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 over-looked: the ability to think critically.
Identifying a problem, determining the best solution and choosing the most effective method 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 giving 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 Rasmussen College School of Nursing.
Critical thinking is embedded in a nurse’s everyday routine. They flex this mental muscle each day they enter the floor. 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 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. You will often find yourself in situations where there are few “correct” forms of care, but one that is most appropriate. 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 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.
You’re now well aware of the importance of critical thinking skills in nursing. Even if you wouldn’t consider yourself a high-caliber critical thinker today, you can work toward strengthening that skill. The more you practice it, the better you will become and the more naturally it will come to you.
Critical thinking isn’t the only component that makes an effective nurse. Learn about how else you can position yourself to climb the ranks in your nursing career in our article, "Nursing Career Advancement: 7 Ways to Stand Out in Your Scrubs."
*This article was originally published in July 2012. It has since been updated to include information relevant to 2017.
Assessing the neurologic status of unconscious or comatose patients can be a challenge because they can’t cooperate actively with your examination. But once you become proficient in performing this exam, you’ll be able to detect early significant changes in a patient’s condition—in some cases, even before these show up on more advanced diagnostic tests. Subtle changes in findings may indicate the need for further testing.
Before the advent of computed tomography (CT) in the 1970s, the neurologic examination was the main tool used to monitor a patient’s neurologic condition. Although it’s still an integral assessment component for critically ill patients, many bedside nurses overlook or underuse it. One reason may be that, unlike CT scans and other diagnostic tools, its results come in shades of gray, not black and white.
Quicker and easier than you might think
The neuro exam can be conducted quickly and is easy to integrate into your daily assessment. It starts the moment you meet the patient. Performing it early is crucial because this helps you establish a baseline for later comparison.
For accurate interpretation of assessment findings, nurses on the offgoing and oncoming shifts should evaluate the patient’s neurologic status together during shift changes or care transfers (as well as with the medical team on rounds). Once you’ve completed the initial assessment, subsequent assessments can be either basic or more in-depth.
Two types of neuro exams
The type of neuro exam you conduct depends on whether your patient can follow commands. If she can, your exam can be more comprehensive and should include evaluation of:
- level of consciousness (LOC)
- cranial nerves I through XII
- motor response
If your patient can’t follow commands, you’ll be able to assess only the pupils, eye opening, motor response, and some of the cranial nerves. Yet despite the relative brevity of this type of exam, it can yield a significant amount of information.
First step: Evaluate ABCs and vital signs
As with any patient, give top priority to assessing the ABCs—airway, breathing, and circulation. Ask yourself: Is the airway patent? If so, is the patient able to maintain it?
Next, check vital signs: Are her respirations adequate? Are her vital signs stable? Is her blood pressure high enough to perfuse the brain and other vital organs? Be aware that current or progressive injury to the brain and brain stem may make vital signs unstable, but this situation can be complex: Although unstable vital signs can reduce neurologic response, brain injury itself may cause unstable vital signs.
To appropriately assess the patient’s peak neurologic status, be sure to evaluate oxygenation and circulation. Ideally, you should conduct the neuro exam when the patient’s blood pressure, temperature, heart rate, and heart rhythm are normal. Be aware that a temporary decline in neurologic status caused by insufficient oxygenation or circulation still represents a neurologic change—and leads to permanent neurologic loss unless the underlying problem is corrected.
Assess LOC, eye opening, and motor response
Once you’ve established that your patient is stable enough to assess, begin the neuro exam itself. To determine if the patient is unconscious and unable to follow commands, use the Glasgow Coma Scale (GCS) to test eye opening, best motor response, and best verbal response. An unconscious patient is likely to open her eyes only in response to pain, if at all; obviously, you can’t test her best verbal response at all.
To assess motor response using the GCS, apply a painful or other noxious stimulus to a central part of the body; for instance, use trapezius squeezing, supraorbital pressure, earlobe pinching, or a sternal rub. (See Testing your patient’s response to pain.) Then watch for specific motor responses, as specified in the GCS. In an unconscious patient, the best response is localization, in which she reaches across the midline toward the stimulus site as though trying to stop the pain. In a semipurposeful (withdrawal) response, she recoils as though attempting to withdraw or escape from the pain.
A flexion motor response (decorticate posturing) is marked by inward flexion of the elbows, wrists, and hands accompanied by extension and plantarflexion of the feet. An extension motor response (decerebrate posturing) is straightening or stiff extension of the arms, with wrists rotated outward, knees and ankles rigidly straight, and plantarflexion of the feet.
After assessing eye opening and verbal and motor responses, assign a GCS score. The best possible score is 15, which indicates the patient is awake, oriented, and following commands. The lowest possible score is 3, which means the patient doesn’t open the eyes and has no motor or verbal response to a central stimulus.
Usually, a GCS of 8 or less indicates severe brain insult; the patient may be unable to maintain an airway, may require airway protection or even intubation, and may need to go to the intensive care unit for airway monitoring.
If the patient is intubated, write the letter “T” (for endotracheal tube) or “ETT” on the GCS form, indicating the patient might be able to verbalize if not intubated. If the patient was sedated during the exam, write the letter “S” (for sedation), acknowledging that sedation may have decreased the GCS score.
If your patient has a GCS score of 8 or less, follow the steps below to complete the neurologic assessment of the unconscious patient.
Pupil evaluation includes assessment of pupil size, shape, and equality before and after exposure to light. Normally, pupils are equal in size and about 2 to 6 mm in diameter, but they may be as large as 9 mm. Also, the pupils may be pinpoint, small, large, or dilated. Normal pupil shape is round; variations include irregular, keyhole, and ovoid. (See Visualizing a keyhole pupil.)
To assess the patient’s pupils, hold both eyelids open and shine a light into the eyes. The pupils should constrict immediately and equally bilaterally; after you remove the light, they should immediately dilate back to baseline. Document the response: Is it brisk, sluggish, nonreactive, or fixed? Immediately report any changes from baseline. In many cases, a change in pupillary response, such as unequal or dilated pupils, results from a progressive neurologic condition.
Fixed and dilated pupils are an ominous sign that warrant immediate physician notification (unless the patient’s pupils have just been dilated chemically). For true changes in pupillary response, expect the physician to order further diagnostic tests, such as a CT scan.
Assess cranial nerves
Findings from cranial nerve (CN) assessment can tell much about the patient’s midbrain, pons, and medullary functions. Although some nurses find this assessment intimidating, it’s not that difficult. (See Assessing cranial nerves in the unconscious patient.)
The oculocephalic (doll’s eye) and oculovestibular (cold caloric) tests, which reveal brain stem function, are performed only by physicians on patients who don’t respond to the exam methods described above. These tests aid prognosis of severely brain-injured patients.
The oculocephalic test evaluates extraocular muscle movements (controlled by CNs III and VI). The examiner moves the patient’s head from side to side forcefully and quickly; in an abnormal response (an ominous sign), the eyes remain stationary. This exam is contraindicated in patients with suspected cervical spinal cord injury.
Oculovestibular testing also evaluates CNs III and VI, along with CN VIII. The physician instills iced saline solution into the ear canal and observes for nystagmus (involuntary rapid eye movements). In a normal response, the eyes show conjugate movement and nystagmus in the direction of the irrigated ear, indicating an intact brain stem. Absence of nystagmus is an abnormal response signifying a decrease in consciousness with severe brain stem injury. The oculovestibular test is contraindicated in patients with ruptured tympanic membranes or otorrhea; results may be false-positive in patients who are on ototoxic drugs (including phenytoin) or who have Ménière’s disease.
Document and follow up on findings
By following these guidelines, you can quickly and easily perform a neuro exam on the unconscious patient. Establish your patient’s baseline early, and make sure you know how to differentiate normal and abnormal neurologic findings. Remember that changes can be subtle and should be documented and reported promptly. Most importantly, use your nurse’s “sixth sense”—that gut feeling most of us have when something just isn’t right.
Barker E. Neuroscience Nursing: A Spectrum of Care. 3rd ed. St. Louis, MO: Elsevier/Mosby; 2008.
Hickey J. The Clinical Practice of Neurological and Neurosurgical Nursing. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
Both authors work in the Neurosciences Intensive Care Unit at Harborview Medical Center in Seattle, Washington. Elizabeth Anness is a staff nurse; Kelly Tirone is an assistant nurse manager.