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A crisis in critical thinking.

ABSTRACT Aggregate results for competency assessment of new registered nurses using the Performance Based Development System indicate that most new graduates do not meet expectations for entry-level clinical judgment ability. This article discusses implications for nursing education and offers recommendations for developing clinical judgment in nursing students.

Key Words Competence Assessment--Clinical Judgment--Critical Thinking--Patient Safety--Nursing Education


WHY CAN'T NEW REGISTERED NURSE GRADUATES THINK LIKE NURSES? Unfortunately, findings reported by the author in the early 1990 have not changed (1.2). Only 35 percent of new RN graduates, regardless of educational preparation and credentials, meet entry expectations for clinical judgment. Although well versed in content, the majority are unable, or have considerable difficulty, translating knowledge and theory into practice. This article presents possible causes and potential solutions for lack of critical thinking ability among nursing students.

The Evaluation Process Since 1985, a valid and reliable competency-assessment system, Performance Based Development System (PBDS), has been used in more than 350 health care agencies in 46 states to assess nurses' critical thinking and interpersonal skills ability. Reliability and validity of the assessment components have been reported in previous publications (1,2). In addition to being reported to each participating agency, annual assessment results are aggregated and interpreted by staff members at Performance Management Services, Inc. (PMSI). The aggregate data are used as benchmarks and to monitor patterns or trends.

Table 1 displays aggregate results from 1995 to 2004 for experienced (more than one active year) and inexperienced RNs. Both ranges and mean averages are relatively consistent for both groups, giving further support to the system's reliability. The percentages given for individuals meeting expectations are based only on critical thinking results. Because patient safety is given more weight in the assessment than customer satisfaction, interpersonal skill results are summarized but affect the final conclusion only when they are negative.

Critical thinking, primarily as clinical judgment, is assessed using three patient-focused uncued exercises. Each exercise has a different level of difficulty and verisimilitude. The simplest exercise is a written, out-of-context series of patient and job events that evaluate the ability to determine the relative priority of each situation and effectively manage those that are urgent. The second assessment component, visual and out-of-context, evaluates the RN's ability to accurately recognize and effectively manage peripheral intravenous problems. Application of aseptic principles is also included. The third, and most complex, contextual exercise uses a series of patient video simulations to evaluate the RN's ability to: accurately identify patient problems; safely or effectively manage these problems in a relevant time period; and support actions taken with relevant rationales or logic. Although findings for all three assessment exercises are considered, assessment findings for the video simulation exercise, because of its verisimilitude, give the most weight to the final conclusion of acceptable or not acceptable.

The PBDS video simulations include patients for all clinical assignments (acute medical-surgical, intensive care adults and neonates, perinatal, mental health, and perioperative). (The general medical-surgical patient situations are singular, actual, physiological, overt and commonly occurring. They range from acute to emergent, and include gastrointestinal, genito-urinary, metabolic, cardiac, respiratory, and neurological problems.) Because of limited clinical experience with any patient population, the general acute medical-surgical patient series is used, regardless of subsequent assignment, with inexperienced RNs to validate already acquired critical thinking ability.

As indicated previously, new employees are assessed for their ability to accurately identify the primary problems or deviations from normal health status; initiate independent and collaborative actions to at least prevent further harm; act within a relevant time period; and support actions with a rationale. These expectations are consistent and congruent with concepts described by Clarke and Aiken to support the need for more nurses at the bedside. Their article, "Failure to Rescue" (3), describes patient situations very similar to those assessed in PBDS in which nurses did, or did not, intervene to reverse complications or problems not present on admission.

Not only is it critical that nurses are present, they must make accurate decisions about what is happening, what needs to be done, how soon, and why. A trained hospital or PMSI employee compares the given responses to validated criteria for each situation, summarizes findings for all assessment components, and determines a final conclusion for ability to meet expectations. The overall conclusion ranges on a continuum from unacceptable (unsafe) to expert (exceeds expectations). New RNs are expected to be at the entry (safe practice) point. Following the assessment, each individual receives an action plan that includes subsequent development and, if needed, reassessment after development strategies are implemented.

Findings What are the findings for the 65 percent to 76 percent of inexperienced RNs who do not meet expectations for entry-level clinical judgment ability? Employers reasonably expect inexperienced RNs to accurately recognize and/or synthesize the patient's clinical data or primary problem focus. When the nurse is unable to do so, the patient's problem is unlikely to be safely managed.

Analyses of 10 years of assessment data reveal several consistent limitations related to accurate problem recognition. Examples include the following:

* At least 50 percent of inexperienced RNs conclude that a 24-hour postsplenectomy patient with acute, sudden onset of right chest pain accompanied by severe shortness of breath and arterial blood gas results of respiratory alkalosis has only either the latter or nonspecific "respiratory distress." They treat this emergent patient with only a paper bag to rebreathe carbon dioxide, totally ignoring the implications of the other clinical symptoms.

* A second example is a patient post-head trauma and fractured arm who exhibits, within 24 hours of the assault, overt decrease in mental status, bradycardia, and widened pulse pressure (elevated systolic, decreased diastolic pressures). Twenty-five to 35 percent of inexperienced RNs, who accurately note the vital sign changes, conclude "hypovolemic shock" with management relevant to systemic blood loss, but hazardous for the actual patient problem.

* A third consistently found limitation is the inability to accurately differentiate the cause of patients' decreased urine output. This symptom, regardless of other clinical data, is identified and managed as "fluid overload" with diuretic therapy.

Many inexperienced RNs also attempt to use a nursing diagnosis for the problem focus. Whatever the original intent for its use, the results are at best cumbersome and at worst risible. Examples of misuse of nursing diagnoses are displayed in Table 2.

Employers also reasonably expect inexperienced RNs, when managing patient health problems, to do the right thing for the right reason. Similar to problem identification, analyses of data reveal consistent limitations. Examples include: inability to differentiate when and why diuretics are used; giving K-exalate to patients with elevated potassium levels regardless of cause; anticipation of Vitamin K for patients with coagulation problems regardless of cause; indiscriminate monitoring of all vital signs without relevance or priority; and reluctance to initiate more than low flow (2 liters) oxygen for patients with severe respiratory distress. Additional examples of mismanagement are displayed in Tables 3 and 4.

Analyses over 10 years consistently find no significant differences in clinical judgment ability based on educational preparation or credential. The same ability ranges are found within diploma, associate degree, and baccalaureate graduates. The author does not believe that educators in any of these nursing programs teach such mismanagement, but somehow this is what graduates have learned.

Implications for Nursing Education Why are so many women and men, bright enough to meet academic entry and exit requirements and pass state licensing requirements, not able to accurately identify and/or safely manage patients' problems? Unfortunately, there is no simple or single answer to answer this complex question. Problem causes can be related to: changes in health care practices such as shortened length of hospital stays; sicker, more acute patients; nursing education fads; and decrease in continuous clinical practice hours. Some nurse educators may claim that the cause is a different population of entering students with less ability or lower qualifications. The consistency of PBDS reassessment findings, however, would not support this hypothesis. RN graduates do possess potential ability to think critically and make acceptable clinical judgments.

This author believes that a highly probable cause is the emphasis on teaching more and more content in the nursing education curricula rather than a focus on use of or application of knowledge. A look at the size and plethora of nursing textbooks supports this conclusion.

The PBDS model expects RN graduates to think at the application, analysis, and synthesis levels of cognitive ability. Recall and understanding of content, or selection of the correct answer, do not equate to clinical judgment. Although a valid argument might be made for using the multiple-choice format in nursing course exams as preparation for the NCLEX-RN, students will also pass the licensing exam by determining why answers are "right" or "wrong" based on application of knowledge and logical reasoning. In the real world, patients do not present the nurse with a written description of their clinical symptoms and a choice of written potential solutions.

Students need consistent experience with both visual simulations and real patients to learn how to effectively focus on and manage patient problems. Writing care plans does not substitute for being there when complications occur. Knowing about does not equal making clinical decisions. Nursing is a practice art that requires the use of knowledge within a specific set of circumstances. Smart nurses are effective nurses when they think critically, not when they can pass multiple-choice tests.

Developing Clinical Judgment Contrary to common belief, more education, particularly as part of content-focused nurse internships or residency programs, does not yield significant positive results. Inexperienced RNs will learn to think critically only by expecting and rewarding them for doing just that, not stating facts.

As previously described in this article, each RN with unacceptable assessment PBDS results receives a follow-up plan based on the assessment findings. The plan can include development, clinical practice, and evaluation interventions. Development interventions are generally not attendance at didactic lectures or teacher-driven courses, but, rather, individual or group participation in implicit questioning activities that require learners to apply, analyze, and synthesize knowledge for specific--usually visual--patient situations. Educators and clinical specialists learn how to use these nontraditional strategies as a substitute for, or enhancement of, content-focused sessions.

The most critical intervention needed, however, for improved clinical judgment is clinical practice with a preceptor who coaches by asking questions, rather than giving answers or doing the usual show-and-tell. Clinical coaches are provided with specific questions to ask based on assessment findings. An example is the quintessential or evaluative question: "What evidence do you have (primary/secondary source, objective/subjective) or need to collect to determine the effectiveness of your intervention?" This question needs to be asked every day in relation to different interventions for the same or different patients.

These strategies work. Table 5 displays reassessment results for seven groups of inexperienced RNs. Four groups experienced PBDS competency-focused internships and three control groups attended traditional internships in hospital settings. All participants were initially assessed with the same general adult acute patient video simulations and reassessed with different patient situations that were relevant to their clinical assignment.

The PBDS competency-focused approaches do not require a specific group internship, but can be used with any individual. Unlike traditional internships, which may last six to 12 months, positive results on reassessments are obtained on average for 70 percent of inexperienced RNs within 10 to 12 weeks.

Both experienced and inexperienced RNs are a critical, but costly, component for health care agencies. Competence assessment and development, expected elements of doing business, need to yield an acceptable return on investment of time, dollars, and resources. Although employers cannot expect new RN graduates to be competent, they can reasonably expect, upon graduation and licensing, a practitioner who can meet safe entry expectations. This outcome can be achieved by refocusing on both the art and science of nursing. Like getting to Carnegie Hall, being an effective nurse requires practice, practice, practice.


(1.) del Bueno, D.J. (1990) Experience, education, and nurses' ability to make clinical judgments. Nursing & Health Care, 11(6), 290-294.

(2.) del Bueno, D.J. (1994).Why can't new grads think like nurses? Nurse Educator, 19(4), 9-11.

(3.) Clarke, S. P., & Aiken, L. H. (2003). Failure to rescue. AJN, 103(1), 42-47.

Dorothy del Bueno, EdD, RN, is senior consultant, Performance Management Services, Inc., Tustin, California. For more information, visit
Table 1 . Performance Management Services, Inc. (PMSI) Assessments:
New Registered Nurse Hires Meeting Expectations (percent)


1995 through 2000
22 hospitals 6,884 (62 percent) 3,536 (33 percent)
1 ambulatory Range 48 to 80 Range 12 to 61
 percent percent

11 freestanding hospitals 2,298 (63 percent) 1,100 (26 percent)
7 systems Range 46 to 83 Range 12 to 55
1 ambulatory percent percent

9 freestanding hospitals 3,200 (72 percent) 1,376 (35 percent)
14 systems Range 42 to 90 Range 13 to 67
1 ambulatory percent percent

24 freestanding hospitals 4,254 (68 percent) 1,766 (35 percent)
10 systems Range 31 to 92 Range 6 to 64
1 ambulatory percent percent

78 hospitals 3,777 (66 percent) 2,210 (30 percent)
1 ambulatory) Range 38 to 84 Range 3 to 56
 percent percent

TOTALS 20,413 10,988

Note. These data represent facilities implementing PBDS for the first
time during the year indicated, plus clients rated by PMSI. All
assessments validated by PMSI.

Table 2. Nursing Diagnoses Given in Assessments


-- For patients with acute abdomen/peritonitis, DKA, CVA


-- Mood change related to hospitalization as evidenced by poor

-- Agitation related to ICP as a result of fluid volume excess

-- Inability to cope with illness and present condition due to
active lifestyle


-- Ineffective individual coping related to various home treatments and
medical regime

-- Noncompliance with medical regime related to advanced age
and absent caregiver as evidenced by verbally stating confusion
of schedule

-- Alteration in health maintenance, noncompliance

-- Learned helplessness


-- Ineffective coping skills related to change in lifestyle as
evidenced by depressed mood and appetite

-- Alteration in sensory perception

-- Diversional activity deficit related to long periods in bed

-- Social isolation related to hip fracture secondary to


-- Spiritual distress related to change in body function and appearance

-- Alteration in grooming related to frustration with operative site

-- High anxiety related to hospitalization

-- Activity intolerance related to pain

-- Altered sleep related to constant interruption as evidenced by
patient feeling anxious and restless


-- Altered coping mechanism related to hospitalization and exacerbation
of chronic illness

Table 3. Management/Actions Given in Assessments

* Check blood sugar as it may decrease as body uses more to fight

* Insulin and glucagon to lower the blood sugar

* Ambulate patient and do ROM to decrease BS (insulin was not given)

* Give 2 units PRBC to counteract increased H/H (DKA patient)

* Give antacid to decrease pH / Give bicarb to reverse alkalosis

* Give heparin (to a patient accurately identified as
thrombocytopenia) ... it will help him clot / Give anticoagulant
to trick the body and stop bleeding

* Teach slow deep breaths to help kidneys compensate alkalosis
(pulmonary embolus patient)

* Assess eyeballs for fluid overload

* Check ammonia level as patient is seeing yellow (digtoxicity)

* Give oxygen to perfuse the kidneys

* Give calcium gluconate to reverse digtoxicity

* Give aminophylline to increase HR (digtoxic patient)

* Ambulate patient (with acute abdomen labeled ruptured appendix) to
promote peristalsis

* Teach deep breathing to prevent hemolysis (pulmonary embolus patient)

* Lower HOB as increased HOB could cause ICP to increase

* Anti-diarrheal meds (for accurately labeled bowel obstruction

* Teach patient to blow nose with mouth open to decrease IICP

* Check (IICP) patient for bulging eyeballs

* Give IV fluids with lasix for hypovolemic shock patient to replace
lost fluids but not raise BP (patient actually has lowered HR and
higher BP because of IICP)

Table 4. Rationales Given for Actions in Assessments

* Take IICP patient to bathroom so he can void thereby decreasing ICP

* Bradycardia can cause hypovolemic shock

* Give orange juice to increase platelets--because decreased platelets
result in compromised immune system

* Elevate the patient's feet to increase venous circulation to the
brain in order to decrease ICP

* Patient is in alkalosis from not breathing enough hydrogen

* Elevated BUN/CR indicate liver problems

* Respiratory alkalosis may indicate shock

* Patient is breathing rapidly to exhale C[O.sub.2] as a result
of cardiopulmonary status due to dehydration

* Liver function tests (for embolus patient) can indicate where it is

* Remove mashed potatoes from tray because potatoes have high K+
content (renal failure)

* Decrease CBI to prevent fluid overload (renal failure)

* Strain the urine for size and number of ketones (DKA)

* Monitor the postpartum patient with rectal pressure for pulmonary

* Give IV of NS to decrease the free-floating fat in circulation
(fat embolus/CVA)

* Check for facial swelling as this indicates risk of losing patent

Table 5.
Initial Clinical Judgment Assessment Results vs Reassessment Results

Traditional Initial Assessment Reassessment
Internships (percent acceptable) (percent acceptable)

Group 1 (n = 35) 23% 43%
Group 2 (n = 45) 31% 38%
Group 3 (n = 20) 25% 45%

PBDS Strategies Used

Group 1 (n = 43) 36% 83%
Group 2 (n = 65) 28% 63%
Group 3 (n = 39) 36% 80%
Group 4 (n = 15) 8% 75%
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Author:Del Bueno, Dorothy
Publication:Nursing Education Perspectives
Date:Sep 1, 2005
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