To provide safe, high-quality care, nurses must make rational clinical decisions and solve problems. Nurses need critical thinking skills to handle increasingly complex cases.

• Why Is Research Important in Nursing?
• Why Is the Nursing Process Important?
• Why Compassion is Important in Nursing

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Critical Thinking

High quality, safe patient care is dependent upon the healthcare provider’s ability to reason, think, and make judgments about care. Critical thinking, clinical reasoning and judgment are integral to quality clinical decisions and actions. Today’s healthcare landscape has transitioned towards an environment where patients are more medically complex, an aging population with chronic illness, and increased socioeconomic diversity. In order to provide quality patient-centered care, nurses need to develop CT skills in order to provide patients with expert care (Brunt, 2005).

Developing CT is an ethical responsibility of professional nursing practice, and a component for sound clinical judgments and safe decision-making. Thinking in a logical, systematic way, being open to questioning current practice, and reflecting on one’s practice regularly are some key features that strengthen nurses’ CT skills.

The quality of clinical decision-making is influenced by a number of factors, including experience, level of education, time pressures, and also the culture of the nursing unit (Johansson, Pilhammar, & Willman 2009). Developing critical thinking skills has the potential to improve personal practice and patient outcomes.

Critical thinking (CT) is a process used for problem-solving and decision-making. CT is a broad term that encompasses clinical reasoning and clinical judgment. Clinical reasoning (CR) is a process of analyzing information that is relevant to patient care. When data is analyzed, clinical judgments about care is made. The process of analyzing the data, making decisions is the result of CT—thinking critically throughout the entire patient situation, weighing all relevant options and using CT skills to make the best decision for the patient.

While many definitions have been cited for CT (see below), there is a general agreement that CT is a purposeful action that includes analysis, logical reasoning, intuition, and reflection. Making a concerted effort to critically think during patient care leads to safe, effective decisions. Developing CT skills is key for all nurses, they spend the most time with patients, and are able to recognize subtle changes in their patients and are positioned to make quick, precise decisions, often lifesaving. Using effective CT skills allows nurses to shape the outcome of a patient’s experience with the healthcare system.

The concept of critical thinking has been an integral part of professional frameworks for generations, yet scholars still debate a universal accepted definition. Dozens of CT definitions have been published, with each of them sharing some common features, such as reflection, contemplation, holism, and intuition. The list below shares a variety of CT definitions:

“The rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, ideas, statement beliefs and action” (Bandman & Bandman, 1995, p. 7)

A reflective skepticism; “reflecting on the assumptions underlying our and others’ ideas and actions and contemplative alternative ways of thinking and living” (Brookfield, 1987, p. 18)

“The process of purposeful self-regulatory judgment . . . gives reasoned consideration to evidence, context, conceptualization, methods and criteria: (Facione, 2006, p. 21)

“Reasonable and reflective thinking that is focused upon deciding what to believe or do” (Kennedy, Fisher, & Ennis, 1991, p.46)

“An investigation whose purpose is to explore a situation, phenomenon, question, or problem to arrive at a hypothesis or conclusion about it that integrates all available information and that, therefore, can be convincingly justified” (Kurfiss, 1988, p. 37)

“The propensity and skill to engage in an activity with reflective skepticism” (McPeck, 1961, p. 8)

“The deliberative nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting and evaluating information that is both factual and belief based” (National League for Nursing Accrediting Commission, 2000, p. 8)

“A unique kind of purposeful thinking in which the thinker systematically and habitually imposes criteria and intellectual standards upon the thinking, taking charge of the construction of thinking, guiding the construction of the thinking according to the standard, and assessing the effectiveness of the thinking according to the purpose, the criteria and the standards” (Paul, 1993, p. 21)

“In nursing . . . an essential component of professional accountability and quality nursing care [that exhibits] confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance and reflection.” (Scheffer & Ruberfeld, 2000, p. 357)

Concepts Related to Critical Thinking

Clinical Reasoning

• A process where nurses integrate and analyze patient data to make decisions about patient care (Simmons, Lanuza, Fonteyn, & Hicks, 2003)

Clinical Decision-Making

• A process of choosing between different options or alternatives (Thompson & Stapley, 2011)

Clinical Judgment

• A cognitive process used to make judgments based on patient data and cues. Nurses interpret a patient’s concerns, needs, and health problems for proper decision-making (Tanner, 2006, p. 204)
• Outcome of critical thinking in nursing practice; judgments begin with the end goal in mind; outcomes are met, involves evidence (Pesut, 2001)

Logical Reasoning

• Arriving at a conclusion based on relatively small amounts of knowledge and/or information (Westcott, 1968)
• “Drawing inferences or conclusions that are supported in or justified by evidence (Alfaro-LeFevre, 2015, p. 232)
• A purposeful analysis of one’s current and past actions (Schon, 1987)

Experience and Clinical Reasoning

According to Benner’s (1984) novice to expert model, expert nurses have an intuitive grasp of their patients’ problems, their approach is fluid, flexible, and proficient. Compared to novice nurses, they are more task oriented and require frequent verbal and physical cues to provide care.

Novice nurses are challenged with overcoming a knowledge gap, leading to less effective decisions and actions. Compared to experienced nurses, who are challenged with traditional thinking, leading to less effective clinical judgments and decisions (Cappelletti et al., 2014). Successful CR and decision-making require a balance of intuition and evidence-based thinking to make effective clinical decisions (Simmons et al., 2003).

Andersson et al. (2012) found nurses who were specialized in their setting (more experience) used a more holistic approach to making decisions (p. 876), compared to less experienced nurses who used a “task-and action-oriented approach” (p. 873). Gaining experience and knowledge is one way to improve thinking and decision-making, though improving CT skills can close the gap. Being open-minded, self-aware, and reflective offers nurses important information that can improve CR and decision-making. Clinical judgment (akin to CR) improves over time with nurses who uses reflection as a guide for decisions and actions (Cappelletti et al., 2014).

Critical Thinking and Clinical Decision-Making

Lee et al. (2017) conducted an integrated review on nine studies to determine whether effective CT impacted clinical decision-making. Four studies found CT impacted decision-making, though five studies did not find a correlation. Due to poor study designs, Lee et al. (2017) could not come to a clear decision on whether there was as significant correlation.

CT continues to be an important factor for problem-solving, regardless if studies can confirm a correlation to decision-making. Developing CT skills, such as reflection, intuition, and logical reasoning, are essential behaviors that lead to a patient-centered approach. Nurses who stop and think about what worked for a patient in the past, may consider the same option again, or may choose an alternative. Considering all possibilities with the patient’s best interest in mind is part of CT and making clinical decisions.

Researchers will continue to study the impact of CT on nursing care. Nurse educators will continue emphasize CT in the curriculum and assist students in developing CT skills throughout all levels of education as they offer students tools and methods for problem-solving.

Rubenfeld and Scheffer (2001) explain the essence of CT in nursing practice:

Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge (2001, p. 125).

Standards of Practice

Critical thinking and clinical reasoning are weaved throughout the Nursing Scope and Standards of Practice and Code of Ethics (American Nurses Association [ANA], 2021). The nursing process itself, Standards 1-6, are essentially a tool used for clinical reasoning. The standards require core cognitive competencies and guide nurses to use patient data to make effective clinical decisions.

The  Essentials

Clinical Judgement is one of the eight featured concepts within The Essentials (American Association of Colleges of Nursing [AACN], 2021, p.12). The process of clinical judgement, as earlier in this section, is the outcome of critical thinking.

The Essentials explains how a liberal arts education is critical to exposing nurses to a broad worldview, giving them a holistic perspective that engages them in promoting health equity and social justice, , and “forms the basis for clinical reasoning and subsequent clinical judgments” (AACN, 2021, p. ).

Problem-Solving A pproaches

Reflective thinking.

Reflection is a powerful tool for recognizing errors in judgment, questioning one’s response, and ultimately improving outcomes. Below are two practice examples that illustrate the power of reflective thinking with interprofessional communication and patient care:

Novice and senior nurse communication

• Problem: A novice nurse is struggling with inserting IVs just about every shift. One day, the nurse asks the same more experienced nurse for help again. The nurse listens though does not turn around to face the nurse when questioned, and responds in a swift, aggressive way, “I’m swamped, we have no aides today and I’m falling behind with everything. I’ll help you when I get time, but it’s going to be a while.”
• Impact: The nurse’s patient is at risk for injury without an IV line. The patient may be upset and unsatisfied with care knowing the IV was out for an extended period of time. The nurse feels dejected, does not feel like she is a valued team member, and loses further confidence in her abilities. She considers quitting her job or transferring to another unit.
• Reflection: The experienced nurse realizes she was not empathetic to the nurse’s needs and impatient and aggressive in her response. She realizes the nurse is new and doesn’t have much confidence in her skills yet. She also knows the nurse is probably disappointed in the lack of teamwork and camaraderie. Most of all, she feels bad about disrespecting her coworker.
• Impact of reflection : After reflection of the situation, the nurse apologizes for her poor behavior. She states she will work with her each shift they work together, she will share personal tips and review educational materials. Additionally, she will offer to have her observe her IV insertions until she has mastered the skill. She will also make sure the new nurse feels like she is part of the team, not just the new nurse.

Shift report

• Problem: The oncoming nurse enters his patient room for the first time and finds the foley bag is full and the patient is complaining of abdominal discomfort.
• Impact: The patient is at risk for infection and may be disappointed with the quality of nursing care.
• Reflection: The oncoming nurse realizes there is always one or two problems or inconsistencies when he assesses his patients for the first time. He knows the outgoing nurses are skilled and provide quality care and considers another reason for the errors. After thinking about this for a while, he believes the process for shift report can help reduce change of shift errors. The nurse realizes there needs to be a better way for sharing patient information during change of shift.
• Impact of reflection: The nurse researches evidence-based practices to improve safety and quality during shift change. The nurse shares a copy of the review article on bedside report with his manager. The nurse offers to be a change champion on the unit to implement a new process for shift report.

L ong-term impact of reflection :

• Improved team cohesiveness, nurse retention and job satisfaction
• Improved patient satisfaction experience and quality of care, leading to higher insurance reimbursement

Glynn (2012) states reflective thinking enhances clinical judgment and gives nurses the opportunity to learn from actual or perceived errors. In regard to the communication scenario, it’s through reflection that nurses can think about their behaviors and responses. Reflect on the message for clarity, and whether it was shared in an empathetic and respective way.

As discussed in the communication chapter, poor communication is the number one reason for medication errors and sentinel events. Through reflection, miscommunication can be identified, solutions found, and implemented. In order for this process to come to fruition, nurses must take the initiative to reflect on their practice.

Creative Thinking

Creative thinking helps nurses generate alternative approaches to clinical decision-making. This type of thinking works especially well with medically complex patients, where care needs to be individualized to reach desired outcomes.

Akin to the concept of “thinking outside the box”, finding a novel approach to patient care prevents traditional, stagnant thinking. Choosing alternatives based solely on creative thinking can negatively impact outcomes unless it is paired with the skill of critical thinking. Critical thinking requires the nurse to view the patient holistically,

Nurses access knowledge unconsciously and trust this information as fact. Often referred to as a “gut feeling”, intuition comes naturally. Intuition is not a tool that is sought out at will, instead the knowledge emerges naturally during a care experience, resulting in firm actions and decisions. Intuition is a measure of professional expertise (Smith, Thurkettle, & Cruz, 2004), a type of clinical judgement that develops over time (Benner, 1984). Since this knowledge is considered intangible or irrelevant, some disregard it, though many studies have shown its positive influence in making accurate decisions and improving the quality of care (Robert, Tilley & Petersen, 2014).

• Nurses will recognize something about their patient that they can’t explain, and will make decisions on care without concrete evidence to back up their actions. Such actions can be lifesaving (Billay, Myrick, Luhanga & Yonge 2007). Each clinical experience acts as a learning experience for which lessons are learned and applied to the next experience (McCutcheon & Pincombe, 2001).
• Holtslander (2008) states Carper’s (1978) seminal work on the fundamental ways of knowing was published as a reaction to the overemphasis of empirical (scientific) knowledge in nursing practice. One of the four ways of knowing , called aesthetic knowing , explains the component of art within nursing practice, an, awareness of the patient, viewing the patient as unique. This viewpoint allows nurses to consider more than just empirical knowledge to guide practice.

Critical Thinking Skills

As discussed earlier, CT encompasses a broad range of reasoning skills that lead to effective decision-making. Through the process of clinical reasoning and judgment, nurses make best choice after assembling and analyzing patient data.

White (2003) studied senior baccalaureate nurses and found the following five themes were essential to developing clinical decision-making skills:

• Gaining confidence in clinical skills
• Building relationships with staff
• Connecting with patients
• Gaining comfort in self as a nurse
• Understanding the clinical picture

Scheffer and Rubenfeld (2000) found CT is comprised of affective and cognitive components. Affective components refer to an individual’s feelings and attitudes, and cognitive components refer to thought processes. The CT components include 10 habits of the mind (affective components) and seven skills (cognitive components), as follows:

Habits of the mind

• Confidence : assurance of one’s reasoning abilities
• C ontextual perspective : considerate of the whole situation, including relationships, background and environment relevant to some happening
• C re a tivity : intellectual inventiveness used to generate, discover, or restructure ideas; imagining alternatives
• F lexibility : capacity to adapt, accommodate, modify or change thoughts, ideas, and behaviors
• I nquisitiveness : an eagerness to know by seeking knowledge and understanding through observation and thoughtful questioning in order to explore possibilities and alternatives
• I ntellectual integrity : seeking the truth through sincere, honest processes, even if the results are contrary to one’s assumptions and beliefs
• I ntuition : insightful sense of knowing without conscious use of reason
• O pen-mindedness : a viewpoint characterized by being receptive to divergent views and sensitive to one’s biases
• P erseverance : pursuit of a course with determination to overcome obstacles
• R eflection : contemplation upon a subject, especially one’s assumptions and thinking for the purposes of deeper understanding and self-evaluation (Scheffer & Rubenfeld, 2000, p. 358)
• Analyzing : separating or breaking a whole into parts to discover their nature, function and relationships
• A pplying standards : judging according to established personal, professional or social rules or criteria
• D iscriminating : recognizing differences and similarities among things or situations and distinguishing carefully as to category or rank
• I nformation seeking : searching for evidence, facts or knowledge by identifying relevant sources and gathering objective, subjective, historical, and current data from those sources
• L ogical reasoning : drawing inferences or conclusions that are supported in or justified by evidence
• P redicting : envisioning a plan and its consequences
• T ransforming knowledge : changing or converting the condition, nature, form, or function of concepts among contexts (Scheffer & Rubenfeld, 2000, p. 358)

Development of CT is a lifelong process that requires nurses to be self-aware, and to use knowledge and experience as a tool to become a critical thinker. As nurses move along the continuum from novice to expert, one’s competence and ability to critically think will expand (Brunt, 2005).

• Transitions to Professional Nursing Practice. Authored by : Jamie Murphy. Provided by : SUNY Delhi. Located at : https://courses.lumenlearning.com/suny-delhi-professionalnursing . License : CC BY: Attribution

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• Critical Thinking

Q&A: What is critical thinking and when would you use critical thinking in the clinical setting?

(Write 2-3 paragraphs)

In literature ‘critical thinking’ is often used, and perhaps confused, with problem-solving and clinical decision-making skills and clinical reasoning. In practice, problem-solving tends to focus on the identification and resolution of a problem, whilst critical thinking goes beyond this to incorporate asking skilled questions and critiquing solutions.

Critical thinking has been defined in many ways, but is essentially the process of deliberate, systematic and logical thinking, while considering bias or assumptions that may affect your thinking or assessment of a situation. In healthcare, the clinical setting whether acute care sector or aged care critical thinking has generally been defined as reasoned, reflective thinking which can evaluate the given evidence and its significance to the patient’s situation. Critical thinking occasionally involves suspension of one’s immediate judgment to adequately evaluate and appraise a situation, including questioning whether the current practice is evidence-based. Skills such as interpretation, analysis, evaluation, inference, explanation, and self-regulation are required to interpret thinking and the situation. A lack of critical thinking may manifest as a failure to anticipate the consequences of one’s actions.

Critical thinking is that mode of thinking – about any subject, content, or problem — in which the thinker improves the quality of his or her thinking by skillfully taking charge of the structures inherent in thinking and imposing intellectual standards upon them.

The Paul-Elder framework has three components:

• The elements of thought (reasoning)
• The intellectual standards that should be applied to the elements of reasoning
• The intellectual traits associated with a cultivated critical thinker that result from the consistent and disciplined application of the intellectual standards to the elements of thought.

Critical thinking can be defined as, “the art of analysing and evaluating thinking with a view to improving it”. The eight Parts or Elements of Thinking involved in critical thinking:

• All reasoning has a purpose (goals, objectives).
• All reasoning is an attempt to figure something out, to settle some question, to solve some problem .
• All reasoning is based on assumptions (line of reasoning, information taken for granted).
• All reasoning is done from some point of view.
• All reasoning is based on data, information and evidence .
• All reasoning is expressed through, and shaped by, concepts and ideas .
• All reasoning contains inferences or interpretations by which we draw conclusions and give meaning to data.
• All reasoning leads somewhere or has implications and consequence.

Q&A: To become a nurse requires that you learn to think like a nurse. What makes the thinking of a nurse different from a doctor, a dentist or an engineer?

It is how we view the health care consumer or aged care consumer, and the type of problems nurses deal with in clinical practice when we engage in health care patient centred care. To think like a nurse requires that we learn the content of nursing; the ideas, concepts, ethics and theories of nursing and develop our intellectual capacities and skills so that we become disciplined, self-directed, critical thinkers.

As a nurse you are required to think about the entire patient/s and what you have learnt as a nurse including; ideas, theories, and concepts in nursing. It is important that we develop our skills so that we become highly proficient critical thinkers in nursing.

In nursing, critical thinkers need to be:

Nurses need to use language that will clearly communicate a lot of information that is key to good nursing care, for handover and escalation of care for improving patient safety and reducing adverse outcomes, some organisations use the iSoBAR (identify–situation–observations–background–agreed plan–read back) format. Firstly, the “i”, for “identify yourself and the patient”, placed the patient’s identity, rather than the diagnosis, in primary position and provided a method of introduction. (This is particularly important when teams are widely spread geographically.) The prompt, “S” (“situation”) “o” for “observations”, was included to provide an adequate baseline of factual information on which to devise a plan of care. and “B” (“background”), “A” “agreed plan” and “R” “read back” to reinforce the transfer of information and accountability.

In clinical practice experienced nurses engage in multiple clinical reasoning episodes for each patient in their care. An experienced nurse may enter a patient’s room and immediately observe significant data, draw conclusions about the patient and initiate appropriate care. Because of their knowledge, skill and experience the expert nurse may appear to perform these processes in a way that seems automatic or instinctive. However, clinical reasoning is a learnt skill.

Key critical thinking skills – the clinical reasoning cycle / critical thinking process

To support nursing students in the clinical setting, breakdown the critical thinking process into phases;

• Decide/identify

This is a dynamic process and nurses often combine one or more of the phases, move back and forth between them before reaching a decision, reaching outcomes and then evaluating outcomes.

For nursing students to learn to manage complex clinical scenarios effectively, it is essential to understand the process and steps of clinical reasoning. Nursing students need to learn rules that determine how cues shape clinical decisions and the connections between cues and outcomes.

Start with the Patient – what is the issue? Holistic approach – describe or list the facts, people.

Collect information – Handover report, medical and nursing, allied health notes. Results, patient history and medications.

• New information – patient assessment

Process Information – Interpret- data, signs and symptoms, normal and abnormal.

• Analyse – relevant from non-relevant information, narrow down the information
• Evaluate – deductions or form opinions and outcomes

Identify Problems – Analyse the facts and interferences to make a definitive diagnosis of the patients’ problem.

Establish Goals – Describe what you want to happen, desired outcomes and timeframe.

Take action – Select a course of action between alternatives available.

Evaluate Outcomes – The effectiveness of the actions and outcomes. Has the situation changed or improved?

Reflect on process and new learning – What have you learnt and what would you do differently next time.

Scenario: Apply the clinical reasoning cycle, see below, to a scenario that occurred with a patient in your clinical practice setting. This could be the doctor’s orders, the patient’s vital signs or a change in the patient’s condition.

(Write 3-5 paragraphs)

Important skills for critical thinking

Some skills are more important than others when it comes to critical thinking. The skills that are most important are:

• Interpreting – Understanding and explaining the meaning of information, or a particular event.
• Analysing – Investigating a course of action, that is based upon data that is objective and subjective.
• Evaluating – This is how you assess the value of the information that you have. Is the information relevant, reliable and credible?

This skill is also needed to determine if outcomes have been fully reached.

Based upon those three skills, you can use clinical reasoning to determine what the problem is.

These decisions have to be based upon sound reasoning:

• Explaining – Clearly and concisely explaining your conclusions. The nurse needs to be able to give a sound rationale for their answers.
• Self-regulating – You have to monitor your own thought processes. This means that you must reflect on the process that lead to the conclusion. Be on alert for bias and improper assumptions.

Critical thinking pitfalls

Errors that occur in critical thinking in nursing can cause incorrect conclusions. This is particularly dangerous in nursing because an incorrect conclusion can lead to incorrect clinical actions.

Illogical Processes

A common illogical thought process is known as “appeal to tradition”. This is what people are doing when they say it’s always been done like this. Creative, new approaches are not tried because of tradition.

All people have biases. Critical thinkers are able to look at their biases and not let them compromise their thinking processes.

Biases can complicate decision making, communication and ultimately effect patient care.

Closed Minded

Being closed-minded in nursing is dangerous because it ignores other team members points of view. Essential input from other experts, as well as patients and their families are also ignored which ultimately impacts on patient care. This means that fewer clinical options are explored, and fewer innovative ideas are used for critical thinking to guide decision making.

So, no matter if you are an intensive care nurse, community health nurse or a nurse practitioner, you should always keep in mind the importance of critical thinking in the nursing clinical setting.

It is essential for nurses to develop this skill: not only to have knowledge but to be able to apply knowledge in anticipation of patients’ needs using evidence-based care guidelines.

American Management Association (2012). ‘AMA 2012 Critical Skills Survey: Executive Summary’. (2012). American Management Association. http://playbook.amanet.org/wp-content/uploads/2013/03/2012-Critical-Skills-Survey-pdf.pdf   Accessed 5 May 2020.

Korn, M. (2014). ‘Bosses Seek ‘Critical Thinking,’ but What Is That?,’ The Wall Street Journal . https://www.wsj.com/articles/bosses-seek-critical-thinking-but-what-is-that-1413923730?tesla=y&mg=reno64-wsj&url=http://online.wsj.com/article/SB12483389912594473586204580228373641221834.html#livefyre-comment Accessed 5 May 2020.

School of Nursing and Midwifery Faculty of Health, University of Newcastle. (2009). Clinical reasoning. Instructors resources. https://www.newcastle.edu.au/__data/assets/pdf_file/0010/86536/Clinical-Reasoning-Instructor-Resources.pdf  Accessed 11 May 2020

The Value of Critical Thinking in Nursing + Examples. Nurse Journal social community for nurses worldwide. 2020.  https://nursejournal.org/community/the-value-of-critical-thinking-in-nursing/ Accessed 8 May 2020.

Paul And Elder (2009) Have Defined Critical Thinking As: The Art of Analysing And Evaluating …

https://www.chegg.com/homework-help/questions-and-answers/paul-elder-2009-defined-critical-thinking-art-analyzing-evaluating-thinking-view-improving-q23582096 Accessed 8 May 2020 .

Cody, W.K. (2002). Critical thinking and nursing science: judgment, or vision? Nursing Science Quarterly, 15(3), 184-189.

Facione, P. (2011). Critical thinking: What it is and why it counts. Insight Assessment , ISBN 13: 978-1-891557-07-1.

McGrath, J. (2005). Critical thinking and evidence- based practice. Journal of Professional Nursing, 21(6), 364-371.

Porteous, J., Stewart-Wynne, G., Connolly, M. and Crommelin, P. (2009). iSoBAR — a concept and handover checklist: the National Clinical Handover Initiative. Med J Aust 2009; 190 (11): S152.

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Applying critical thinking to nursing, bob price healthcare education and practice development consultant, surrey, england.

Critical thinking and writing are skills that are not easy to acquire. The term ‘critical’ is used differently in social and clinical contexts. Nursing students need time to master the inquisitive and ruminative aspects of critical thinking that are required in academic environments. This article outlines what is meant by critical thinking in academic settings, in relation to both theory and reflective practice. It explains how the focus of a question affects the sort of critical thinking required and offers two taxonomies of learning, to which students can refer when analysing essay requirements. The article concludes with examples of analytical writing in reference to theory and reflective practice.

Nursing Standard . 29, 51, 49-60. doi: 10.7748/ns.29.51.49.e10005

[email protected]

All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

Received: 23 February 2015

Accepted: 10 April 2015

education - students - study skills - studying - academic assignments - continuing professional development - CPD - clinical reasoning - critical appraisal - learning outcomes - reflection - reflective practice

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Critical Thinking: A Simple Guide and Why It’s Important

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Critical Thinking: A Simple Guide and Why It’s Important was originally published on Ivy Exec .

Strong critical thinking skills are crucial for career success, regardless of educational background. It embodies the ability to engage in astute and effective decision-making, lending invaluable dimensions to professional growth.

At its essence, critical thinking is the ability to analyze, evaluate, and synthesize information in a logical and reasoned manner. It’s not merely about accumulating knowledge but harnessing it effectively to make informed decisions and solve complex problems. In the dynamic landscape of modern careers, honing this skill is paramount.

The Impact of Critical Thinking on Your Career

☑ problem-solving mastery.

Visualize critical thinking as the Sherlock Holmes of your career journey. It facilitates swift problem resolution akin to a detective unraveling a mystery. By methodically analyzing situations and deconstructing complexities, critical thinkers emerge as adept problem solvers, rendering them invaluable assets in the workplace.

☑ Refined Decision-Making

Navigating dilemmas in your career path resembles traversing uncertain terrain. Critical thinking acts as a dependable GPS, steering you toward informed decisions. It involves weighing options, evaluating potential outcomes, and confidently choosing the most favorable path forward.

☑ Enhanced Teamwork Dynamics

Within collaborative settings, critical thinkers stand out as proactive contributors. They engage in scrutinizing ideas, proposing enhancements, and fostering meaningful contributions. Consequently, the team evolves into a dynamic hub of ideas, with the critical thinker recognized as the architect behind its success.

☑ Communication Prowess

Effective communication is the cornerstone of professional interactions. Critical thinking enriches communication skills, enabling the clear and logical articulation of ideas. Whether in emails, presentations, or casual conversations, individuals adept in critical thinking exude clarity, earning appreciation for their ability to convey thoughts seamlessly.

☑ Adaptability and Resilience

Perceptive individuals adept in critical thinking display resilience in the face of unforeseen challenges. Instead of succumbing to panic, they assess situations, recalibrate their approaches, and persist in moving forward despite adversity.

☑ Fostering Innovation

Innovation is the lifeblood of progressive organizations, and critical thinking serves as its catalyst. Proficient critical thinkers possess the ability to identify overlooked opportunities, propose inventive solutions, and streamline processes, thereby positioning their organizations at the forefront of innovation.

☑ Confidence Amplification

Critical thinkers exude confidence derived from honing their analytical skills. This self-assurance radiates during job interviews, presentations, and daily interactions, catching the attention of superiors and propelling career advancement.

So, how can one cultivate and harness this invaluable skill?

✅ developing curiosity and inquisitiveness:.

Embrace a curious mindset by questioning the status quo and exploring topics beyond your immediate scope. Cultivate an inquisitive approach to everyday situations. Encourage a habit of asking “why” and “how” to deepen understanding. Curiosity fuels the desire to seek information and alternative perspectives.

✅ Practice Reflection and Self-Awareness:

Engage in reflective thinking by assessing your thoughts, actions, and decisions. Regularly introspect to understand your biases, assumptions, and cognitive processes. Cultivate self-awareness to recognize personal prejudices or cognitive biases that might influence your thinking. This allows for a more objective analysis of situations.

✅ Strengthening Analytical Skills:

Practice breaking down complex problems into manageable components. Analyze each part systematically to understand the whole picture. Develop skills in data analysis, statistics, and logical reasoning. This includes understanding correlation versus causation, interpreting graphs, and evaluating statistical significance.

✅ Engaging in Active Listening and Observation:

Actively listen to diverse viewpoints without immediately forming judgments. Allow others to express their ideas fully before responding. Observe situations attentively, noticing details that others might overlook. This habit enhances your ability to analyze problems more comprehensively.

✅ Encouraging Intellectual Humility and Open-Mindedness:

Foster intellectual humility by acknowledging that you don’t know everything. Be open to learning from others, regardless of their position or expertise. Cultivate open-mindedness by actively seeking out perspectives different from your own. Engage in discussions with people holding diverse opinions to broaden your understanding.

✅ Practicing Problem-Solving and Decision-Making:

Engage in regular problem-solving exercises that challenge you to think creatively and analytically. This can include puzzles, riddles, or real-world scenarios. When making decisions, consciously evaluate available information, consider various alternatives, and anticipate potential outcomes before reaching a conclusion.

✅ Continuous Learning and Exposure to Varied Content:

Read extensively across diverse subjects and formats, exposing yourself to different viewpoints, cultures, and ways of thinking. Engage in courses, workshops, or seminars that stimulate critical thinking skills. Seek out opportunities for learning that challenge your existing beliefs.

✅ Engage in Constructive Disagreement and Debate:

Encourage healthy debates and discussions where differing opinions are respectfully debated.

This practice fosters the ability to defend your viewpoints logically while also being open to changing your perspective based on valid arguments. Embrace disagreement as an opportunity to learn rather than a conflict to win. Engaging in constructive debate sharpens your ability to evaluate and counter-arguments effectively.

✅ Utilize Problem-Based Learning and Real-World Applications:

Engage in problem-based learning activities that simulate real-world challenges. Work on projects or scenarios that require critical thinking skills to develop practical problem-solving approaches. Apply critical thinking in real-life situations whenever possible.

This could involve analyzing news articles, evaluating product reviews, or dissecting marketing strategies to understand their underlying rationale.

In conclusion, critical thinking is the linchpin of a successful career journey. It empowers individuals to navigate complexities, make informed decisions, and innovate in their respective domains. Embracing and honing this skill isn’t just an advantage; it’s a necessity in a world where adaptability and sound judgment reign supreme.

So, as you traverse your career path, remember that the ability to think critically is not just an asset but the differentiator that propels you toward excellence.

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National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

• Hardcopy Version at National Academies Press

7 Educating Nurses for the Future

You cannot transmit wisdom and insight to another person. The seed is already there. A good teacher touches the seed, allowing it to wake up, to sprout, and to grow. —Thich Nhat Hanh, global spiritual leader and peace activist

By 2030, the nursing profession will look vastly different and will be caring for a changing America. Nursing school curricula need to be strengthened so that nurses are prepared to help promote health equity, reduce health disparities, and improve the health and well-being of everyone. Nursing schools will need to ensure that nurses are prepared to understand and identify the social determinants of health, have expanded learning experiences in the community so they can work with different people with varied life experiences and cultural values, have the competencies to care for an aging and more diverse population, can engage in new professional roles, are nimble enough to adapt continually to new technologies, and can lead and collaborate with other professions and sectors. And nursing students—and faculty—not only need to reflect the diversity of the population, but also need to help break down barriers of structural racism prevalent in today’s nursing education.

Throughout the coming decade, it will be essential for nursing education to evolve rapidly in order to prepare nurses who can meet the challenges articulated in this report with respect to addressing social determinants of health (SDOH), improving population health, and promoting health equity. Nurses will need to be educated to care for a population that is both aging, with declining mental and physical health, and becoming increasingly diverse; to engage in new professional roles; to adapt to new technologies; to function in a changing policy environment; and to lead and collaborate with professionals from other sectors and professions. As part of their education, aspiring nurses will need new competencies and different types of learning experiences to be prepared for these new and expanded roles. Also essential will be recruiting and supporting diverse students and faculty to create a workforce that more closely resembles the population it serves. Given the growing focus on SDOH, population health, and health equity within the public health and health care systems, the need to make these changes to nursing education is clear. Nurses’ close connection with patients and communities, their role as advocates for well-being, and their placement across multiple types of settings make them well positioned to address SDOH and health equity. For future nurses to capitalize on this potential, however, SDOH and equity must be integrated throughout their educational experience to build the competencies and skills they will need.

The committee’s charge included examining whether nursing education provides the competencies and skills nurses will need—the capacity to acquire new competencies, to work outside of acute care settings, and to lead efforts to build a culture of health and health equity—as they enter the workforce and throughout their careers. A thorough review of the current status and future needs of nursing education in the United States was beyond the scope of this study, but in this chapter, the committee identifies priorities for the content and nature of the education nurses will need to meet the challenge of addressing SDOH, advancing health equity, and improving population health. Nursing education is a lifelong pursuit; nurses gain knowledge and skills in the classroom, at work, through continuing professional development, and through other formal and informal mechanisms ( IOM, 2016b ). While the scope of this study precluded a thorough discussion of learning outside of nursing education programs, readers can find further discussion of lifelong learning in A Framework for Educating Health Professionals to Address the Social Determinants of Health ( IOM, 2016b ), Redesigning Continuing Education in the Health Professions ( IOM, 2010 ), and Exploring a Business Case for High-Value Continuing Professional Development: Proceedings of a Workshop ( NASEM, 2018a ).

To change nursing education meaningfully so as to produce nurses who are prepared to meet the above challenges in the decade ahead will require changes in four areas: what is taught, how it is taught, who the students are, and who teaches them. This chapter opens with a description of the nursing education system and the need for integrating equity into education, and then examines each of these four areas in turn:

• domains and competencies for equity,
• expanded learning opportunities,
• recruitment of and support for diverse prospective nurses, and
• strengthening and diversification of the nursing faculty.

In addition to changes in these specific areas, there is a need for a fundamental shift in the idea of what constitutes a “quality” nursing education. Currently, National Council Licensure Examination (NCLEX) pass rates are used as the primary indicator of quality, along with graduation and employment rates ( NCSBN, 2020a ; O’Lynn, 2017 ). This narrow focus on pass rates has been criticized for diverting time and attention away from other goals, such as developing student competencies, investing in faculty, and implementing innovative curricula ( Giddens, 2009 ; O’Lynn, 2017 ; Taylor et al., 2014 ). In addition, the NCLEX is heavily focused on acute care rather than on such areas of nursing as primary care, disease prevention, SDOH, and health equity ( NCSBN, 2019 ). In response to such concerns about the NCLEX, the National Council of State Boards of Nursing (NCSBN) conducted a study to identify additional quality indicators for nursing education programs; indicators were identified in the areas of administration, program director, faculty, students, curriculum and clinical experiences, and teaching and learning resources ( Spector et al., 2020 ). To realize the committee’s vision for nursing education, it will be necessary for nursing schools, accreditors, employers, and students to look beyond NCLEX pass rates and include these types of indicators in the assessment of a quality nursing education.

• OVERVIEW OF NURSING EDUCATION

Nurses are educated at universities, colleges, hospitals, and community colleges and can follow a number of educational pathways. Table 7-1 identifies the various degrees that nurses can hold, and describes the programs that lead to each degree and the usual amount of time required to complete them. In 2019, there were more than 200,000 graduates from baccalaureate, master’s, and doctoral nursing programs in the United States and its territories, including 144,659 who received a baccalaureate degree ( AACN, 2020a ) (see Table 7-2 ).

Pathways in Nursing Education.

Number of Graduates from Nursing Programs in the United States and Territories, 2019.

Nursing programs are nationally accredited by the Accreditation Commission for Education in Nursing (ACEN); the Commission on Collegiate Nursing Education (CCNE); the Commission for Nursing Education and Accreditation (CNEA); and other bodies focused on specialty areas of nursing, such as midwifery. Graduating registered nurses (RNs) seek licensure as nurses through state boards, and take examinations administered by the NCSBN as graduates with their first professional degree and then as specialists with certification exams offered through specialty organizations. These bodies set minimum standards for nursing programs and establish criteria for certification and licensing, faculty qualifications, course offerings, and other features of nursing programs ( Gaines, n.d. ).

The Need for Nursing Education on Social Determinants of Health and Health Equity

A report of the Institute of Medicine (IOM) from nearly two decades ago asserts that all health professionals, including nurses, need to “understand determinants of health, the link between medical care and healthy populations, and professional responsibilities” ( IOM, 2003 , p. 209). The literature is replete with calls for all nurses to understand concepts associated with health equity, such as disparities, culturally competent care, equity, and social justice. For example, Morton and colleagues (2019) identify essential content to prepare nurses for community-based practice, including SDOH, health disparities/health equity, cultural competency, epidemiology, community leadership, and the development of enhanced skills in community-based settings. O’Connor and colleagues (2019) call for an inclusive educational environment that prepares nurses to care for diverse patient populations, including the study of racism’s impacts on health from the genetic to the societal level, systems of marginalization and oppression, critical self-reflection, and preparation for lifelong learning in these areas. And Thornton and Persaud (2018) state that the content of nursing education should include instruction in cultural sensitivity and culturally competent care, trauma-informed care and motivational interviewing, screening for social needs, and referring for services. These calls align with the Health Resources and Services Administration’s (HRSA’s) most recent strategic plan, which prioritizes the development of a health care workforce that is able to address current and emerging needs for improving equity and access ( HRSA, 2019 ). Additionally, recommendations of the National Advisory Council on Nurse Education and Practice (NACNEP) (2016) include that population health concepts be incorporated into nursing curriculum and that undergraduate programs create partnerships with HRSA, the U.S. Department of Veterans Affairs (VA), and the Indian Health Service (IHS), agencies that serve rural and frontier areas, to increase students’ exposure to different competencies, experiences, and environments.

In concert with these perspectives and recommendations, nursing organizations have developed guidelines for how nursing education should prepare nurses to work on health equity issues and address SDOH. In 2019, the National League for Nursing (NLN) issued a Vision for Integration of the Social Determinants of Health into Nursing Education Curricula , which describes the importance of SDOH to the mission of nursing and makes recommendations for how SDOH should be integrated into nursing education (see Box 7-1 ).

National League for Nursing’s (NLN’s) Vision for Integration of the Social Determinants of Health into Nursing Education Curricula.

As described in Chapter 9 , the American Association of Colleges of Nursing’s (AACN’s) Essentials 1 provides an outline for the necessary curriculum content and expected competencies for graduates of baccalaureate, master’s, and doctor of nursing practice (DNP) programs. Essentials identifies “Clinical Prevention and Population Health” as one of the nine essential areas of baccalaureate nursing education. Among other areas of focus, Essentials calls for baccalaureate programs to prepare nurses to

• collaborate with other health care professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions;
• assess the health, health care, and emergency preparedness needs of a defined population;
• collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and the prevention of illness, injury, disability, and premature death;
• participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness, and equity; and
• advocate for social justice, including a commitment to the health of vulnerable populations and the elimination of health disparities.

Curriculum content and expected competencies laid out in Essentials for master’s- and DNP-level nursing education also address SDOH, disparities, equity, and social justice ( AACN, 2006 , 2011 ). While Essentials only guides baccalaureate, master’s, and DNP programs, the document’s emphasis on health equity and SDOH demonstrates the importance of these topics to the nursing profession as a whole.

As of 2020, AACN has been shifting toward a competency-based curriculum. As part of this effort, AACN published a draft update to Essentials that identifies 10 domains for nursing education: knowledge for nursing practice; person-centered care; population health; scholarship for nursing discipline; quality and safety; interprofessional partnerships; systems-based practice; informatics and health care technologies; professionalism; and personal, professional, and leadership development. Within these 10 domains are specific competencies that AACN believes are essential for nursing practice ( AACN, 2020b ), including

• engage in effective partnerships,
• advance equitable population health policy,
• demonstrate advocacy strategies,
• use information and communication technologies and informatics processes to deliver safe nursing care to diverse populations in a variety of settings, and
• use knowledge of nursing and other professions to address the health care needs of patients and populations.

Nurses themselves have also indicated the need for more education and training on these topics. The 2018 National Sample Survey of Registered Nurses (NSSRN) asked the question, “As of December 31, 2017, what training topics would have helped you do your job better?” Figure 7-1 shows the percentage of six different training topics that RNs said would help them do their job better. Overall, RNs working in schools, public health, community health, and emergency and urgent care were more likely than RNs working in all other employment settings listed in Figure 7-1 to indicate that they could have done their job better if they had received training in SDOH, population health, working in underserved communities, caring for individuals with complex health and social needs, and especially mental health. These results could reflect RNs encountering increasingly complex individuals and populations, rising numbers of visits and caseloads, the fact that the RNs working in these settings frequently provide care for people facing multiple social risk factors that harm their health and well-being, or inadequacy of the training in these areas that RNs had received. RNs—particularly those working in informatics, health care management and administration, and education—also indicated that training in value-based care would have been helpful. Additionally, RNs who had graduated after 2010 were more likely than those who had graduated before then to indicate that they could have done their job better with training across all of these topics.

Training topics that would have helped registered nurses do their jobs better, by type of work performed and graduation from their nursing program, 2018. SOURCE: Calculations based on the 2018 National Sample Survey of Registered Nurses (HRSA, 2020). (more...)

Nurse practitioners (NPs) have also indicated the need for more training in SDOH. In response to the 2018 NSSRN question described above, NPs working in public health and community health, emergency and urgent care, education, and long-term care reported that they could have done their job better if they had received training in SDOH, mental health, working in underserved communities, and providing care for medically complex/special needs. Across all types of practice settings, one-third felt that training in mental health issues would have helped them do their job better, while very few NPs indicated that training in value-based care would have been helpful. Additionally, NPs who had graduated since 2010 were more likely than those who had graduated before then to indicate that they would have benefited from training in these topics. Figure 7-2 shows the percentage of six different training topics that NPs mentioned would have helped them do their job better.

Training topics that would have helped nurse practitioners do their jobs better, by type of work performed and graduation from their nursing education program, 2018. SOURCE: Calculations based on the 2018 National Sample Survey of Registered Nurses (HRSA, (more...)

The Need for Integration of Social Determinants of Health and Health Equity into Nursing Education

Despite guidelines from both the American Association of Colleges of Nursing (AACN) and the National League for Nursing (NLN) and numerous calls for including equity, population health, and SDOH in nursing education, SDOH and related concepts are not currently well integrated into undergraduate and graduate nursing education. Nor has the degree to which nurses are prepared and educated in these areas been studied systematically ( NACNEP, 2019 ; Tilden et al., 2018 ). The committee was unable to locate a central repository of information about the coursework and other educational experiences available to nursing students across types of programs and institutions, or any other source of systematic analysis of nursing curricula. This lack of information about nursing preparation programs limits the conclusions that can be drawn about them. Thus, the discussion in this chapter is based on the assumption that some nursing programs are likely already pursuing many of the goals identified herein, but that this critically important content is not yet standard practice throughout nursing education.

One way to explore whether and how health equity and related concepts are currently integrated into nursing education is to look at accreditation standards. While the standards do not detail every specific topic to be covered in nursing curricula, they do set expectations, convey priorities, and identify important areas of study. For example, the accreditation standards of the CCNE state that advanced practice registered nurse (APRN) programs must include study of advanced physiology, advanced health assessment, and advanced pharmacology ( CCNE, 2018 ). Accreditation standards could be used to prioritize the inclusion of health equity and SDOH in nursing curriculum; however, this is not currently the case. The CCNE standards state that accredited programs must incorporate the AACN Essentials into their curricula, and while these standards do not specifically mention equity, SDOH, or other relevant concepts ( CCNE, 2018 ), that is expected to change to correspond with the updates to the Essentials described previously (see Box 7-1 ). CNEA’s accreditation standards likewise include no mention of population health, SDOH, or health equity ( NLN, 2016 ), although a more recent document from NLN makes a strong case for the integration of SDOH into nursing education curricula ( NLN, 2019 ). ACEN’s associate’s and baccalaureate standards call for inclusion of “cultural, ethnic, and socially diverse concepts” in the curriculum; the master’s and doctoral standards require that curriculum be “designed so that graduates of the program are able to practice in a culturally and ethnically diverse global society,” but do not address health equity, population health, or SDOH.

Another approach for examining the inclusion of these concepts in nursing education is to look at exemplar programs. As part of the Future of Nursing: Campaign for Action, the Robert Wood Johnson Foundation commissioned a study of best practices in nursing education to support population health ( Campaign for Action, 2019b ). That report notes that although many nursing programs reported including population health content in their curriculum, few incorporated the topic substantially. However, the report also identifies exemplars of programs with promising population health models. These exemplars include Oregon Health & Science University, which incorporates population health throughout the curriculum as a key competency; Rush University, which incorporates cultural competence throughout the curriculum; and Thomas Jefferson University, which offers courses in health promotion, population health, health disparities, and SDOH. NACNEP has also examined exemplars of nursing programs that incorporate health equity and SDOH into their curricula ( NACNEP, 2019 ). The programs highlighted include the University of Pennsylvania School of Nursing, which has a course called Case Study—Addressing the Social Determinants of Health: Community Engagement Immersion ( Schroeder et al., 2019 ). This course offers experiential learning opportunities that focus on SDOH in vulnerable and underserved populations and helps students design health promotion programs for these communities. The school also offers faculty education in SDOH.

As far as the committee was able to determine, most programs include content on SDOH in community or public health nursing courses. However, this material does not appear to be integrated thoroughly into the curriculum in the majority of programs, nor could the committee identify well-established designs for curricula that address this content outside of community health rotations ( Campaign for Action, 2019b ; Storfjell et al., 2017 ; Thornton and Persaud, 2018 ). In the committee’s view, a single course in community and/or public health nursing is insufficient preparation for creating a foundational understanding of health equity and for preparing nurses to work in the wide variety of settings and roles envisioned in this report. Ideally, education in these concepts would be integrated throughout the curriculum to give nurses a comprehensive understanding of the social determinants that contribute to health inequities ( NACNEP, 2019 ; NLN, 2019 ; Siegel et al., 2018 ). Moreover, academic content alone is insufficient to provide students with the knowledge, skills, and abilities they need to advance health equity; rather, expanded opportunities for experiential and community learning are critical for building the necessary competencies ( Buhler-Wilkerson, 1993 ; Fee and Bu, 2010 ; NACNEP, 2016 ; Sharma et al., 2018 ). All those involved in nursing education—administrators, faculty, accreditors, and students—need to understand that health equity is a core component of nursing, no less important than alleviating pain or caring for individuals with acute illness. Graduating students need to understand and apply knowledge of the impact of such issues as classism, racism, sexism, ageism, and discrimination and to be empowered to advocate on these issues for people who they care for and communities.

As currently constituted, then, nursing education programs fall short of conveying this information sufficiently in the curriculum or through experiential learning opportunities. Yet, the existing evidence on what nursing education programs offer is scant. Research is therefore needed to assess whether and how many nursing programs are offering sufficient coursework and learning opportunities related to SDOH and health equity and to examine the extent to which graduating nurses have the competencies necessary to address these issues in practice.

The Need for BSN-Prepared Nurses

The 2011 The Future of Nursing report includes the recommendation that the percentage of nurses who hold a baccalaureate degree or higher be increased to 80 percent by 2020. The report gives several reasons for this goal, including that baccalaureate-prepared nurses are exposed to competencies including health policy, leadership, and systems thinking; they have skills in research, teamwork, and collaboration; and they are better equipped to meet the increasingly complex demands of care both inside and outside the hospital ( IOM, 2011 , p. 170). In 2011, 50 percent of employed nurses held a baccalaureate degree or higher; as of 2019, that proportion had increased to 59 percent ( Campaign for Action, 2020 ). Both the number of baccalaureate programs and program enrollment have increased substantially since 2011 2 ( AACN, 2019a ), and the number of RNs who went on to receive BSNs in RN-to-BSN programs increased 236 percent between 2009 and 2019 ( Campaign for Action, n.d. ). However, the goal of 80 percent of nurses holding a BSN was still not achieved by 2020, for a number of reasons. Although the proportion of new graduates with a BSN is higher than the proportion of existing nurses with a BSN, the percentage of new graduates joining the nursing workforce each year is small. Given this ratio, it would have been “extraordinarily difficult” to achieve the goal of 80 percent by 2020 ( IOM, 2016a ; McMenamin, 2015 ). Nurses already in the workforce face barriers to pursuing a BSN, including time, money, work–life balance, and a perception that additional postlicense education is not worth the effort ( Duffy et al., 2014 ; Spetz, 2018 ). Moreover, schools and programs have limited capacity for first-time nursing students and ADN, LPN nurses, or RNs without BSN degrees ( Spetz, 2018 ).

Nonetheless, the goal of achieving a nursing workforce in which 80 percent of nurses hold a baccalaureate degree or higher remains relevant, and continuing efforts to increase the number of nurses with a BSN are needed. Across the globe, the proportion of BSN-educated nurses is correlated with better health outcomes ( Aiken et al., 2017 ; Baker et al., 2020 ), and there are clear differences as well as similarities between associate’s degree in nursing (ADN) programs and BSN programs. In particular, BSN programs are more likely to cover topics relevant to liberal education, organizational and systems leadership, evidence-based practice, health care policy, finance and regulatory environments, interprofessional collaboration, and population health ( Kumm et al., 2014 ). Accelerated, nontraditional, and other pathways to the BSN degree are discussed later in this chapter.

The Need for PhD-Prepared Nurses

There are two types of doctoral degrees in nursing: the PhD and the DNP. The former is designed to prepare nurse scientists to conduct research, whereas the latter is a clinically focused doctoral degree designed to prepare graduates with advanced competencies in leadership and management, quality improvement, evidence-based practice, and a variety of specialties. PhD-prepared nurses are essential to the development of the research base required to support evidence-based practice and add to the body of nursing knowledge, and DNP-educated nurses play a key role in translating evidence into practice and in educating nursing students in practice fundamentals ( Tyczkowski and Reilly, 2017 ) (see Chapter 3 for further discussion of the role of DNPs).

The number of nurses with doctoral degrees has grown rapidly since the 2011 The Future of Nursing report was published ( IOM, 2011 ). As a proportion of doctorally educated nurses, however, the number of PhD graduates has remained nearly flat. In 2010, there were 1,282 graduates from DNP programs and 532 graduates receiving a PhD in nursing. By 2019, the number of DNP graduates had grown more than 500 percent to 7,944, while the number of PhD graduates had grown about 50 percent to 804 ( AACN, 2011 , 2020a ).

The slow growth in PhD-prepared nurses is a major concern for the profession and for the nation, because it is these nurses who serve as faculty at many universities and who systematically study issues related to health and health care, including the impact of SDOH on health outcomes, health disparities, and health equity. PhD-prepared nurses conduct research on a wide variety of issues relating to SDOH, including the effect of class on children’s health; linguistic, cultural, and educational barriers to care; models of care for older adults aging in place; and gun violence (Richmond and Foman, 2018; RWJF, 2020 ; Szanton et al., 2014 ). Nurse-led research provided evidence-based solutions in the early days of the COVID-19 pandemic for such challenges as the shift to telehealth care, expanding demand for health care workers, and increased moral distress ( Lake, 2020 ). However, Castro-Sánchez and colleagues (2021) note a dearth of nurse-led research specifically related to COVID-19; they posit that this gap can be attributed to workforce shortages, a lack of investment in clinical academic leadership, and the redeployment of nurses into clinical roles. More PhD-prepared nurses are needed to conduct research aimed at improving clinical and community health, as well as to serve as faculty to educate the next generation of nurses ( Broome and Fairman, 2018 ; Fairman et al., 2020 ; Greene et al., 2017 ).

Nursing practice is dependent on a robust pipeline of research to advance evidence-based care, inform policy, and address the health needs of people and communities ( Bednash et al., 2014 ). The creation of the BSN-to-PhD direct entry option has helped produce more research-oriented nurse faculty ( Greene et al., 2017 ), but time, adequate faculty mentorship, mental health issues, and financial hardships, including the cost of tuition, are barriers for nurses pursuing these advanced degrees ( Broome and Fairman, 2018 ; Fairman et al., 2020 ; Squires et al., 2013 ). One approach for increasing the number of PhD-prepared nurses is the Future of Nursing Scholars program, which successfully graduated approximately 200 PhD students through an innovative accelerated 3-year program ( RWJF, 2021 ). Similar programs have been funded by such foundations as the Hillman Foundation and Jonas Philanthropies to help stimulate the pipeline, build capacity (especially in health policy) among graduates, and model innovative curricular approaches ( Broome and Fairman, 2018 ; Fairman et al., 2020 ).

• DOMAINS AND COMPETENCIES FOR EQUITY

As noted earlier, a number of existing recommendations specify what nurses need to know to address SDOH and health inequity in a meaningful way. In addition, the Future of Nursing: Campaign for Action surveyed and interviewed faculty and leaders in nursing and public health, asking about core content and competencies for all nurses ( Campaign for Action, 2019b ). Respondents specifically recommended that nursing education cover seven areas:

• policy and its impact on health outcomes;
• epidemiology and biostatistics;
• a basic understanding of SDOH and illness across populations and how to assess and intervene to improve health and well-being;
• health equity as an overall goal of health care;
• interprofessional team building as a key mechanism for improving population health;
• the economics of health care, including an understanding of basic payment models and their impact on services delivered and outcomes achieved; and
• systems thinking, including the ability to understand complex demands, develop solutions, and manage change at the micro and macro system levels.

Drawing on all of these recommendations, guidelines, and perspectives, as well as looking at the anticipated roles and responsibilities outlined in other chapters of this report, the committee identified the core concepts pertaining to SDOH, health equity, and population health that need to be covered in nursing school and the core knowledge and skills that nurses need to have upon graduation. For consistency with the language used by the AACN, these are referred to, respectively, as “domains” (see Box 7-2 ) and “competencies” (see Box 7-3 ). The domains in Box 7-2 are fundamental content that the committee believes can no longer be covered in public health courses alone, but need to be incorporated and applied by nursing students throughout nursing curricula. All nurses, regardless of setting or type of nursing, need to understand and be prepared to address the underlying barriers to better health in their practice.

Domains for Nursing Education.

Competencies for Nursing Education, Depending on Preparation Level.

The committee believes that incorporation of these domains and competencies can guide expeditious and meaningful changes in nursing education. The committee acknowledges that making room for these concepts will inevitably require eliminating some existing material in nursing education. The committee does not believe that it is the appropriate entity to identify what specific curriculum changes should be made; a nationwide evaluation will be needed to ensure that nursing curricula are preparing the future workforce with the skills and competencies they will need. The committee also acknowledges that nursing programs differ in length, and that an ADN program cannot cover SDOH equity to the same extent as a BSN program. The specific knowledge and skills a nurse will need will vary depending on her or his level of nursing education. For example, a nurse with a BSN may need to understand and be able to use the technologies that are relevant to his or her area of work (e.g., telehealth applications, electronic health records [EHRs], home monitors), while an APRN may need a deeper understanding of how to analyze health records in order to provide care and monitor health status for populations outside clinical settings.

Nonetheless, nursing education at all levels—from licensed practical nurse (LPN) to ADN to BSN and beyond—needs to incorporate and integrate the domains and competencies in Boxes 7-2 and 7-3 to the extent possible so as to develop knowledge and skills that will be relevant and useful to nurses and essential to achieving equity in health and health care. Given the relationship among SDOH, social needs, and health outcomes and the increasing focus of health care systems on addressing these community and individual needs, the domains and competencies identified here are essential to ensure that all nurses understand and can apply concepts related to these issues; work effectively with people, families, and communities across the spectrum of SDOH; promote physical, mental, and social health; and assume leadership and entrepreneurial roles to create solutions, such as by fostering partnerships in the health and social sectors, scaling successful interventions, and engaging in policy development. While none of the domains listed in Box 7-2 are new to nursing, the health inequities that have become increasingly visible—especially as a result of the COVID-19 pandemic—demand that these domains now be substantively integrated into the fabric of nursing education and practice.

Many sources highlight both the challenges faced by front-line graduates when confronted with these issues, and the reality that many nursing schools lack faculty members with the knowledge and competencies to educate nurses effectively on these issues ( Befus et al., 2019 ; Effland et al., 2020 ; Hermer et al., 2020 ; Levine et al., 2020 ; Porter et al., 2020 ; Rosa et al., 2019 ; Valderama-Wallace and Apesoa-Varano, 2019 ). To remedy the latter gap, educators need to have a clear understanding of these issues and their links to both educational and patient outcomes (see the section below on strengthening and diversifying the nursing faculty). It is important to note as well that some of these topics, including the connections among implicit biases, structural racism, and health equity, may be difficult for educators and students to discuss (see Box 7-4 ).

Discussing Difficult Topics.

Given the limited scope of this report, the committee has chosen to highlight three of the competencies from Box 7-3 in this section. 3 The first is delivering person-centered care to diverse populations. As the United States becomes increasingly diverse, nurses will need to be aware of their own implicit biases and be able to interact with diverse patients, families, and communities with empathy and humility. The second is learning to collaborate across professions, disciplines, and sectors. As discussed previously in this report, addressing SDOH is necessarily a multisectoral endeavor given that these determinants go beyond health to include such issues as housing, education, justice, and the environment. The third is continually adapting to new technologies. Advances in technology are reshaping both health care and education, and making it possible for both to be delivered in nontraditional settings and nontraditional ways. In the present context, technology can expand access to underserved populations of patients and students—for example, telehealth and online platforms can be used to connect with those living in rural areas—but it can also exacerbate existing disparities and inequities. Nurses need to understand both the promises and perils of technology, and be able to adapt their practice and learning accordingly.

Delivering Person-Centered Care and Education to Diverse Populations

As discussed in Chapter 2 , people’s family and cultural background, community, and other experiences may have profound impacts on their health. Given the increasing diversity of the U.S. population, it is critical that nurses understand the impact of these factors on health, can communicate and connect with people of different backgrounds, and can be self-reflective about how their own beliefs and biases may affect the care they provide. To this end, the committee believes it is essential that nursing education include the concepts of cultural humility and implicit bias as a thread throughout the curriculum.

An integral part of learning about these concepts is an opportunity to reflect on what one is learning and to draw connections with past learning and experiences. Researchers have established that instruction that guides students in reflection helps reinforce skills and competencies (see, e.g., NASEM, 2018c ). This idea has been explored in the context of education in health professions and has been identified as a valuable way to foster understanding of health equity and SDOH ( IOM, 2016b ; Mann et al., 2007). While the strategies, goals, and structure of such reflection may vary, the process in general helps learners in health care settings examine their own values, assumptions, and beliefs ( El-Sayed and El-Sayed, 2014 ; Scheel et al., 2017 ). In the course of structured reflection, for example, students might consider how such issues as racism, implicit bias, trauma, and policy affect the care people receive and create conditions for poor health, or how their own experiences and identities influence the care they provide.

Cultural Humility

In recent years, the focus in discussions of patient care has shifted from cultural competency to cultural humility ( Barton et al., 2020 ; Brennan et al., 2012 ; Kamau-Small et al., 2015 ; Periyakoil, 2019 ; Purnell et al., 2018 ; Walker et al., 2016 ). The concept of cultural competency has been interpreted by some as limited for a number of reasons. First, it implies that “culture” is a technical skill in which clinicians can develop expertise, and it can become a series of static dos and don’ts ( Kleinman and Benson, 2006 ). Second, the concept of cultural competency tends to promote a colorblind mentality that ignores the role of power, privilege, and racism in health care (Waite and Nardi, 2017). Third, cultural competency is not actively antiracist but instead leaves institutionalized structures of White privilege and racism intact ( Schroeder and DiAngelo, 2010 ).

In contrast, cultural humility is defined by flexibility, a lifelong approach to learning about diversity, and a recognition of the role of individual bias and systemic power in health care interactions ( Agner, 2020 ). Cultural humility is considered a self-evaluating process that recognizes the self within the context of culture ( Campinha-Bacote, 2018 ). The concept of cultural humility can be woven into most aspects of nursing and interprofessional education. For example, case studies in which students learn about the experience of a particular disease or strategies for disease prevention can be designed to model culturally humble approaches in the provision of nursing care and the avoidance of stereotypical thinking ( Foronda et al., 2016 ; Mosher et al., 2017 ). One effective approach to cultivating cultural humility is to accompany experiential learning opportunities or case studies with reflection that expands learning beyond skills and knowledge. This includes questioning current practices and proposing changes to improve the efficiency and quality of care, equality, and social justice ( Barton et al., 2020 ; Foronda et al., 2013 ). Programs designed to develop nurses’ cultural sensitivity and humility, as well as cultural immersion programs, have been developed, and research suggests that such programs can effectively develop skills that strengthen nurses’ confidence in treating diverse populations, improve patient and provider relationships, and increase nurses’ compassion ( Allen, 2010 ; Gallagher and Polanin, 2015 ; Sanner et al., 2010 ).

Implicit Bias

Implicit bias is an unconscious or automatic mental association made between members of a group and an attribute or evaluation ( FitzGerald and Hurst, 2017 ). For example, a clinician may unconsciously view White patients as more medically compliant than Black patients ( Sabin et al., 2008 ). These types of biases not only can have consequences for individual health outcomes ( Aaberg, 2012 ; Linden and Redpath, 2011 ) but also may play a role in maintaining or exacerbating health disparities ( Blair et al., 2011 ). There are many resources available for implicit bias awareness and training; for example, Harvard University offers a number of Implicit Association Tests (IATs), the Institute for Healthcare Improvement offers free online resources to address implicit bias, and the AACN offers implicit bias workshops for nurses ( AACN, n.d. ; Foronda et al., 2018 ).

Evidence on the use of implicit bias training is limited. One review of the use of an IAT in health professions education found that the test had contrasting uses, with some curricula using it as a measure of implicit bias and others using it to initiate discussions and reflection. The review found a dearth of research on the use of IATs; the authors note that the nature of implicit bias is highly complex and cannot necessarily be reduced to the “time-limited” use of an IAT ( Sukhera et al., 2019 ). A systematic review of interventions designed to reduce implicit bias found that many such interventions are ineffective, and some may even increase implicit biases. The authors note that while there is no clear path for reducing biases, the lack of evidence does not weaken the case for “implementing widespread structural and institutional changes that are likely to reduce implicit biases” (FitzGerald et al., 2019). One promising model is an intervention that helps participants break the “prejudice habit” ( Devine et al., 2012 ). This multifaceted intervention, which includes situational awareness of bias, education about the consequences of bias, strategies for reducing bias, and self-reflection, has been shown to reduce implicit racial bias for at least 2 months ( Devine et al., 2012 ). Clearly, more research is needed in this area.

Learning to Collaborate Across Professions, Disciplines, and Sectors

As discussed in Chapter 9 , eliminating health disparities will require the active engagement and advocacy of a broad range of stakeholders working in partnership to address the drivers of structural inequities in health and health care ( NASEM, 2017 ). In these efforts, nurses may lead or work with people from a variety of professions, disciplines, and sectors, including, for example, physicians, social workers, educators, policy makers, lawyers, faith leaders, government employees, community advocates, and community members. Working across sectors, especially as they relate to SDOH (food insecurity, transportation barriers, housing, etc.), is a critical competence. Collaboration among these types of stakeholders has multiple benefits, including broader expertise and perspective, the capacity to address wide-ranging social needs, the ability to reach underserved populations, and sustainability and alignment of efforts (see Chapter 9 for further discussion). A traditional nursing education, which focuses on what is taught rather than on building competencies, is unlikely to give students the understanding of broader social, political, and environmental contexts that is necessary for working in these types of strategic partnerships ( IOM, 2016b ). If nursing students are to be prepared to practice interprofessionally after graduation, they must be given opportunities to collaborate with others before graduation ( IOM, 2013 ) and to build the competencies they will need for collaborative practice. The Interprofessional Education Collaborative (IPEC) identified four core competencies for interprofessional collaborative practice ( IPEC, 2016 ). While these competencies were developed specifically to prepare students for interprofessional practice within health care, they are also applicable to broader collaborations among other professions, disciplines, and sectors both within and outside of health care:

• Work with individuals of other professions to maintain a climate of mutual respect and shared values.
• Use the knowledge of one’s own role and those of other professionals to appropriately assess and address the health care needs of patients and to promote and advance the health of populations.
• Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease.
• Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles in planning, delivering, and evaluating patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable.

There are opportunities for nursing students to gain interprofessional and multisector collaborative competencies through both experiential learning in the community (discussed in detail below) and classroom work. Increasingly, nursing schools are working with other institutions to offer students classes in which they learn with or from students and professionals in other disciplines. For example, the University of Michigan Center for Interprofessional Education offers courses in such topics as health care delivery in low- and middle-income countries, social justice, trauma-informed practice, interprofessional communication, and teamwork. Courses are open to students from the schools of social work, pharmacy, medicine, nursing, dentistry, physical therapy, public health, and business. 4

Despite the benefits of interprofessional education, however, there are barriers that affect the implementation of such programs in health professions education, including different schedules, lack of meeting space, incongruent curricula plans, faculty not trained to teach interprofessionally, faculty overload, and the challenge of providing adequate opportunities for all levels of students ( NLN, 2015a ). The use of simulation has been proposed as a vehicle for overcoming such barriers to impart interprofessional collaborative competencies ( NLN, 2013 ); a systematic review of the evidence found that this approach can be effective ( Marion-Martins and Pinho, 2020 ). Nurses can also gain interprofessional experience by pursuing dual degrees. For example, the University of Pennsylvania offers dual degrees that combine nursing with health care management, bioethics, public health, law, or business administration.

Continually Adapting to New Technologies

Nurses can use a wide variety of existing and emerging technologies and tools to address SDOH and provide high-quality care to all patients (see Box 7-5 ). Broadly speaking, these technologies and tools fall into three categories: patient-facing, clinician-facing, and data analytics. Patient- and clinician-facing tools collect data and help providers and patients connect and make decisions about care. Data analytics uses data, collected from patients or other sources, to analyze trends, identify disparities, and guide policy decisions. Beginning as students, all nurses need to be familiar with these technologies, be able to engage with patients or other professionals around their appropriate use, and understand how their use has the potential to exacerbate inequalities.

Highlights from the Seattle Townhall on Technology and Health Equity and Implications for Nursing Education.

Patient-facing technologies include apps and software, such as mobile and wearable health devices, as well as telehealth and virtual visit technologies ( FDA, 2020 ). These tools allow nurses and other health care providers to expand their reach to those who might otherwise not have access because of geography, transportation, social support, or other challenges. For example, telehealth and mobile apps allow providers to see people in their homes, mitigating such barriers to care as transportation while also helping providers understand people in the context of their everyday lives. Essential skills for nurses using these new tools will include the ability to project a caring relationship through technology (Massachusetts Department of Higher Nursing Education Initiative, 2016 ) and to use technology to personalize care based on patient preferences, technology access, and individual needs ( NLN, 2015b ). The role of telehealth and the importance of training nurses in this technology have been recognized for several years ( NONPF, 2018 ; Rutledge et al., 2017 ), but the urgent need for telehealth services during the COVID-19 pandemic has made it “imperative” to include telehealth training in nursing curricula ( Love and Carrington, 2020 ). Moreover, it is anticipated that the shift to telehealth for some types of care will become a permanent feature of the health care system in the future ( Bestsennyy et al., 2020 ).

Clinician-facing technologies include EHRs, clinical decision support tools, mobile apps, and screening and referral tools ( Bresnick, 2017 ; CDC, 2018 ; Heath, 2019 ). A number of available digital technologies can facilitate the collection and integration of data on social needs and SDOH and help clinicians hold compassionate and empathetic conversations about those needs ( AHA, 2019 ; Giovenco and Spillane, 2019 ). In 2019, for example, Kaiser Permanente launched its Thrive Local network (Kaiser Permanente, 2019 ), which can be used to screen for social needs and connect people with community resources that can meet these needs. The system is integrated with the EHR, and it is capable of tracking referrals and outcomes to measure whether needs are being met; these data can then be used to continuously improve the network.

Nurses will need to understand how and when to use these types of tools, and can leverage their unique understanding of patient and community needs to improve and expand them. As described in Chapter 10 , such technologies as EHRs and clinical alarms can burden nurses and contribute to workplace stress. However, nurses have largely been left out of conversations about how to design and use these systems. For example, although nurses are one of the primary users of EHR systems, little research has been conducted to understand their experiences with and perceptions of these systems, which may be different from those of other health care professionals ( Cho et al., 2016 ; Higgins et al., 2017 ). Out of 346 usability studies on health care technologies conducted between 2003 and 2009, only 2 examined use by nurses ( Yen and Bakken, 2012 ). Educating nurses to understand and assess the benefits and drawbacks of health care technologies and have the capacity to help shape and revamp them can ultimately improve patient care and the well-being of health professionals.

Tools for data analytics are increasingly important for improving patient care and the health of populations ( Ibrahim et al., 2020 ; NEJM Catalyst, 2018 ). Analysis of large amounts of data from such sources as EHRs, wearable monitors, and surveys can help in detecting and tracking disease trends, identifying disparities, and finding patterns of correlation ( Breen et al., 2019 ; NASEM, 2016a ; Shiffrin, 2016 ). The North Carolina Institute for Public Health, for example, collaborated with a local health system in analyzing data to inform a community health improvement plan ( Wallace et al., 2019 ). Data on 12 SDOH indicators were sourced from the American Community Survey and mapped by census tract. The mapping provided a visualization of the disparities in the community and allowed the health system to focus its efforts strategically to improve community health. The North Carolina Department of Health and Human Services later replicated this strategy across the entire state ( NCDHHS, 2020 ).

There are opportunities for nurses to specialize in this type of work. For example, nursing informatics is a specialized area of practice in which nurses with expertise in such disciplines as information science, management, and analytical sciences use their skills to assess patient care and organizational procedures and identify ways to improve the quality and efficiency of care. In the context of SDOH, nursing informaticists will be needed to leverage artificial intelligence and advanced visualization methods to summarize and contextualize SDOH data in a way that provides actionable insights while also eliminating bias and not overwhelming nurses with extraneous information. Big data are increasingly prevalent in health care, and nurses need the skills and competencies to capitalize on its potential ( Topaz and Pruinelli, 2017 ). Even nurses who do not specialize in informatics will need to understand how the analysis of massive datasets can impact health ( Forman et al., 2020 ; NLN, 2015b ). Investments in expanding program offerings, certifications, and student enrollment will be needed to meet the demand for nurses with such skills.

As noted, however, despite its promise for improving patient care and community health, technology can also exacerbate existing disparities ( Ibrahim et al., 2020 ). For example, people who lack access to broadband Internet and/or devices are unable to take advantage of such technologies as remote monitoring and telehealth appointments ( Wise, 2012 ). Older adults, people with limited formal education, those living in rural and remote areas, and the poor are less likely to have access to the Internet. As health care becomes more reliant on technology, these groups are likely to fall behind ( Arcaya and Figueroa, 2017 ). In addition, such technologies as artificial intelligence and algorithmic decision-making tools may exacerbate inequities by reflecting existing biases ( Ibrahim et al., 2020 ). Nursing education needs to prepare nurses to understand these potential downsides of technology in order to prevent and mitigate them. This has become a particularly critical issue during the COVID-19 pandemic, with the rapid shift to telehealth potentially having consequences for those with low digital literacy, limited English proficiency, and a lack of access to the Internet ( Velasquez and Mehrotra, 2020 ).

Not all nurses will need to acquire all of the key technological competencies; curricula can be developed according to the likely needs of nurses working at different levels. For example, most nurses will need the knowledge and skills to use telehealth, digital health tools, and data-driven clinical decision-making skills in practice, whereas nurse informaticians and some doctoral-level nurses will need to be versed in device design, bias assessment in algorithms, and big data analysis.

• EXPANDING LEARNING OPPORTUNITIES

As stated previously, the domains and competencies enumerated above cannot be conveyed to nursing students through traditional lectures alone. Building the competencies to address population health, SDOH, and health inequities will require substantive experiential learning, collaborative learning, an integrated curriculum, and continuing professional development throughout nurses’ careers ( IOM, 2016b ). The 2019 Campaign for Action survey of nursing educators and leaders found that a majority of respondents identified “innovative community clinical experiences” and “interprofessional education experiences” as the top methods for teaching population health ( Campaign for Action, 2019b ). A recurrent theme in interviews with respondents was the importance of active and experiential learning, with opportunities for partnering with nontraditional agencies ( Campaign for Action, 2019b ). These types of community-based educational opportunities, particularly when they involve partnerships with others, are critical for nursing education for multiple reasons.

First, experience in the community is essential to understanding SDOH and gaining the competencies necessary to advance health equity ( IOM, 2016b ). In fact, restricting education in SDOH to the classroom may even be harmful, given the finding of a 2016 study that medical students who learned about SDOH in the classroom rather than through experiential learning demonstrated an increase in negative attitudes toward medically underserved populations ( Schmidt et al., 2016 ).

Second, community-based education offers opportunities for students to engage with community partners from other sectors, such as government offices of housing and transportation or community organizations, preparing them for the essential work of participating in and leading partnerships to address SDOH. An example is a pilot interdisciplinary partnership between a school of nursing and a city fire department in the Pacific Northwest that allows students to practice such skills as motivational interviewing to identify the range of problems (e.g., transportation issues, difficulty accessing insurance or providers, lack of caregiving support) faced by people calling emergency services ( Yoder and Pesch, 2020 ).

Third, nursing is increasingly practiced in community settings, such as schools and workplaces, as well as through home health care ( WHO, 2015 ). Nursing students are prepared to practice in hospitals, but do not necessarily receive the same training and preparation for these other environments ( Bjørk et al., 2014 ). Education in the community allows nursing students to learn about the broad range of care environments and to work collaboratively with other professionals who work in these environments. For example, students may work in a team with community health workers, social workers, and those from other sectors (e.g., housing and transportation), work that both enriches the experience of student nurses and creates bridges between nursing and other fields ( Zandee et al., 2010) . Nurses who have these experiences during school may then be more prepared to lead and participate in multisector efforts to address SDOH—the importance of which is emphasized throughout this report—once they enter practice. Evidence suggests that graduating students are more likely to seek work in areas that are familiar to them from their education, clinical experience, and theoretical training ( Jamshidi et al., 2016 ); thus, these nontraditional educational experiences may increase the number of nurses interested in working in the community. Moreover, while training in acute care settings has often been regarded as more valuable than that provided in community settings, evidence indicates that the two offer comparable opportunities for learning clinical skills ( Morton et al., 2019 ). In fact, clinical care in community-based settings can present greater complexity relative to that in the hospital, and some technical skills (e.g., epidemiologic disease tracking, tuberculosis assessment and management, immunizations) are more available in community than in acute care settings ( Morton et al., 2019 ).

Some nursing programs have incorporated community-based experiential learning into their programs. At community colleges and universities, schools have implemented nurse-managed clinics that serve the local population and their own students while also giving students technical skills and experience in interacting with the community. Lewis and Clark Community College, for example, operates a mobile health unit that brings health and dental care to six counties in southern Illinois ( Lewis and Clark, n.d. ), while nursing students at Alleghany College of Maryland can gain experience in the Nurse Managed Wellness Clinic, which offers such services as immunizations, screenings, and physicals ( Alleghany College, 2020 ). At the baccalaureate and master’s level, a number of schools offer longitudinal, integrated experiences in settings as varied as federally qualified health centers (FQHCs), public health departments, homeless shelters, public housing sites, public libraries, and residential addiction programs ( AACN, 2020c ). Students and faculty at the University of Washington School of Nursing, for example, support community-oriented projects in partnership with three underserved communities in the Seattle area. Graduate students work for 1 year on grassroots projects (e.g., food banks, school health) and then reinforce this experience with 1 year of work at the policy level ( AACN, 2020c ). At the doctoral level, Washburn University transformed its DNP curriculum to incorporate SDOH and reinforce that instruction through experiential learning in the community (see Box 7-6 ). In addition to clinical education, nursing students can participate in nontraditional clinical community engagement and service learning opportunities, such as volunteering at a homeless shelter or working in a service internship for a community organization. These opportunities get students into the community, help them build relationships with people from health care and other sectors, and promote understanding of and engagement with SDOH ( Bandy, 2011 ).

Pine Ridge Family Health Center.

Simulation-Based Education

Simulation-based education is another useful tool for teaching nursing concepts and developing competencies and skills ( Kononowicz et al., 2019 ; Poore et al., 2014 ; Shin et al., 2015 ). It can range from very low-tech (e.g., using oranges to practice injections) to very high-tech (e.g., a virtual reality emergency room “game”), but all simulations share the ability to bridge the gap between education and practice by imparting skills in a low-risk environment ( SSIH, n.d. ).

Simulations give students an opportunity to make real-time decisions and interact with virtual patients without having to face many of the challenges of traditional clinical education ( Hayden et al., 2014 ). They can be used to enhance many types of skills, including communication ( NASEM, 2018b ), cultural sensitivity ( Lau et al., 2016 ), and screening for SDOH ( Thornton and Persaud, 2018 ). Several simulation-based tools are available for learning about the realities of poverty, such as the Community Action Poverty Simulation (see Box 7-7 ) and the Cost of Poverty Experience ( ThinkTank, n.d. ). Such tools can help nurses identify ways in which their practice could directly mitigate the effects of poverty on individuals, families, and communities. Evaluations of poverty simulations have found that they can positively impact attitudes toward poverty and empathy among nurses and nursing students ( Phillips et al., 2020 ; Turk and Colbert, 2018 ), although one study noted that the simulations should be accompanied by the inclusion of social justice concepts throughout the curriculum to achieve lasting change ( Menzel et al., 2014 ).

The Community Action Poverty Simulation.

Individual schools may or may not have the resources or faculty to support some types of simulation activities. For those that do not, simulation centers shared by schools of multiple professions and hospitals can provide access ( Marken et al., 2010 ). For example, the New York Simulation (NYSIM) Center was created through a public–private partnership to manage interprofessional, simulation-based education for students and hospital employees across multiple sites ( NYSIM, 2017 ). The opportunity to take part in simulation experiences with students from other health professions can also improve collaboration and teamwork and prepare nurses for practicing interprofessionally in the workplace (von Wendt and Niemi-Murola, 2018 ).

Limitations on in-person clinical training during the COVID-19 pandemic conditions have demonstrated the promise of simulation-based education as a way to supplement traditional nursing education, allowing students to complete their education and sustaining the nursing workforce pipeline ( Horn, 2020 ; Jiménez-Rodríguez et al., 2020 ; Yale, 2020 ). Before the pandemic, the NCSBN conducted a longitudinal, randomized controlled trial of the use of simulation and concluded that substituting simulation-based education for up to half of a nursing student’s clinical hours produces comparable educational outcomes and students who are ready to practice ( Hayden et al., 2014 ). The COVID-19 pandemic has necessitated and accelerated the use of simulation to replace direct care experience in nursing schools, and state boards of nursing have loosened previous restrictions on its use ( NCSBN, 2020b ). Evaluation of this expanded use of simulation and other virtual experiences during the pandemic is needed, both in preparation for future emergencies and for use in nursing education generally.

• RECRUITING AND SUPPORTING DIVERSE PROSPECTIVE NURSES

The composition of the population of prospective nurses and the ways they are supported throughout their education are important factors in how prepared the future nursing workforce will be to address SDOH and health equity. As discussed in prior chapters, developing a more diverse nursing workforce will be key to achieving the goals of reducing health disparities, providing culturally relevant care for all populations, and fostering health equity (Center for Health Affairs, 2018 ; IOM, 2011 , 2016 ; Williams et al., 2014 ). A diverse workforce is one that reflects the variations in the nation’s population in such characteristics as socioeconomic status, religion, sexual orientation, gender, race, ethnicity, and geographic origin.

The nursing workforce has historically been overwhelmingly White and female, although it is steadily becoming more diverse (see Chapter 3 ). The 2016 IOM report assessing progress on the 2011 The Future of Nursing report notes that shifting the demographics of the overall workforce is inevitably a slow process since only a small percentage of the workforce leaves and enters each year ( IOM, 2016a ). The pipeline of students entering the field, on the other hand, can respond much more rapidly to efforts to increase diversity ( IOM, 2016a ). Since the 2011 report was published, significant gains have been realized in the diversity of nursing students. The number of graduates from historically underrepresented ethnic and racial groups more than doubled for BSN programs, more than tripled for entry-level master’s programs, and more than doubled for PhD programs ( AACN, 2020a ). The number of underrepresented students graduating from DNP programs grew by more than 1,000 percent, although this gain was due in large part to rapid growth in these programs generally. Yet, despite these gains, nursing students remain largely female and White: in 2019, 85–90 percent of students were female, and around 60 percent were White. The percentages of ADN, BSN, entry-level master’s, PhD, and DNP graduates in 2019 by race/ethnicity and gender are shown in Tables 7-3 and 7-4 , respectively. For example, the proportion of Hispanic or Latino nurses is highest among ADN graduates (12.8 percent) and lowest among PhD (5.5 percent) and DNP (6 percent) graduates, while the proportion of Asian nurses is highest among MSN graduates (11.2 percent) and lower among graduates with all other degrees. The proportion of PhD graduates who are male (9.9 percent) is significantly lower than the proportion of graduates with other degrees who are male.

Nursing Program Graduates by Degree Type and by Race/Ethnicity, 2019.

Nursing Program Graduates by Degree Type and Gender, 2019.

Diversifying and strengthening the nursing student body—and eventually, the nursing workforce—requires cultivating an inclusive environment, recruiting and admitting a diverse group of students, and providing students with support and addressing barriers to their success throughout their academic career and into practice. In addition, it is essential to make available information that will enable prospective students to make informed decisions about their education and give them multiple pathways for completing their education (e.g., distance learning, accelerated programs). Accrediting bodies can play a role in advancing diversity and inclusion in nursing schools by requiring certain policies, practices, or systems. For example, the accreditation standards for medical schools of the Liaison Committee on Medical Education (LCME) include the following expectation ( LCME, 2018 ):

A medical school has effective policies and practices in place, and engages in ongoing, systematic, and focused recruitment and retention activities, to achieve mission appropriate diversity outcomes among its students, faculty, senior administrative staff, and other relevant members of its academic community. These activities include the use of programs and/or partnerships aimed at achieving diversity among qualified applicants for medical school admission and the evaluation of program and partnership outcomes.

Currently, none of the major nursing accreditors (ACEN, CCNE, CNEA) includes similar language in its accreditation standards. As shown in Table 7-5 , of six possible areas for standards on diversity and inclusion, ACEN and CCEN have standards only for student training, while CNEA has standards for student training and faculty diversity. No nursing accreditors have standards for student diversity; in comparison, accrediting bodies for pharmacy, physician assistant, medical, and dental schools all have such standards.

Diversity and Inclusion in Accreditation Standards.

Cultivating an Inclusive Environment

Efforts to recruit and educate prospective nurses to serve a diverse population and advance health equity will be fruitless unless accompanied by efforts to acknowledge and dismantle racism within nursing education and nursing practice ( Burnett et al., 2020 ; Schroeder and DiAngelo, 2010 ; Villaruel and Broome, 2020 ; Waite and Nardi, 2019 ). The structural, individual, and ideological racism that exists in nursing is rarely called out, and this silence further entrenches the idea of Whiteness as the norm within nursing while marginalizing and silencing other groups and their perspectives ( Burnett et al., 2020 ; Iheduru-Anderson, 2020 ; Schroeder and DiAngelo, 2010 ). Non-White students report a wide variety of negative experiences in nursing school, including unsupportive faculty, discrimination and microaggressions 5 on the part of faculty and peers, bias in grading, loneliness and social isolation, feeling unwelcome and excluded, being viewed as a homogeneous population despite being from varying racial/ethnic groups, lack of support for career choices, and a lack of mentors ( Ackerman-Barger et al., 2020 ; Graham et al., 2016 ; Johansson et al., 2011 ; Loftin et al., 2012 ; Metzger et al., 2020 ). These experiences are associated with adverse outcomes that include disengagement from education, loss of “self,” negative perceptions of inclusivity and diversity at the institution, and institutions’ inability to recruit and retain a diversity of students ( Metzger et al., 2020 ). By contrast, when students characterize the learning environment as inclusive, they are more satisfied and confident in their learning and rate themselves higher on clinical self-efficacy and clinical belongingness ( Metzger and Taggart, 2020 ).

Notably, however, underrepresented and majority students describe inclusive environments differently. In a study of fourth-year baccalaureate nursing students, both groups described an inclusive classroom as one where they felt comfortable and respected and had a sense of belonging, but underrepresented minority students also noted the importance of feeling safe, feeling free from hostility, and being seen as themselves and not a representative of their group ( Metzger and Taggart, 2020 ). Both groups agreed that inclusivity requires a top-down approach, and that faculty are particularly influential in creating an inclusive environment, yet underrepresented students shared many experiences in which faculty either disrupted the sense of belonging or did not intervene when someone else did ( Metzger and Taggart, 2020 ).

While increased attention has recently been focused on increasing diversity in nursing education, the pervasiveness of racism requires more open acknowledgment and discussion and a systematic and intentional approach that may, as discussed earlier, be uncomfortable for some ( Ackerman-Barger et al., 2020 ; Villaruel and Broome, 2020 ). Cultivating an inclusive environment requires acknowledging and challenging racism in all aspects of the educational experience, including curricula, institutional policies and structures, pedagogical strategies, and the formal and informal distribution of resources and power ( Iheduru-Anderson, 2020 ; Koschmann et al., 2020 ; Metzger and Taggart, 2020 ; Schroeder and DiAngelo, 2010 ; Villaruel and Broome, 2020 ; Waite and Nardi, 2019 ). Nursing school curricula have historically focused on the contributions of White and female nurses ( Waite and Nardi, 2019 ). The weight given to this curricular content sends a message to students—both White students and students of color—about what faculty consider important ( Villaruel and Broome, 2020 ). Moving forward, curricula need to include a critical examination of the history of racism within nursing and an acknowledgment and celebration of the contribution of nurses of color ( Waite and Nardi, 2019 ). Such efforts need to be led by a broad group of individuals from all levels within an institution; racism in institutional practices can be so ingrained that it is difficult for those with power to recognize ( Villaruel and Broome, 2020 ). Faculty often understand the importance of an inclusive learning environment, but struggle with moving from intention to action (Beard, 2013, 2014 ; Metzger et al., 2020 ).

While institutional efforts to change organizational culture are thoroughly described in the literature, they remain too rare to address the problems described above effectively ( Breslin et al., 2018 ). In the early 2000s, the University of Washington School of Nursing implemented a project designed to change the “climate of whiteness” at the school ( Schroeder and DiAngelo, 2010 ). The project involved many facets, including year-long antiracist workshops; a comprehensive and institutionalized diversity statement; and action plans for addressing admission barriers, encouraging ongoing education for faculty, and disseminating antiracist information to the entire campus. The authors of an evaluation of the project note that while initial feedback was positive, changing the sociopolitical climate of a school is a long-term process that requires institutional commitment, innovative leadership, long- and short-term strategies, and patience ( Schroeder and DiAngelo, 2010 ). Unfortunately, many administrators and leaders may hesitate to initiate dialogues about these issues or may lack knowledge of how to address the challenges, and in many institutions, faculty and administrators from underserved groups have been expected to carry this burden, which can allow their colleagues to remain passive ( Lim et al., 2015 ). The committee stresses that addressing racism and discrimination within the nursing profession requires more than mere programs or statements; it requires developing action-oriented strategies, holding difficult conversations about privilege, dismantling long-standing structures and traditions, conducting curricular reviews to detect biases and correct as necessary, and exploring how interpersonal and structural racism shapes the student experience both consciously and unconsciously ( Burnett et al., 2020 ; Iheduru-Anderson, 2020 ; Waite and Nardi, 2019 ).

Recruitment and Admissions

Many social and structural barriers impede the entry of underrepresented students into the nursing profession ( NACNEP, 2019 ). Several approaches can be taken to improve access for prospective underrepresented students and, by extension, increase the diversity of the nursing workforce. Recruitment of underrepresented students can start years before nursing school through such approaches as improved K–12 science education ( AAPCHO, 2009 ) and outreach to junior high and high school students, such as through summer pipeline programs ( Katz et al., 2016 ) or health career clubs ( Murray et al., 2016 ). K–12 education is particularly important for sparking students’ interest in the health professions, as well as for giving them the foundational knowledge necessary for success ( NASEM, 2016b ). One innovative approach to preparing young people for a career in nursing is the Rhode Island Nurses Institute Middle College Charter High School (RINIMC). RINIMC offers a free, 4-year, nursing-focused, high school education open to any student in Rhode Island; students graduate with experience in health care as well as up to 20 college credits. Nearly half of the program’s students are Latinx, and more than one-third are Black ( RINIMC, n.d. ). Establishing a pathway to nursing education for diverse students well before undergraduate school is important, particularly for first-generation students ( Katz et al., 2016 ; McCue, 2017 ). Some states offer dual enrollment programs. An example is Ohio’s College Credit Plus program, in which students in grades 7 to 12 have the opportunity to earn college and high school credits simultaneously, thus preparing them for postsecondary success. 6

Once students have applied to nursing school, a system of holistic admissions can improve the diversity of the incoming class ( Glazer et al., 2016 , 2020 ). A holistic admissions system involves evaluating an applicant based not only on academic achievement but also on experiences, attributes, potential contributions, and the fit between the applicant and the institutional mission ( DeWitty, 2018 ; NACNEP, 2019 ). Schools that have implemented such a system have seen an increase in the diversity of their student body ( Glazer et al., 2016 , 2018 ). Academic measures (e.g., graduation and exam pass rates) have remained unchanged or improved, and schools have reported increases in such measures as student engagement, cooperation and teamwork, and openness to different perspectives ( Artinian et al., 2017 ; Glazer et al., 2016 , 2020 ). In a recent paper published by AACN (2020d) , the following promising practices in holistic admissions were identified: (1) review institutional mission, vision, and values statements to ensure that they value diversity and inclusion; (2) create an “experience, attributes, and metrics (E-A-M) model” (p. 16) that connects back to the institution’s mission statement; (3) identify recruitment practices that align with the E-A-M model; (4) design rubrics to be used by admissions committees that are reflective of the E-A-M model; (5) engage faculty and staff in the holistic admissions review process; (6) use technology resources such as a centralized application system to maintain efficiencies; (7) develop tailored support services for underrepresented students; and (8) engage in a review and assessment of the entire process.

Addressing Barriers to Success

Part of cultivating an inclusive educational environment is acknowledging and addressing barriers that may prevent students from achieving their potential. As noted previously, some students—particularly those from underrepresented groups—may need support in a number of areas, including economic, social and emotional, and academic and career progression. Attention to the barriers faced by students is essential at each step along the pathway from high school preparation; to recruitment, admission, retention, and academic success in nursing school; to graduation and placement in a job; to retention and advancement within a nursing career ( IOM, 2016b ).

Providing Economic Supports

Cost is a key factor in decisions about nursing education for most students, and is particularly salient for those from underrepresented groups, who come disproportionately from families with comparatively low incomes and levels of wealth ( Diefenbeck et al., 2016 ; Graham et al., 2016 ; Sullivan, 2004 ). Sabio and Petges (2020) interviewed associate’s degree nursing students in a Midwestern state and found that the total cost of a baccalaureate degree and student debt was the greatest barrier to pursuing a degree, followed by family and personal, such as head-of-household, responsibilities. This challenge is pervasive in higher education, and there are indications that the problem is growing (Advisory Committee on Student Financial Assistance, 2013 ). Students need to have the financial resources not only for tuition but also for an array of education-related expenses, including housing, food, work attire, books, and supplies.

Providing clear information about the costs of nursing education and available financial supports early in the recruitment and admission process is key to identifying those who need help and encouraging them to enroll ( Pritchard et al., 2016 ). Recruitment and admission practices need to take into account student finances and how future salaries affect choices, particularly for certain groups of students. Most health care systems provide some level of tuition reimbursement for baccalaureate and higher education, and this support may lead students toward certain settings (e.g., acute care) and away from others (e.g., public health, primary care) ( Larsen, 2012 ). Other financial support options are available, including the Public Service Loan Forgiveness program, which offers full forgiveness after 10 years for employees of nonprofit or government organizations ( U.S. Department of Education, n.d.b ), and programs through HRSA that award loan repayment to RNs and advanced practice nurses who work in health professions shortage areas for at least 2 years ( HRSA, 2021 ).

State policy reform can help remove some of the structural barriers to education. For example, New York State has implemented a program that allows New York households earning less than $125,000 annually to qualify for free instate tuition at state public universities ( New York State, n.d. ). New nurses who complete an associate’s degree in New York are required to complete a bachelor’s degree within 10 years of graduation; free in-state tuition could make a considerable difference for these nurses in pursuing their next degree. While it is too early to assess the effects on the composition of the nursing workforce, this approach bears further evaluation. Certainly it is critical for state policies to facilitate the financing of nursing education using models other than additional student loans. There are demonstrated disparities in the burden of student debt between Black and White students (Brookings Institution, 2016 ), and the risk of assuming large amounts of debt for students from disadvantaged backgrounds may be one they cannot afford to take. Therefore, innovative financing models are necessary to ensure that all nurses can pursue educational opportunities.

It is also important to note that as they progress in their education, students of many backgrounds may experience food insecurity, struggles with housing, or issues with transportation that affect their ability to perform ( AAC&U, 2019 ; Laterman, 2019 ; Strauss, 2020 ). Institutions need to ensure that students’ basic needs are met during their studies through sustained, multiyear funding and resources to support students facing financial emergencies.

Social and Academic Supports

Once students have been admitted, some nursing schools offer programs, such as summer programs that bridge high school and college, designed to prepare them academically and socially for the rigors of nursing education. Some of these programs are designed specifically for underrepresented and/or first-generation college students ( Pritchard et al., 2016 ), who may lack adequate family, emotional, and moral support; mentorship opportunities; professional socialization; and academic support ( Banister et al., 2014 ; Loftin et al., 2012 ). A study at the University of Cincinnati College of Nursing found that the impact of its summer bridge program lasted throughout the first year of school, and that grade point averages and retention were similar between underrepresented and majority students ( Pritchard et al., 2016 ). The Recruitment & Retention of American Indians into Nursing (RAIN) program at the University of North Dakota conducts a “No Excuses Orientation” workshop to give incoming American Indian students an opportunity to create connections and become acquainted with people and resources at the university ( UND, 2020 ). Tribal leaders are included in the orientation, along with discussions of cultural and family values and issues.

Another approach for supporting students is through mentoring programs. As discussed in Chapter 9 , these programs create supportive environments by providing peer and faculty role modeling, academic guidance, and support ( Wilson et al., 2010 ). Evidence indicates that mentoring programs for students from underrepresented groups are more effective when they include nurses and faculty from those groups, who have firsthand understanding of the unique challenges these students and nurses regularly confront ( Banister et al., 2014 ). This observation underscores the need for diverse faculty, mentors, and preceptors with the availability and willingness to guide these students and teach them leadership. For example, the RAIN program provides mentoring to American Indian students; staff and leaders are heavily involved in the local American Indian communities, and many are tribal members themselves (Minority Nurse, 2013 ).

Students who represent the first generation in their families to enter a postsecondary institution may face challenges other students do not, and are more likely to graduate if they receive support ( Costello et al., 2018 ). Parents and significant others can be a crucial source of support ( Pritchard et al., 2020 ); socializing and educating family members about the rigors of nursing programs may facilitate their support for students. A variety of programs around the country have succeeded in increasing graduation rates among first-generation students, including pipeline programs that have successfully increased the diversity of candidates entering nursing. These programs include HRSA pipeline programs; HOSA-Future Health Professionals; and university-based programs such as the Niganawenimaanaanig program at Bemidji State University in Minnesota, created to support American Indian nursing students ( HOSA, 2012 ; HRSA, 2017 ; Wilkie, 2020 ). Federal funding is available for these types of programs from sources that include HRSA’s Health Careers Opportunity Program and Nursing Workforce Diversity Grant program. However, the need for such programs exceeds the available funding. Box 7-8 lists some of the ways in which nursing programs can support their students’ success.

Examples of Supports for Nursing Students.

Data on Quality

One important tool for recruiting a more diverse student population is providing relevant data to prospective students so they can make informed decisions about where to study. These data could include NCLEX pass rates; however, these rates alone are insufficient to determine whether a school is likely to have the resources to support a student through to graduation. Data on student retention, graduation by demographic, full cost to attend, tuition, and other quality indicators can signal to both consumers and funders whether a nursing education program has the necessary infrastructure and support to retain students from diverse backgrounds. Pass rates can be reported by race, ethnicity, socioeconomic status, first-time college/university attendees, adult learners with children living at home, and status as an English as a second language (ESL) learner to help students choose a program that best suits their needs. It is also important for schools to provide on their websites demographic information about their current enrollees. As discussed above, NCSBN identified additional quality indicators for nursing education; as these indicators begin to be measured and reported, the data can help prospective students make more informed choices.

Educational Pathways and Options

As nursing education programs adapt their curricula and other learning experiences to better address SDOH and health equity, it will be important to consider the educational pathways students may follow, both in their initial preparation and as they progress in their careers. A key way of strengthening the nursing workforce will be to encourage nurses to pursue the next level of education and certification available to them and to improve access to these educational opportunities, especially for those from underrepresented communities ( Jones et al., 2018 ; Phillips and Malone, 2014 ).

One way to improve access and encourage nurses to take the next step in their education is by offering expedited programs that allow them to complete their degree in less time. For example, there are articulation agreements, either among educational institutions or at the state or regional level, that align the content and requirements of programs. These types of agreements accelerate the RN-to-BSN and RN-to-MSN pathways and allow students to easily transfer credits between community colleges and universities ( AACN, 2019b ). There are also bridge programs available for LPNs who wish to pursue the ADN or BSN degree. Investments in articulation programs have been responsible in part for an increase in the number of employed nurses with a baccalaureate degree, from 49 percent in 2010 to 59 percent in 2019 ( Campaign for Action, n.d. ). Further progress in this area is needed, however, particularly for partnerships between baccalaureate nursing programs and academic institutions that serve underrepresented populations (e.g., tribal colleges, historically Black colleges and universities). A model of this type of partnership can be found in the New Mexico Nursing Education Consortium, 7 which coordinates prelicensure nursing curricula in 16 locations at state, tribal, and community colleges.

Nursing education can also be expedited through the use of a competency-based curriculum that allows students to progress by demonstrating the required competencies rather than meeting specific hour requirements ( U.S. Department of Education, n.d.a ). With this approach, which is currently used, for example, by Western Governors University, students can self-pace their education and potentially save time and money by learning the material quickly or tapping previous knowledge ( WGU, 2020 ). This type of educational approach may be particularly useful for nontraditional students who are entering nursing with other experiences and education. For example, a person with a background as a nursing or medical assistant may find that he or she can quickly master some of the required material for a nursing degree, particularly at the beginning. Workers from other sectors may also be able to pivot to nursing. During the COVID-19 pandemic, a study identified health care jobs, such as nursing assistant, that out-of-work hospitality workers could quickly transition to pursue ( Miller and Haley, 2020 ). While the study did not include jobs that required further education or certification, the shared skill sets that the authors identified include many skills that are central to nursing.

Another approach for increasing access to nursing education is to expand the use of distance learning opportunities. Distance learning gives students flexibility, and may be particularly beneficial for those from rural areas or other areas without a nursing school in the vicinity ( NCSBN, 2020b ). Rural areas face multiple challenges: rural populations have high rates of chronic disease and have difficulty accessing care because of provider shortages in these areas (see Chapter 2 ). Relative to their urban counterparts, rural nurses are less likely to hold a BSN ( Merrell et al., 2020 ). Distance learning has been used for many years to reach rural populations, but there are challenges with respect to regulation and ensuring the quality of education ( NCSBN, 2020a ). Efforts have been made to assess and improve the quality of distance learning; Quality Matters, for example, is an organization that provides peer-reviewed evaluation of distance or hybrid programs using a set of quality standards. 8 While many nursing programs are adhering to these standards ( Quality Matters, 2020 ), many are not, and the quality of distance learning remains uneven. The rapid rollout of distance learning during the COVID-19 pandemic has provided a unique opportunity to evaluate the effectiveness of different strategies for distance learning and to leverage this experience to expand and improve distance learning opportunities in the future.

• STRENGTHENING AND DIVERSIFYING THE NURSING FACULTY

A system of nursing education that can prepare students from diverse backgrounds to address SDOH and health equity requires a diverse faculty ( NACNEP, 2019 ; Thornton and Persaud, 2018 ). Unfortunately, the faculty currently teaching in nursing programs is overwhelmingly White and female: as of 2018, full-time faculty in nursing schools were about 93 percent female, and only 17.3 percent were from underrepresented groups, up from 11.5 percent in 2009 ( AACN, 2020c ).

In addition to this lack of diversity, the number of faculty may be inadequate to prepare the next generation of nurses: not only were there 1,637 faculty vacancies in 2019 across 892 nursing schools, but the schools surveyed hoped to create 134 new faculty positions in that year ( AACN, 2020c ). These shortages contributed to decisions to turn away more than 80,000 qualified applicants, although other insufficiencies also played a part. The AACN report cites several key reasons for faculty shortages: increasing average age of faculty members and associated increasing retirement rates, high compensation in other settings that attracts current and potential nurse educators, and an insufficient pool of graduates from master’s and doctoral programs ( AACN, 2020c ; Fang and Bednash, 2017 ). A 2020 NACNEP report calls the faculty shortage a “long-standing crisis threatening the supply, education, and training of registered nurses” and recommends federal efforts as well as a coordinated private–public response to address the shortage ( NACNEP, 2020 ).

Finally, faculty must have the knowledge, skills, and competencies to prepare their students for the challenges of advancing health equity and fully understanding the implications of SDOH for their daily practice ( NACNEP, 2019 ). If health equity and SDOH are to be integrated throughout the curriculum (as discussed earlier in this chapter), all faculty, including tenure-track faculty, clinical instructors, mentors, and preceptors, must have these competencies ( Thornton and Persaud, 2018 ). To develop these competencies, nursing schools must commit resources and support to faculty development ( Thornton and Persaud, 2018 ).

Diversifying the Faculty

As noted, diverse faculty are needed to broaden the perspectives and experiences to which nursing students are exposed and to serve as mentors and role models for diverse students ( Phillips and Malone, 2014 ). Unfortunately, minority faculty members often face barriers similar to those faced by students, including an unwelcoming environment; feeling marginalized, underappreciated, and invisible; a lack of support; feelings of tokenism; and the inability to integrate into existing faculty structures ( Beard and Julion, 2016 ; Hamilton and Haozous, 2017 ; Iheduru-Anderson, 2020 ; Kolade, 2016 ; Salvucci and Lawless, 2016 ; Whitfield-Harris and Lockhart, 2016 ). Faculty from underrepresented groups report feeling isolated, lacking in mentorship and collegial support, and burdened by having to represent the entire underrepresented community ( Kolade, 2016 ; Whitfield-Harris et al., 2017 ). In addition, as discussed in Chapter 9 , faculty from underrepresented racial and ethnic groups face a “diversity tax,” in which they are asked to be part of efforts to improve diversity and inclusion to serve on committees; mentor underrepresented students; and participate in other activities that are uncompensated, unacknowledged, and unrewarded ( Gewin, 2020 ). These demands on underrepresented faculty can lead to frustration, burnout, and a feeling that they have been given responsibility for institutional diversity ( Gewin, 2020 ).

These experiences of minority faculty can result in high attrition and low satisfaction ( Whitfield-Harris et al., 2017 ), and further research is needed on specific ways in which institutions can recruit and support a diverse faculty ( Whitfield-Harris et al., 2017 ). Proposed approaches include cultivating an inclusive educational environment ( Hamilton and Haozous, 2017 ), taking intentional action and holding open discourse to strengthen the institutional commitment to diversity ( Beard and Julion, 2016 ), improving financial assistance and mentorship opportunities for faculty ( Salvucci and Lawless, 2016 ), and conducting climate surveys to better understand the feelings and experiences of underrepresented faculty and using these data to improve the institutional culture ( DeWitty and Murray, 2020 ). The challenges these faculty face and the opportunities to address these challenges highlight the importance of efforts by schools of nursing to recruit, support, and retain diverse faculty.

Faculty Development

Collectively, nursing school faculty need to be prepared to teach their students about the complex linkages among population health, SDOH, and health outcomes ( NLN, 2019 ; Thornton and Persaud, 2018 ). To do so, as discussed above, nurse educators need to move beyond teaching abstract principles to integrating the core concepts and competencies related to these linkages into the entire learning experience across nursing education programs. They also need to create a truly inclusive and safe educational environment and prepare nurses to care for a diverse population, which, as discussed above, requires that they understand issues of racism and systems of marginalization and engage in critical self-reflection ( O’Connor et al., 2019 , Peek et al., 2020 ). Yet, many faculty in nursing schools lack the knowledge and experience needed to develop curricula and strategies for incorporating SDOH into all areas of nursing education ( NACNEP, 2019 ; Valderama-Wallace and Apesoa-Varano, 2019 ).

Several approaches are available for preparing nursing school faculty to teach content related to SDOH and health equity. One approach, discussed above, is to actively recruit more diverse faculty who reflect the nation’s population and provide different perspectives and role models for students ( The Macy Foundation, 2020 ). Another approach is to encourage the development and dissemination of evidence-based methods for teaching nursing students how they can incorporate these core concepts into nursing practice. For example, educators involved in developing innovative models of classroom and experiential learning could focus on disseminating these models with the assistance of nursing associations and organizations, including through publication, continuing education programs, or faculty-to-faculty education and mentoring. Finally, institutions can provide in-depth and sustained learning opportunities for faculty, staff, and preceptors focused on how they can support their students in learning about SDOH and health equity both within and outside of the classroom ( IOM, 2016b ). While some funding sources are available for these types of efforts, including support from private foundations and HRSA grants for faculty development, the critical importance of this content to health outcomes argues for providing more such resources.

• IMPLICATIONS OF COVID-19 FOR NURSING EDUCATION

It has been 100 years since a global event has had an impact on nursing education in the United States and around the world equal to that of the COVID-19 pandemic. Both World War I and the influenza pandemic of 1918 to 1920 led to transformations in nursing education, including standardization of training and professionalization of the field. The COVID-19 pandemic has already led to innovations that are likely to shape the future of nursing education. Faculty have adopted new teaching strategies, demonstrating creativity and adaptability, within a span of days or weeks, while such technologies as simulation-based education have quickly been adapted to replace in-person clinical hours ( Jiménez-Rodríguez et al., 2020 ). In one example of a rapid pivot, educators at the University of Pennsylvania School of Nursing transitioned a community immersion course from in-person to virtual form when all in-person classes were canceled. While they faced challenges, the educators found that students were able to remain dedicated to their community partnerships and to think creatively about how to meet their learning objectives ( Flores et al., 2020 ). These and similar innovations may ultimately guide the way to expanding and improving nursing education.

At the same time, however, the pandemic has highlighted challenges and inequities in nursing education. Simulated clinical experiences are practical only if a school and its students have access to computers with enough power to run the software, for example. While online learning has been in use for more than a decade, not all schools or faculty are prepared to deliver content in this way, nor are all students capable of accessing the necessary technology. Moreover, as practice settings have been emptied of non-COVID patients, programs have been facing multiple challenges in providing students with sufficient hours of instruction, training, and clinical practice. These challenges have underscored the limitations of traditional ways of educating nurses even as they have presented unique opportunities for innovation. To translate these short-term challenges into long-term improvements in nursing education will require

• evaluation of such practices as distance learning and virtual experiential learning to identify and disseminate best practices;
• a sense of urgency in the development of substantial changes, such as modifications of curriculum and the adoption of new technologies; and
• partnership with public- and private-sector organizations, associations, and researchers that can bring both resources and expertise to the tasks of strengthening nursing education.
• CONCLUSIONS

Currently, most nursing schools tend to cover the topics of SDOH, health equity, and population health in isolated, stand-alone courses. This approach is insufficient for creating a foundational understanding of these critical issues and for preparing nurses to work in a wide variety of settings. This content needs to be integrated and sustained throughout nursing school curricula and paired with community-based experiential opportunities whereby students can apply their knowledge, build their skills, and reflect on their experiences.

Conclusion 7-1: A curriculum embedded in coursework and experiential learning that effectively prepares students to promote health equity, reduce health disparities, and improve the health and well-being of the population will build the capacity of the nursing workforce.

Preparing nursing students to address SDOH and improve health equity will require more than didactic learning and traditional clinical experiences. It will require that students engage actively in experiences that will expand and diversify their understanding of nursing practice, prepare them to care for diverse populations with empathy, and allow them to build the necessary skills and competencies for the nursing practice of tomorrow.

Conclusion 7-2: Increasing the number of nurses with PhD degrees who focus on the connections among social determinants of health, health disparities, health equity, and overall health and well-being will build the evidence base in this area. Building capacity in schools of nursing will require financial resources, including scholarship/loan repayment opportunities; adequate numbers of expert faculty available to mentor; and curriculum revisions to focus more attention on social determinants of health and health equity.

Having more nurses prepared at the PhD level will help build the knowledge base in the nursing profession for other nurses to translate (DNPs) and use in practice settings (LPNs, RNs, APRNs).

Conclusion 7-3: Learning experiences that develop nursing students’ understanding of health equity, social determinants of health, and population health and prepare them to incorporate that understanding into their professional practice include opportunities to learn cultural humility and recognize one’s own implicit biases; gain experience with interprofessional collaboration and multisector partnerships to enable them to address social needs comprehensively and drive structural improvements; develop such technical competencies as use of telehealth, digital health tools, and data analytics; and gain substantive experience with delivering care in diverse community settings, such as public health departments, schools, libraries, workplaces, and neighborhood clinics.

Building a diverse nursing workforce is a critical component of the effort to prepare nurses to address SDOH and health equity. While the nursing workforce has steadily grown more diverse, nursing schools need to continue and expand their efforts to recruit, support, and mentor diverse students.

Conclusion 7-4: Successfully diversifying the nursing workforce will depend on holistic efforts to support and mentor/sponsor students and faculty from a wide range of backgrounds, including cultivating an inclusive environment; providing economic, social, professional, and academic supports; ensuring access to information on school quality; and minimizing inequities.

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See https://www ​.aacnnursing ​.org/Education-Resources ​/AACN-Essentials (accessed April 13, 2021).

See Chapter 3 for demographic information on employed nurses in the United States.

For further discussion of domains and competencies, see AACN, 2020b ; Campaign for Action, 2019b ; IOM, 2016b ; NACNEP, 2019 ; NLN, 2019 ; Thornton and Persaud, 2018 .

Not all courses are open to students from all schools.

Brief and commonplace daily indignities (see Chapter 10 ).

See https://www ​.ohiohighered ​.org/collegecreditplus (accessed April 13, 2021).

See https://www ​.nmnec.org (accessed April 13, 2021).

See https://www ​.qualitymatters.org (accessed April 13, 2021).

• Cite this Page National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11. 7, Educating Nurses for the Future.
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