critical thinking training for nurses

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?

The Value of Critical Thinking in Nursing

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

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

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

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

How Do Nurses Use Critical Thinking?

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

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

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

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

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

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

Top 5 Ways Nurses Can Improve Critical Thinking Skills

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

Case-Based Approach

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

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

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

Practice Self-Reflection

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

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

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

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

Develop a Questioning Mind

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

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

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

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

Practice Self-Awareness in the Moment

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

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

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

Use a Process

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

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

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

Common Critical Thinking Pitfalls in Nursing

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

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

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

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

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

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

An Essential Skill for All Nurses

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

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

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

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

How does nursing school develop critical thinking skills?

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

Do only nurse managers use critical thinking?

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

Meet Our Contributors

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

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

Jenna Liphart Rhoads, Ph.D., RN

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

Nicholas McGowan, BSN, RN, CCRN

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

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Key Concepts of Critical Thinking in Nursing

Course highlights.

• In this course we will learn about key concepts and importance of critical thinking in nursing.
• You’ll also learn the basics of critical thinking education, followed by common exercises.
• You’ll leave this course with a broader understanding of how to develop and utilize strategies that promote critical thinking in nursing.

Contact Hours Awarded: 2

Course By: Keith Wemple BSN, RN, CCRN, CMC

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➀ Read and Learn

The following course content

How many times did you hear the phrase “critical thinking” in your training to become a nurse? I must have heard it a thousand times, and I still don’t think I ever had a clear definition of it in my mind. What exactly is critical thinking? In this course, we will answer those questions and provide insight into how you can teach critical thinking in nursing. Also included are some self-guided exercises to practice critical thinking skills. After all this, you will be ranting about the vital importance of critical thinking, too.

Ask yourself...

How would you define critical thinking in your mind?  

Do you think of yourself as a critical thinker?

What is Critical Thinking?  

Critical thinking is a term that is difficult to define because it is, by nature, somewhat subjective. The National Council for Excellence in Critical Thinking defines it as “the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action,” (4). That’s a long definition. Essentially, critical thinking is a way of thinking that allows a person to recognize important information and process it to solve problems. Let us break this down further into the key characteristics of critical thinkers.

How are “text-book smart” and “street smart” different from each other?  

Information Gathering 

There are some key characteristics of critical thinkers that appear consistently throughout the literature. The first of these attributes is information gathering (1). Critical thinkers are adept at gathering information from situations. They pay attention to details and pick up on the information that others may miss. Critical thinkers try to uncover the particulars to ensure they are well informed in their thinking and decision-making. Critical thinking is not a passive acceptance of information but rather an active collection of data. In terms of nursing, the critical thinker will place a lot of importance on their assessment. Rather than focusing simply on the tasks that need to be completed, critical thinking in nursing means staying in tune with assessment findings and changes. For example, if a patient has labs drawn, the critically thinking nurse will watch for the results of these labs to have the most up-to-date information and be alert to any changes. 

How do you incorporate “information gathering” into your routine?

Investigating 

Another important attribute of critical thinkers is their habit of investigating (1). They do not accept information at face value. They have a tendency to question information, especially that which contradicts other data. When critical thinkers see the information that doesn’t seem right or raises questions, they investigate it. This way of thinking goes together with seeking out information.   

With critical thinking in nursing, a nurse may ask themselves, “What else do I need to know? What comes next?” Rather than simply reporting one change to the physician, they think “what could this change represent? What other information would support this idea?” Continuing our example of following labs, if the nurse notices that the white blood cell count has increased, they will investigate to see why that might be. They would likely assess the patient for signs of infection, such as fever or chills.   

If you get the feeling that “something isn’t right,” what do you do next?  

Evaluation 

Critical thinkers also can evaluate the information they have gathered to create new ideas or hypotheses (1). This is the cognitive “connecting the dots” that allows critical thinkers to synthesize pieces of data into a complete picture of what is happening.   

Critical thinking in nursing doesn’t mean just collecting and reporting information; they process it and form ideas of their own. They ask questions like “how do these pieces of information fit together? Does this fit with any knowledge I already have?” Going back to our example, let’s say after the nurse notices the white blood cell count and assesses the patient, they find the patient has a fever and cloudy urine. Evaluation of this information would lead the nurse to think the patient has a urinary tract infection (UTI).   

Think of a time you diagnosed a patient’s problem. How did you come to this conclusion?  

Problem Solving 

An important aspect of critical thinking is problem solving. After gathering and evaluating information, the critical thinker tries to solve any problems that surface (1). This is a key point that separates critical thinking from merely being perceptive. Recognizing important information and problems is vital but being able to then think through and solve the problem is what makes critical thinking stand out. Looking at our example again, once the nurse has recognized symptoms consistent with a UTI they will begin formulating ideas on how to treat the problem. The first action would likely be notifying the provider of all the information gathered, the nurse’s hypothesis and a recommendation to solve the problem. You may recognize this format as being similar to Situation-Background-Assessment-Recommendation (SBAR). SBAR is a tool that is used to help guide critical thinking in nursing (1).   

• What information/assessments do you focus on for the patients you care for?  
• What characteristics do you think a critical thinker should have?  
• Have you recognized patterns in how your providers/institution solve common problems?  
• Have you ever had a provider recommend a treatment you disagree with? Why did you disagree?  

Why is Critical Thinking Important?  

Now that we understand what exactly critical thinking means, let’s ask: why is it so important? You may have already formulated some ideas about how critical thinking in nursing can be helpful in practice. Critical thinking is a pattern of recognizing and reacting to the most important pieces of information. This is crucial in nursing, where we are presented with a plethora of information and expected to use the most important pieces to save lives and make people healthy. Now, let us get more specific on what areas would benefit from critical thinking in nursing.   

Patient Outcomes 

First, and maybe most important, is that critical thinking improves patient outcomes (3).   

Studies have shown that critical thinking skills in nurses are linked to lower hospital costs to patients, as well as to the facility thanks to lower in-hospital complications (3). Critical thinking by nurses also decreases the length of hospital stay (4). It has also been shown to improve outcomes and lower complications in surgical patients when the operating room nurses had a higher level of critical thinking (3). Despite these positive results and every nursing instructor ranting on the importance of critical thinking, there is a lack of research into the connection between critical thinking in nursing and patient outcomes. This is primarily because of the difficulty of assessing critical thinking skills specific to nurses and linking these skills to a measurable outcome without confounding factors (3). 

Staff Satisfaction 

You will be pleasantly surprised to learn that critical thinking in nursing leads to higher staff satisfaction! Research has found a strong correlation between critical thinking ability and perceived autonomy and job satisfaction in nurses (5). It is believed that critical thinking fosters autonomy or at least increases the sense of autonomy, which generally leads to higher job satisfaction. Critical thinking has been shown to improve confidence as well, and feeling confident in your work generally improves satisfaction as well (5). Interestingly, there has also been research that shows that critical thinking is linked to higher satisfaction with life decisions and less adverse life events (6). The idea here is that critically thinking through a decision before making it leads to less regret. So, this course will make you happier with work and help you make better life choices – you’re welcome. 

Efficiency 

Another important benefit of critical thinking is that it improves efficiency. Studies found that nurses with higher critical thinking skills work more efficiently (1). If you are thinking critically you are better able to prioritize and plan to avoid wasting time and energy. As we all know, nursing can be very demanding, and efficiency is important for tending to all our patients’ needs. Also, if the nurse manager of a unit has higher critical thinking skills, they implement changes that improve overall efficiency and morale (7). This highlights that critical thinking is important to all nursing forms and how one person practicing critical thinking can impact others. 

Healthcare Complexity 

A large reason why critical thinking has become so important is the ever-increasing complexity of healthcare. As we develop new treatments, we are always being asked to learn new processes and how to monitor patients receiving these treatments. Also, as the healthcare system improves treatments, the average patient is becoming older and has more co-morbidities (4). This adds to the complexity of each patient. Critical thinking is a great skill that aids in learning new tasks and comprehending more complicated patients. Nurses arguably have the most complex set of tasks, as we are often asked to perform some of the duties of other healthcare professions. Being adaptable to whatever changes come and taking on new responsibilities is a great benefit of critical thinking.   

• Have you ever seen a colleague miss something that may have harmed the patient?  
• Have you or a colleague ever had a “good catch” that you feel benefited the patient?  
• How do you think critical thinking increases autonomy?  

When have you been asked to make a change to your practice? How did you adapt to this change?  

• How could you make your work routine more efficient?  

Critical Thinking Education  

Now that we understand what critical thinking is and why it’s important let us discuss how critical thinking is taught. Critical thinking in nursing has become an integral part of many programs. Many healthcare institutions are looking for ways to incorporate critical thinking into their training process as well (1). Critical thinking is, however, an abstract concept and truly is a whole new way of thinking. So, how do we teach someone how to think? There are several factors that should be considered when trying to teach or learn critical thinking. 

Educator Influence 

First, educators have an important influence on the instruction of critical thinking skills. Educators that are effective at teaching critical thinking skills are open-minded, flexible, and supportive of their students (1). Showing flexibility and not firmly holding to one set way of doing things allows the students to adopt their own version of critical thinking. Role-modeling, guiding, and being knowledgeable about critical thinking also leads to a more effective educator (1). The educator should guide learners through their understanding of critical thinking while role-modeling critical thinking behaviors. 

Environment 

The learning environment also plays an important role in a nurse’s ability to learn critical thinking skills. The environment should be inclusive, non-judgmental, and allow for open discussion (1). This applies to both nursing schools and nurses being trained into a new unit. Feeling accepted on a unit allows for better learning and has a positive impact on critical thinking skills (1). It is important for nurses looking for a new work unit to find one with a welcoming, safe environment to aid in learning. On the other side, we should always strive as nurses to be inclusive and facilitate this type of environment as it benefits everyone. I was always told that “nurses eat their young,” and this attitude does not foster learning or growth. 

Education System 

The education system also impacts the teaching of critical thinking. Education systems, for one, largely shape the learning environment and educators. The education system should strive to create the type of learning environment where critical thinking skills can grow. Too much emphasis on classroom lectures and power dynamics between teachers and students hinders the development of critical thinking skills (1). Teaching critical thinking as its own subject also helps students learn the skill (1). 

Individual Factors 

Lastly, there are some individual factors that affect a person’s ability to cultivate critical thinking skills. Chief among these are a lack of confidence and fear of questioning an instructor (1). You can see how all these concepts seem to be centered on the fact that learners perform best when they are comfortable and have the freedom to discuss ideas. This is the central concept that should be understood and practiced by both mentor and mentee, as well as the education system as a whole. So, as we move into the next section teaching critical thinking skills, put yourself in a comfortable place – physically and mentally. Be sure to keep thinking of questions and follow your own ideas. 

• What training or education did you receive on critical thinking?
• Who was your favorite instructor/mentor? What did they do to stand apart from others?
• What factors make you more comfortable and likely to learn?  
• What were the dynamics like at your nursing school?   
• Have you ever felt afraid of asking a ' stupid' question? 

Strategies to Promote Critical Thinking  

Now that we have an understanding of the right mindset to have when learning critical thinking, let us actually discover how to teach and learn it. Some common strategies that appear to be effective are targeted questioning, case studies and simulation (1). These are all approaches that require more than one person, so they are best practiced as part of training. If you have a colleague or mentor, you may try some of these strategies with them as well. 

Targeted Questioning 

First, we have targeted questioning, which is a tactic of asking questions in order to promote further thinking (8). This often involves asking questions of increasing difficulty to encourage the learner to think deeper about what the facts represent. It is the educator’s equivalent of a toddler asking “why?” over and over. The purpose is not to be annoying but to discover how deep down the rabbit hole the learner will go. Socratic questioning is another common type of targeted questioning designed to encourage learners to think further on the subject matter. This is commonly used in continuing education (check the italicized text), and helps to promote further thinking on facts rather than just accepting them at face value.  

Case Studies 

The next exercise that helps teach critical thinking is case studies. Case studies help promote critical thinking by allowing learners to think through a real-life scenario without the stressors of experiencing the scenario (1).  

It is important for learners to acknowledge how they might feel in that scenario so that they can be better prepared for the pragmatic aspects and the personal aspects of dealing with the presented problem (4). Case studies typically move chronologically through a scenario and often guide learners through the critical thinking behaviors of information gathering, investigating, evaluating and problem-solving. This helps build the mental framework of moving step-wise through a problem in order to find the best solution.   

Simulation 

Finally, simulation has proven to be useful in fostering critical thinking. Simulation, similar to case studies, promotes thinking through a scenario in a low-risk, low-stress environment with the added benefit of going through the physical motions involved (8). This allows the learner to physically experience the situation as well as think through the problems. This can help familiarize someone with the actual physical interventions involved so they are more comfortable when practiced in real scenarios. This is often used in life support training so that learners understand how to actually connect the defibrillator and which button to press, so there is less fumbling in the high-stress scenario where these motions are used (8).   

• Did you ever have an instructor “grill” you on facts? What did this do for your learning?  
• Have you ever found yourself comparing a problem to a similar previous problem?   
• What is your experience with simulation? 
• Think of a stressful situation you were confronted with at work. Could that situation be captured in a simulation?  

Critical Thinking Exercises  

We have examined ways to teach critical thinking skills to others, but what about developing critical thinking within ourselves? Luckily, there are a couple of exercises that can be practiced individually to foster critical thinking skills. This is helpful to those of us who are finished with our training and looking to better ourselves. Start with a desire to improve, as none of us are perfect. These exercises are best practiced by focusing on a specific scenario, particularly if there is a scenario that you didn’t fully grasp or that felt overwhelming.   

Concept Mapping 

The first exercise is concept mapping. Concept mapping is the practice of visually representing ideas on paper and showing connections between these ideas (2). They are often presented in either a hierarchical or web pattern with the key ideas at the top or center of the diagram, respectively.  

This helps a learner visualize their thinking process and further think about what connected and how. For example, let's think of our scenario earlier with the suspected UTI. We might see a change in vital signs as a central idea which connects us to signs of infection and then to interventions. This can help us see the progression of ideas, how they are connected, and possible other explanations.  

Reflective Writing 

Our final means of learning critical thinking in nursing is reflective writing. Reflective writing or journaling helps to identify thought patterns and promote critical thinking skills (1). Again, this is most useful for examining a specific situation. Breaking down a complex situation when you have more time to analyze it will help you learn more from that challenge.  

It may seem silly to write a journal but reflecting and processing your ideas is an important practice for growth. The act of formulating your thoughts into written words helps to make more sense of the ideas and feelings you have. You don’t have to keep a daily journal, but if you have a challenging shift it may help to reflect on it and write down your ideas. It is important to treat this exercise as a learning opportunity, and to not ruminate on failures or beat yourself up for not being perfect.  

• Practice drawing a concept map of the key concepts of critical thinking from this course.
• Write down a tough scenario you have dealt with at work. What made this experience hard?
• How have you or will you change your practice based on this scenario?

Conclusion  

In summary, critical thinking in nursing is essential. It impacts our efficiency, the well-being of our patients, and our own happiness. Critical thinking is a broad way of thinking that involves gathering information, investigating, and evaluating the information in order to solve a problem. Critical thinking is best learned and practiced with an open mind. We can foster critical thinking in each other through case studies, simulations and targeted questioning. We can improve our critical thinking in nursing skills ourselves by practicing reflective writing and concept mapping. If you are a nurse educator or preceptor, I hope you have found something you can use to shape future nurses. If you are a nurse looking to better understand critical thinking, I hope you have learned something you can take to your nursing practice.  

References + Disclaimer

• Chan, Z. (2013, March 1). A systematic review of critical thinking in nursing education. Retrieved March 17, 2021, from https://www.sciencedirect.com/journal/nurse-education-today
• Lee, W., Chiang, C., Liao, I., Lee, M., Chen, S., & Liang, T. )2013, October 1). The longitudinal effect of concept map teachin on critical thinking of nursing students. Retrieved March 17, 2021, from https://pubmed.ncbi.nlm.nih.gov/22795871/https://doi.org/10.1016/j.nedt.2021.06.010
• Fesler-Birch, D. (2005, April 1). Critical thinking and patient outcomes: A review. Retrieved March 17, 2021, from https://pubmed.ncbi.nlm.nih.gov/15858523/
• Scriven, M., & Paul, R. (2007, January 1). Defining critical thinking. Retrived March 17, 2021, from https://www.criticalthinking.org/pages/defining-critical-thinking/766
• Zurmehly, J. The Relationship of Education Preparation, Autonmy, and Critical Thinking to Nursing Job Satisfacttion. The Journal of Continuing Education in Nursing. 2008;39(10):453-460
• Butler, H. (2012, June 20). Halpern critical thinking assessment predicts real-world outcomes of critical thinking. Retrieved March 17, 2021, from https://onlinelibrary.wiley.com/doi/pdf/10.1002/acp.2851
• Zori, S., Nosek, L., & Musil, C. (2010, July 08). Critical thinking of nurse managers related to staff RNs’ perceptions of the practice environment. Retrieved March 17, 2021, from https://pubmed.ncbi.nlm.nih.gov/20738741/
• Kaddoura, M. New graduate nurses’ perceptions of the effects of clinical simulation on their critical thinking, learning, and confidence. Journal of Continuing Education in Nursing, 41 (11) (2010), pp. 506-516

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How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples

Last updated on August 19th, 2023

Nurses play a critical role in making critical decisions that directly impact patient outcomes in the dynamic field of healthcare. Developing strong critical thinking skills is essential for success in this role.

In this article, we present a comprehensive list of 23 nursing-specific strategies aimed at improving critical thinking and improve the quality of patient care.

24 Strategies to improve critical thinking skills in nursing

You may also want to check out: 15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)

1. Reflective Journaling: Delving into Deeper Understanding

Reflective journaling is a potent tool for nurses to explore their experiences, actions, and decisions.

By regularly pondering over situations and analyzing their thought processes, nurses can identify strengths and areas for improvement.

This practice encourages the conscious development of critical thinking by comparing past experiences with current knowledge and exploring alternative solutions.

After a particularly challenging case, a nurse reflects on their decision-making process, exploring what worked well and what could have been done differently.

2. Meeting with Colleagues: Collaborative Learning for Critical Thinking

Regular interactions with colleagues foster a collaborative learning environment. Sharing experiences, discussing diverse viewpoints, and providing constructive feedback enhance critical thinking skills .

Colleagues’ insights can challenge assumptions and broaden perspectives, ultimately leading to more well-rounded clinical judgments.

A nursing team gathers to discuss a recent complex case, sharing their perspectives, insights, and lessons learned to collectively improve patient care strategies.

3. Concept Mapping: Visualizing Complexity

Concept mapping is an excellent technique to synthesize intricate patient information. By creating visual representations of patient problems and interventions, nurses can identify relationships and patterns that might not be apparent otherwise.

This strategy aids in comprehensive care planning and encourages nurses to think holistically about patient care.

Creating a concept map to connect patient symptoms, diagnostics, and interventions reveals patterns that help the nurse formulate a comprehensive care plan.

4. Socratic Questioning: Digging Deeper into Situations

The art of Socratic questioning involves asking probing questions that lead to deeper understanding.

Applying this technique allows nurses to uncover assumptions, examine inconsistencies, and explore multiple viewpoints.

This approach is especially valuable when reviewing patient history, discussing conditions, and planning care strategies.

When assessing a patient’s deteriorating condition, a nurse asks probing questions to uncover potential underlying causes and prioritize appropriate interventions.

5. Inductive and Deductive Reasoning: From Specifics to Generalizations

Developing skills in both inductive and deductive reasoning equips nurses to analyze situations from different angles.

Inductive reasoning involves drawing conclusions from specific observations, while deductive reasoning starts with general premises to arrive at specific conclusions.

Proficient use of these methods enhances nurses’ ability to make accurate clinical judgments.

When encountering a series of patients with similar symptoms, a nurse uses inductive reasoning to identify a common pattern and deduce potential causes.

6. Distinguishing Statements: Fact, Inference, Judgment, and Opinion

Clear thinking demands the ability to differentiate between statements of fact, inference, judgment, and opinion.

Nurses must critically evaluate information sources, ensuring they rely on evidence-based practice.

This skill safeguards against misinformation and supports informed decision-making.

While reviewing a patient’s history, a nurse differentiates factual medical information from inferences and subjective judgments made by different healthcare professionals.

7. Clarifying Assumptions: Promoting Effective Communication

Recognizing assumptions and clarifying their underlying principles is vital for effective communication. Nurses often hold differing assumptions, which can impact patient care.

By acknowledging these assumptions and encouraging open discussions, nursing teams can collaboratively create care plans that align with patients’ best interests.

Before suggesting a treatment plan, a nurse engages in a conversation with a patient to understand their cultural beliefs and preferences, ensuring assumptions are not made.

8. Clinical Simulations: Learning through Virtual Scenarios

Clinical simulations provide nurses with a risk-free environment to practice decision-making and problem-solving skills.

These virtual scenarios mimic real-life patient situations and allow nurses to test different approaches, assess outcomes, and reflect on their choices.

By engaging in simulations, nurses can refine their critical thinking abilities, learn from mistakes, and gain confidence in their clinical judgment.

Engaging in a simulated scenario where a patient’s condition rapidly changes challenges a nurse’s decision-making skills in a controlled environment.

9. Case Studies and Grand Rounds: Analyzing Complex Cases

Engaging in case studies and participating in grand rounds exposes nurses to complex patient cases that require in-depth analysis.

Working through these scenarios encourages nurses to consider various factors, potential interventions, and their rationale.

Discussing these cases with colleagues and experts fosters collaborative critical thinking and widens the spectrum of possible solutions.

Nurses participate in grand rounds, discussing a challenging case involving multiple medical specialties, encouraging a holistic approach to patient care.

10. Continuing Education and Lifelong Learning: Expanding Knowledge

Staying up-to-date with the latest advancements in nursing and healthcare is crucial for effective critical thinking.

Pursuing continuing education opportunities, attending conferences, and engaging in self-directed learning keeps nurses informed about new research, technologies, and best practices.

This continuous learning enriches their knowledge base, enabling them to approach patient care with a well-rounded perspective.

Attending a nursing conference on the latest advancements in wound care equips a nurse with evidence-based techniques to improve patient outcomes.

11. Debates and Discussions: Encouraging Thoughtful Dialogue

Organizing debates or participating in structured discussions on healthcare topics stimulates critical thinking.

Engaging in debates requires researching and presenting evidence-based arguments, promoting the evaluation of different perspectives.

Nurses can exchange insights, challenge assumptions, and refine their ability to defend their viewpoints logically.

Engaging in a debate on the pros and cons of a new treatment method encourages nurses to critically analyze different viewpoints and strengthen their own understanding.

12. Multidisciplinary Collaboration: Gaining Insights from Various Disciplines

Collaborating with professionals from diverse healthcare disciplines enriches nurses’ critical thinking.

Interacting with doctors, pharmacists, therapists, and other experts allows nurses to benefit from different viewpoints and approaches.

This cross-disciplinary collaboration broadens their understanding and encourages innovative problem-solving.

Collaborating with physical therapists, nutritionists, and pharmacists helps a nurse develop a holistic care plan that addresses all aspects of a patient’s recovery.

13. Ethical Dilemma Analysis: Balancing Patient Autonomy and Best Practice

Ethical dilemmas are common in nursing practice. Analyzing these situations requires nurses to weigh the principles of beneficence, non-maleficence, autonomy, and justice.

By critically examining ethical scenarios, nurses develop the capacity to navigate morally complex situations, prioritize patient welfare, and make ethically sound decisions.

When faced with a patient’s refusal of treatment due to religious beliefs, a nurse evaluates the ethical considerations, respects autonomy, and seeks alternatives.

14. Root Cause Analysis: Investigating Adverse Events

When adverse events occur, performing a root cause analysis helps identify the underlying causes and contributing factors.

Nurses engage in a systematic process of analyzing events, exploring the “5 Whys” technique , and developing strategies to prevent similar occurrences in the future.

This approach cultivates a thorough and analytical approach to problem-solving.

After a medication error, a nurse leads a root cause analysis to identify system failures and implement preventive measures to enhance patient safety.

15. Creative Thinking Exercises: Expanding Solution Repertoire

Encouraging creative thinking through brainstorming sessions or scenario-based exercises widens the range of possible solutions nurses consider.

By thinking outside the box and exploring innovative approaches, nurses develop adaptable problem-solving skills that can be applied to complex patient care challenges.

Brainstorming creative approaches to comfort a distressed pediatric patient empowers a nurse to find innovative methods beyond routine interventions.

16. Journal Clubs: Fostering Evidence-Based Discussion

Participating in journal clubs involves healthcare professionals coming together to dissect recent research articles.

This practice ignites critical thinking by allowing nurses to evaluate study methodologies, scrutinize findings, and consider the implications for their practice.

Engaging in evidence-based discussions not only cultivates a culture of critical inquiry but also reinforces continuous learning.

At the monthly journal club meeting, Nurse Mark engages in a discussion on a recent research article focusing on pain management strategies for post-operative patients.

The group analyzes the study design, scrutinizes the findings, and considers the potential implications for their practice.

During the discussion, Mark raises thought-provoking questions about the study’s methodology and suggests potential applications in their hospital’s patient care protocols.

This active participation in journal clubs not only refines Mark’s critical thinking but also instills evidence-based practices into his nursing approach.

17. Critical Reflection Groups: Collaborative Learning and Analysis

Similarly, establishing critical reflection groups, where nurses meet regularly to discuss experiences, cases, and challenges, fosters collective learning.

These sessions encourage the exchange of diverse perspectives, enriching the analysis process and ultimately enhancing patient care strategies.

Through shared insights and discussions, nurses can refine their clinical reasoning and broaden their problem-solving capabilities.

Nurse Emma actively participates in critical reflection groups in order to broaden her clinical knowledge. During a recent meeting, the group tackled a difficult patient case with complicated symptomatology.

Emma suggests alternative diagnostic pathways based on her own experiences. Emma’s critical thinking skills are honed as a result of the group’s dynamic interaction, which also emphasizes the importance of collaborative decision-making in complex scenarios.

18. Mindfulness and Reflection Practices: Enhancing Self-Awareness

Mindfulness techniques, such as meditation and deep breathing, encourage self-awareness and a clear mind.

Engaging in these practices helps nurses become more attuned to their thoughts and emotions, leading to better self-regulation and improved decision-making during high-pressure situations.

Engaging in mindfulness exercises before a demanding shift helps a nurse maintain focus, manage stress, and make clear-headed decisions.

19. Problem-Based Learning: Applying Knowledge in Real Scenarios

Problem-based learning involves presenting nurses with real-world patient cases and encouraging them to collaboratively solve the problems.

This approach bridges the gap between theoretical knowledge and practical application, fostering critical thinking through active problem-solving.

Working through a simulated patient case challenges nurses to apply theoretical knowledge to practical situations, refining their clinical reasoning.

20. Self-Assessment and Feedback: Evaluating Decision-Making Skills

Regularly assessing one’s own decision-making process and seeking feedback from peers and mentors is essential for improvement.

Reflecting on past decisions, considering alternative approaches, and understanding the rationale behind them contribute to the refinement of critical thinking skills.

A nurse evaluates their performance after a patient’s unexpected complication, seeking feedback from peers and mentors to identify areas for improvement.

21. Cultural Competence Training: Navigating Diverse Perspectives

Cultural competence training enhances critical thinking by enabling nurses to understand the diverse cultural beliefs and practices of patients.

This knowledge is vital for providing patient-centered care, as it encourages nurses to think critically about the unique needs of each individual.

A nurse attends cultural competence training to understand the dietary preferences of a diverse patient population, ensuring respectful and patient-centered care.

22. Active Listening and Empathetic Communication: Gathering Insights

Active listening and empathetic communication with patients and their families enable nurses to gather comprehensive information about their conditions, concerns, and preferences.

This data forms the basis for critical analysis and informed decision-making in patient care.

Through attentive listening, a nurse uncovers a patient’s underlying concerns, leading to an informed care plan that addresses both medical needs and emotional well-being.

23. Mentorship and Preceptorship: Learning from Experienced Professionals

Having a mentor or preceptor provides novice nurses with the opportunity to learn from experienced professionals.

Mentors guide critical thinking by sharing their insights, challenging assumptions, and offering guidance in complex situations. This relationship fosters growth and expertise development.

A novice nurse gains valuable insight from a mentor, who guides them through complex cases, offering real-world wisdom and refining critical thinking skills.

24. Self-Assessment and Feedback: Evaluating Decision-Making Skills

Reflecting on past decisions, considering alternative approaches, and understanding the rationale behind them contribute to the refinement of critical thinking skills .

Nurse Sarah regularly takes time to assess her decision-making skills by reviewing past patient cases. After a challenging case involving conflicting symptoms, she reflects on her initial approach, the outcomes, and what she could have done differently.

She seeks feedback from her senior colleague, who provides insights on alternative diagnostic paths. Sarah’s self-assessment and feedback-seeking process enable her to identify areas for improvement and refine her critical thinking in similar situations.

• Clinical Reasoning In Nursing (Explained W/ Example)
• 8 Stages Of The Clinical Reasoning Cycle
• What is Critical Thinking in Nursing? (Explained W/ Examples)

Enhancing critical thinking skills is an ongoing journey that transforms nursing practice.

Reflective journaling, collaborative learning, concept mapping, Socratic questioning , reasoning techniques, distinguishing statements, and clarifying assumptions all play integral roles in nurturing these skills.

By incorporating these strategies into their daily routines, nurses can improve their critical thinking skills.

Additionally, this will help nurses in navigating the complexities of the healthcare field with confidence, expertise, and the ability to make well-informed decisions that improve patient outcomes.

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The importance of critical thinking in nursing.

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While not every decision is an immediate life-and-death situation, there are hundreds of decisions nurses must make every day that impact patient care in ways small and large.

“Being able to assess situations and make decisions can lead to life-or-death situations,” said nurse anesthetist Aisha Allen . “Critical thinking is a crucial and essential skill for nurses.”

The National League for Nursing Accreditation Commission (NLNAC) defines critical thinking in nursing this way: “the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief-based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research.”

Why Critical Thinking in Nursing Is Important

An eight-year study by Johns Hopkins reports that 10% of deaths in the U.S. are due to medical error — the third-highest cause of death in the country.

“Diagnostic errors, medical mistakes, and the absence of safety nets could result in someone’s death,” wrote Dr. Martin Makary , professor of surgery at Johns Hopkins University School of Medicine.

Everyone makes mistakes — even doctors. Nurses applying critical thinking skills can help reduce errors.

“Question everything,” said pediatric nurse practitioner Ersilia Pompilio RN, MSN, PNP . “Especially doctor’s orders.” Nurses often spend more time with patients than doctors and may notice slight changes in conditions that may not be obvious. Resolving these observations with treatment plans can help lead to better care.

Key Nursing Critical Thinking Skills

Some of the most important critical thinking skills nurses use daily include interpretation, analysis, evaluation, inference, explanation, and self-regulation.

• Interpretation: Understanding the meaning of information or events.
• Analysis: Investigating a course of action based on objective and subjective data.
• Evaluation: Assessing the value of information and its credibility.
• Inference: Making logical deductions about the impact of care decisions.
• Explanation: Translating complicated and often complex medical information to patients and families in a way they can understand to make decisions about patient care.
• Self-Regulation: Avoiding the impact of unconscious bias with cognitive awareness.

These skills are used in conjunction with clinical reasoning. Based on training and experience, nurses use these skills and then have to make decisions affecting care.

It’s the ultimate test of a nurse’s ability to gather reliable data and solve complex problems. However, critical thinking goes beyond just solving problems. Critical thinking incorporates questioning and critiquing solutions to find the most effective one. For example, treating immediate symptoms may temporarily solve a problem, but determining the underlying cause of the symptoms is the key to effective long-term health.

8 Examples of Critical Thinking in Nursing

Here are some real-life examples of how nurses apply critical thinking on the job every day, as told by nurses themselves.

Example #1: Patient Assessments

“Doing a thorough assessment on your patient can help you detect that something is wrong, even if you're not quite sure what it is,” said Shantay Carter , registered nurse and co-founder of Women of Integrity . “When you notice the change, you have to use your critical thinking skills to decide what's the next step. Critical thinking allows you to provide the best and safest care possible.”

Example #2: First Line of Defense

Often, nurses are the first line of defense for patients.

“One example would be a patient that had an accelerated heart rate,” said nurse educator and adult critical care nurse Dr. Jenna Liphart Rhoads . “As a nurse, it was my job to investigate the cause of the heart rate and implement nursing actions to help decrease the heart rate prior to calling the primary care provider.”

Nurses with poor critical thinking skills may fail to detect a patient in stress or deteriorating condition. This can result in what’s called a “ failure to rescue ,” or FTR, which can lead to adverse conditions following a complication that leads to mortality.

Example #3: Patient Interactions

Nurses are the ones taking initial reports or discussing care with patients.

“We maintain relationships with patients between office visits,” said registered nurse, care coordinator, and ambulatory case manager Amelia Roberts . “So, when there is a concern, we are the first name that comes to mind (and get the call).”

“Several times, a parent called after the child had a high temperature, and the call came in after hours,” Roberts said. “Doing a nursing assessment over the phone is a special skill, yet based on the information gathered related to the child's behavior (and) fluid intake, there were several recommendations I could make.”

Deciding whether it was OK to wait until the morning, page the primary care doctor, or go to the emergency room to be evaluated takes critical thinking.

Example #4: Using Detective Skills

Nurses have to use acute listening skills to discern what patients are really telling them (or not telling them) and whether they are getting the whole story.

“I once had a 5-year-old patient who came in for asthma exacerbation on repeated occasions into my clinic,” said Pompilio. “The mother swore she was giving her child all her medications, but the asthma just kept getting worse.”

Pompilio asked the parent to keep a medication diary.

“It turned out that after a day or so of medication and alleviation in some symptoms, the mother thought the child was getting better and stopped all medications,” she said.

Example #5: Prioritizing

“Critical thinking is present in almost all aspects of nursing, even those that are not in direct action with the patient,” said Rhoads. “During report, nurses decide which patient to see first based on the information gathered, and from there they must prioritize their actions when in a patient’s room. Nurses must be able to scrutinize which medications can be taken together, and which modality would be best to help a patient move from the bed to the chair.”

A critical thinking skill in prioritization is cognitive stacking. Cognitive stacking helps create smooth workflow management to set priorities and help nurses manage their time. It helps establish routines for care while leaving room within schedules for the unplanned events that will inevitably occur. Even experienced nurses can struggle with juggling today’s significant workload, prioritizing responsibilities, and delegating appropriately.

Example #6: Medication & Care Coordination

Another aspect that often falls to nurses is care coordination. A nurse may be the first to notice that a patient is having an issue with medications.

“Based on a report of illness in a patient who has autoimmune challenges, we might recommend that a dose of medicine that interferes with immune response be held until we communicate with their specialty provider,” said Roberts.

Nurses applying critical skills can also help ease treatment concerns for patients.

“We might recommend a patient who gets infusions come in earlier in the day to get routine labs drawn before the infusion to minimize needle sticks and trauma,” Robert said.

Example #7: Critical Decisions

During the middle of an operation, the anesthesia breathing machine Allen was using malfunctioned.

“I had to critically think about whether or not I could fix this machine or abandon that mode of delivering nursing anesthesia care safely,” she said. “I chose to disconnect my patient from the malfunctioning machine and retrieve tools and medications to resume medication administration so that the surgery could go on.”

Nurses are also called on to do rapid assessments of patient conditions and make split-second decisions in the operating room.

“When blood pressure drops, it is my responsibility to decide which medication and how much medication will fix the issue,” Allen said. “I must work alongside the surgeons and the operating room team to determine the best plan of care for that patient's surgery.”

“On some days, it seems like you are in the movie ‘The Matrix,’” said Pompilio. “There's lots of chaos happening around you. Your patient might be decompensating. You have to literally stop time and take yourself out of the situation and make a decision.”

Example #8: Fast & Flexible Decisions

Allen said she thinks electronics are great, but she can remember a time when technology failed her.

“The hospital monitor that gives us vitals stopped correlating with real-time values,” she said. “So I had to rely on basic nursing skills to make sure my patient was safe. (Pulse check, visual assessments, etc.)”

In such cases, there may not be enough time to think through every possible outcome. Critical thinking combined with experience gives nurses the ability to think quickly and make the right decisions.

Improving the Quality of Patient Care

Nurses who think critically are in a position to significantly increase the quality of patient care and avoid adverse outcomes.

“Critical thinking allows you to ensure patient safety,” said Carter. “It’s essential to being a good nurse.”

Nurses must be able to recognize a change in a patient’s condition, conduct independent interventions, anticipate patients and provider needs, and prioritize. Such actions require critical thinking ability and advanced problem-solving skills.

“Nurses are the eyes and ears for patients, and critical thinking allows us to be their advocates,” said Allen.

Image courtesy of iStock.com/ davidf

Last updated on Jan 05, 2024 .

Originally published on Aug 25, 2021 .

The views expressed in this article are those of the author and do not necessarily reflect those of Berxi™ or Berkshire Hathaway Specialty Insurance Company. This article (subject to change without notice) is for informational purposes only, and does not constitute professional advice. Click here to read our full disclaimer

Delegation in Nursing: Steps, Skills, & Solutions for Creating Balance at Work

The 7 Most Common Nursing Mistakes (And What You Can Do If You Make One)

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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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Critical thinking definition

Critical thinking, as described by Oxford Languages, is the objective analysis and evaluation of an issue in order to form a judgement.

Active and skillful approach, evaluation, assessment, synthesis, and/or evaluation of information obtained from, or made by, observation, knowledge, reflection, acumen or conversation, as a guide to belief and action, requires the critical thinking process, which is why it's often used in education and academics.

Some even may view it as a backbone of modern thought.

However, it's a skill, and skills must be trained and encouraged to be used at its full potential.

People turn up to various approaches in improving their critical thinking, like:

• Developing technical and problem-solving skills
• Engaging in more active listening
• Actively questioning their assumptions and beliefs
• Seeking out more diversity of thought
• Opening up their curiosity in an intellectual way etc.

Is critical thinking useful in writing?

Critical thinking can help in planning your paper and making it more concise, but it's not obvious at first. We carefully pinpointed some the questions you should ask yourself when boosting critical thinking in writing:

• What information should be included?
• Which information resources should the author look to?
• What degree of technical knowledge should the report assume its audience has?
• What is the most effective way to show information?
• How should the report be organized?
• How should it be designed?
• What tone and level of language difficulty should the document have?

Usage of critical thinking comes down not only to the outline of your paper, it also begs the question: How can we use critical thinking solving problems in our writing's topic?

Let's say, you have a Powerpoint on how critical thinking can reduce poverty in the United States. You'll primarily have to define critical thinking for the viewers, as well as use a lot of critical thinking questions and synonyms to get them to be familiar with your methods and start the thinking process behind it.

Are there any services that can help me use more critical thinking?

We understand that it's difficult to learn how to use critical thinking more effectively in just one article, but our service is here to help.

We are a team specializing in writing essays and other assignments for college students and all other types of customers who need a helping hand in its making. We cover a great range of topics, offer perfect quality work, always deliver on time and aim to leave our customers completely satisfied with what they ordered.

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Certified Nurse Assistant (CNA) Training

Gritman offers the Palouse’s only Certified Nursing Assistant program, where all training is led by Registered Nurses. Gritman’s CNA program has steadily grown from 20 students each year to more than 70 due to the popularity of our RN-led courses and the area’s high demand for trained caregivers. Area hospitals and care centers rely on Gritman to help train high-tech care with a compassionate touch.

The Certified Nursing Assistant Program is an eight week session hybrid course consisting of regular classes, self study through our online program and clinical hours completed at Gritman Medical Center, Aspen Park and Good Samaritan Society. This course is ideal for individuals looking to begin a career in the healthcare field and those who wish to go on to nursing school or other health related careers.

Classes will include weekday and weekend sessions. It is important for applicants to review the proposed schedule and be available for all class times.

**These classes fill up fast. If you would like to apply, please start Part 1 of the application process by filling out this form , and call  208-883-2224 to pay for your $60 background check. Email us  [email protected] for our most up-to-date schedule of classes. We will set up an appointment to meet with you to discuss paperwork and answer any additional questions you may have.

You may turn in an application as early as you wish. There are several sessions of this course throughout the calendar year. Thank you for your consideration.

Required Course Fees

Non-refundable criminal background check of $60 is required with application to be considered for admission into the program.

Course fee: $1,700 (includes the course fee, textbook, and Basic Life Support for Healthcare Providers training). There is an additional $60 fee for a criminal background check due with application. Registration is not final until student has been issued an acceptance email and until all fees have been paid. Once fees are paid, they are non-refundable for any reason.

Entrance into the CNA program is competitive and requires an application and interview process.

As Ukraine stumbles in war, Kyiv and Western powers struggle to coordinate

KYIV — Sharp fractures are opening between Kyiv and its Western backers, including the United States, over the future of Ukraine’s defense against Russia’s invasion. Ukrainian leaders have increasingly complained that Washington is restricting their ability to respond to Russian attacks as U.S. policymakers push them to do more to fight corruption even amid the worsening war. Meanwhile, European and American officials are quarreling about strategy to turn the tide on the battlefield.

There have been frustrations virtually from the moment Russia’s invasion began in February 2022, but policymakers in Washington, Kyiv and around Europe said tensions have grown sharper in recent weeks as Russia has seized the initiative on the front lines and started recapturing territory liberated earlier in the war.

The sharpest battlefield disagreement at the moment is whether Ukraine can use donated weapons to strike targets on Russian soil. The Biden administration has strictly prohibited Ukraine from using U.S. weaponry to do so because it fears that the heavy U.S. involvement required to operate the weapons could escalate the war into a direct conflict between Washington and Moscow, though it is reexamining its policy.

Some NATO leaders, including the foreign ministers of Finland and Canada, pointedly broke with the United States on Wednesday by publicly declaring that they had never prevented Ukraine from using their donated weapons to strike targets on Russian soil, joining France and NATO Secretary General Jens Stoltenberg in saying that Ukraine has the right to do so. Germany and Italy have sided with the U.S. reluctance.

The disagreement over strikes on Russia is just one example of a broader disconnect between and among Ukraine and its most important military backers over how to deal with the grinding war as Ukraine’s battlefield position continues to weaken. Russia shows no sign of relenting in its bid to occupy and annex four southeast Ukrainian regions and to push beyond if possible. It already seized and illegally annexed Ukraine’s Crimean Peninsula in 2014.

The mounting disputes reflect how a $61 billion package of military assistance approved by Congress last month after months of delays has yet to stabilize Ukraine’s battlefield vulnerability, though U.S. officials say that weapons deliveries should partly ease problems within weeks. Still, Ukrainian leaders are heading into this summer’s intense fighting season at odds with some of their biggest military backers over an array of issues.

The United States and many European nations are also split on matters that include Ukraine’s path to NATO membership — Washington remains cautious — and whether to use frozen Russian assets to fund assistance to Kyiv, an effort the United States and Ukraine support and Europeans largely oppose.

Ukrainian President Volodymyr Zelensky has not shied away from direct attacks on President Biden, telling reporters in Brussels on Tuesday that if the U.S. president skips a Ukrainian-organized peace summit next month in Switzerland, as is likely, “his absence will only be applauded by Putin, personally applauded by Putin, with a standing ovation.”

The meeting in Switzerland does not include Russia, and officials in Moscow have dismissed it as political theater with no chance of delivering an agreement to end the invasion. Ukrainians want to use it to secure broad international backing for their vision.

Zelensky’s anger hardly is reserved for the White House alone. Diplomats and other officials in Kyiv noted that the president has ousted some senior Ukrainian officials who were viewed as being closest to Washington in recent weeks.

And after Secretary of State Antony Blinken played guitar at a Kyiv bar during a visit earlier this month — a performance of “Rockin’ in the Free World” that was intended to demonstrate support — many Ukrainian officials close to Zelensky derided the performance as insensitive.

Some diplomats said that criticism might be another effort to push back at U.S. leaders after Blinken used his visit to redouble demands that Ukraine fight corruption. Ukraine has taken numerous steps to fight graft in recent years, which they insist are not sufficiently recognized in the West.

U.S. officials insist that the core aspects of the relationship remain strong, pointing to a deep working relationship between Washington and Kyiv that includes U.S. military assistance. Biden and Zelensky are expected to meet next month in Italy, and officials are working on a security agreement with Kyiv that will offer military aid for years to come.

But new fissures appear to emerge daily. On Wednesday, a U.S. official said Washington had expressed concerns to Kyiv over Ukraine’s strikes — using its own weapons — on Russian radar stations that provide conventional air defense and early warning of nuclear launches by the West.

These types of public concerns and criticism typically are used by the White House to signal to Moscow that it does not view the war in Ukraine as a direct fight between the United States and Russia — and wants to avoid one — even though Russian President Vladimir Putin, other senior Russian officials and Kremlin propagandists routinely say that Russia, in Ukraine, is fighting the United States and NATO.

Any disagreements between the Zelensky and Biden administrations are picked up with glee by Russian policymakers, who have long sought to amplify and exploit any cracks in Western support for Ukraine.

“The President of Ukraine isn’t … happy with the decision of the #U.S. President not to participate in the so-called summit in Switzerland on #Ukraine,” Mikhail Ulyanov, Russia’s envoy to international institutions in Vienna, wrote on X. “Kiev dictates to the West what and when to do. The West tolerates it,” Ulyanov added, using the Russian spelling of the Ukrainian capital, which typically infuriates Ukrainians.

This article is based on interviews with 25 Ukrainian, European and U.S. policymakers in Kyiv, Washington and Europe. Many spoke on the condition of anonymity to allow a frank discussion of sensitive diplomatic and security issues.

Some of the disagreements stem from natural tensions that arise within a partnership that has had to endure more than two years of war and a steadily rising Ukrainian death toll, officials said. But other fights appear to be more fundamental, especially disagreements over how much to focus on corruption during wartime. Policymakers warn that long-term planning may be elusive.

“We are seeing that Russians are getting more and more assertive,” Latvian President Edgars Rinkevics said in an interview. He said that failing to push back Russia will ultimately fuel instability across the region.

“You see all sorts of small provocations that, frankly, you have to figure out how to deal with,” he said, referencing allegations about possible Russian sabotage and arson across Europe and maritime border disputes in the Baltic Sea and with Estonia.

Russians “see that they can continue,” he said. “So my question is, what are those reasons to believe that allowing Ukraine to hit legitimate military targets is escalatory? If there is good reason to be worried, then I haven’t heard the argument.”

Ukrainian leaders say that the U.S. restrictions against striking Russian territory enabled the Kremlin this spring to build up forces on its own soil and attack Ukraine’s second-largest city, Kharkiv, knowing that Ukrainians’ hands were tied.

“The Russian strategy right now is quite understandable. They’re trying to take as much territory as they can to annihilate our forces and find our weak points,” said Oleksandr Lytvynenko, a senior Ukrainian security official who is the secretary of the country’s National Security and Defense Council.

“Americans think that they should avoid escalation with Russia by creating zones of ambiguity, but it provokes Russia. Russia needs to have very clear lines. A gray zone is just an invitation to try,” Lytvynenko said.

Some Biden administration officials say that it is understandable that Ukrainians are frustrated after waiting seven months for Congress to approve military aid. Any further delay, they say, could have led to a collapse of Ukraine’s front lines. Kyiv remains critically short of soldiers, weapons and ammunition.

U.S. military aid for this year is intended to help bolster the country’s front line defenses and help it hold on to territory currently within Kyiv’s control, ideally exhausting Russian forces as they attack and seek to advance against minefields and other traps.

Ukraine has had significant success pushing back the Russian navy in the Black Sea and in striking Crimea, reducing the Kremlin’s ability to menace the Ukrainian mainland.

“I’m not going to tell you there isn’t ever friction as we wrestle with these critical and challenging pressures of Russia’s full-scale invasion,” a senior U.S. official said. “The depth and breadth of our partnership is sufficient that we can manage disagreements about tactics and find the best way forward as strategic partners.”

Next year, U.S. planners say, Ukraine will have narrowed its personnel shortfall by training a new crop of conscripts. It will also have modern F-16 fighter jets from Western backers, which are expected to arrive this summer.

Also, Russia’s defense industry may have peaked or plateaued by then, American officials say — all reasons to think Ukraine might be in a stronger position, potentially increasing its leverage to impose peace terms in negotiations with Russia, should Ukraine desire it, they say.

But even the thought that negotiations with Moscow are possible demonstrates a serious gap in thinking among top officials in Kyiv and Washington. Many Ukrainians insist that Putin cannot be trusted to uphold any cease-fire agreement, given his oft-stated intention to expand control of Ukrainian territory.

Ukrainian officials also worry about the extensive damage Russian bombing has done to Ukraine’s energy grid, which has forced Ukraine to impose morale-sapping temporary blackouts. The Ukrainians also fear that Western interest in their cause is waning. And some voice concern that a new law to lower the draft age by two years, to 25, will not sufficiently remedy a critical shortage of soldiers.

“I would not build up a strategy on the basis that in a year we will be stronger,” one senior Ukrainian official said.

Another senior Ukrainian official, speaking of the country’s conscripts, said: “They’re not trained, they’re not motivated, they’re not equipped.”

The potential cost of failure is significant. At worst, Russian forces could break through Ukrainian lines and capture significant swaths of territory, including major population centers, officials say, potentially forcing Ukraine to sue for peace on very weak terms.

That could mean even worse problems for Europe and the United States.

“Ukraine is defending a huge part of NATO states, of E.U. states,” said Mykola Davydiuk, a Ukrainian political analyst. “We’ve become a wall. We don’t want to become a gray zone.”

Ukrainians, however, say they need more air defenses and to be allowed to hit targets in Russia.

“We believe in us, but you don’t,” another senior Ukrainian official said, referring to the Americans. “This is the biggest issue right now in our relationship.”

Some of the tensions were clear during Blinken’s trip to Kyiv earlier this month. The visit was intended to deliver a supportive message to Ukrainians — but he also told leaders that they needed to do more to combat corruption.

“Ukraine’s defenses against corruption have to be just as strong as its military defenses,” Blinken said in a speech focused on the country’s future. Ukrainian leaders took exception. In a meeting with Zelensky, the Ukrainian president bristled, according to officials familiar with the interaction.

Afterward, Ukrainian Foreign Minister Dmytro Kuleba said Washington’s focus was out of step with the problem.

“If we were as corrupt as the perception says,” Kuleba told reporters after a meeting with Blinken, institutions such as the European Union and International Monetary Fund “simply wouldn’t be giving us any money.”

U.S. officials — and some Ukrainian ones — have been alarmed in recent weeks by the targeting of reformist officials who were willing to battle corruption inside their own ministries and who appeared especially close to Washington.

The dismissal this month of deputy prime minister Oleksandr Kubrakov, who had been focused on infrastructure and rebuilding Ukraine, was especially alarming, U.S. and European officials said.

The coming months will bring more flash points. European elections in June are likely to bolster far-right forces that are skeptical of Ukraine’s path to joining the European Union. A NATO summit in Washington in July is unlikely to offer Ukraine the clear track toward alliance membership that Kyiv desires.

Each side now says the other may not have a clear path to victory. “It looks like their GPS is jammed,” a second senior European diplomat said of Kyiv’s leadership.

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Capturing New Nurses' Experiences and Supporting Critical Thinking

This study analyzed the contents of critical reflective journals written by new nurses during their orientations using a text network. This study aimed to find ways to reduce turnover and improve clinical field adaptability among new nurses. The authors analyzed the content of reflective journals written by 143 new nurses from March 2020 to January 2021. Text network analysis was performed using the NetMiner 4.4.3 program. After data preprocessing, frequency of occurrence, degree centrality, closeness centrality, betweenness centrality, and eigenvector community were analyzed. In total, 453 words were extracted and refined, and words with high simple frequency and centrality were “incompetence,” “preparation,” “explanation,” “injection,” “time,” “examination,” and “first try.” “Medication” had the highest frequency of occurrence, and “incompetence” was the most important keyword in the centrality analysis. In addition, component analysis and eigenvector community analysis revealed three sub-theme groups: (1) basic nursing skills required for new nurses, (2) insufficient competency, and (3) explanation of nursing work. Significantly, this study is the first to use the text network method to analyze the subjective experiences of the critical reflective journals of new nurses. In conclusion, changes are needed to improve the education system for new nurses and promote efficient sharing of nursing tasks.

“New nurses” are nurses who work in hospitals within their first year of acquiring a nursing license. New nurses experience several challenges while adapting to the clinical environment because they often identify patient problems and make high-quality clinical decisions in rapidly changing clinical settings. Critical thinking ability is essential to overcoming difficulties in meeting these demands. 1 In particular, critical thinking ability positively affects clinical decisions through communication and may help new nurses adapt to their working environment. 2 However, new nurses tend to have lower critical thinking abilities than tenured nurses and require time to develop clinical competencies. 3 Because inadequate critical thinking skills may make it difficult for new nurses to provide optimal nursing care and thus may negatively affect patient safety, 3 new nurses must develop strong critical thinking skills.

Furthermore, critical thinking is a reflective thinking process that enables one to decide what to believe and what to do, 4 and reflection is essential to enhance critical thinking ability. 5 Reflective journaling is an approach to internalizing learned knowledge through reflective thinking and objectifying activities, 6 which in turn may strengthen critical thinking and clinical decision-making abilities. 3 Reflective thinking connects new knowledge with existing knowledge, enables abstract thinking, and enables individuals to use specific solution-oriented strategies based on their knowledge and experiences in response to new problems. 7 In the context of nursing education, reflective journaling crucially allows learners to observe their emotional and psychological states. 8 For new nurses, the process of transitioning from being a nursing student to working as a nurse may be confusing and difficult, and reflective journaling during this period may improve clinical decision-making skills, relieve the challenges associated with the transition process, and promote communication with preceptors and nursing managers. 9 , 10

Reflective journaling is a clinically viable educational method for the self-analysis of clinical decision making in residency programs for new nurses. 11 In particular, reflective journaling is a useful educational method for strengthening clinical adaptation capacity in new nurses. 8 – 10 Analyzing the content of these journals can reveal how best to shape pedagogy to strengthen the competencies of new nurses.

Many studies have been conducted to help new nurses adapt and decrease their turnover. These studies include research on the factors affecting the retention intention and turnover of new nurses, 12 , 13 qualitative research on the practical adaptation experience of new nurses, and literature reviews on new nurse education programs. 14 , 15 However, no study has yet analyzed the reflective journals written by new nurses; therefore, it is necessary to review these journals, which offer insights into the actual experiences of new nurses. Other disciplines, such as pedagogy, have applied text network analysis (TNA) for more objective document research by linking content analysis and social network analysis. 16 The TNA method is an analysis technique that interprets a phenomenon using a network that displays the relationships between the words appearing in the text as “links.” Notably, TNA is a useful analysis method to identify the relationship between core keywords and other keywords. 17 In addition, this method can enhance knowledge of related phenomena through quantitatively examining the words appearing in text and identifying words that co-occur with other specific words. 18 Recently, in the field of nursing, studies have used network analyses to uncover research trends and knowledge structures, 19 , 20 including by analyzing the contents of the practices of nursing students. 21

In response to the gap in the literature, the authors sought to uncover the clinical experiences of new nurses during the orientation period by analyzing their critical reflective journals using the TNA method. In particular, the authors examined the relationships between keywords and main words and experiences. This study's specific objectives were as follows:

• To extract keywords based on their frequency and identify core keywords.
• To identify core topic and sub-theme groups.

Research Design

In this quantitative content analysis study, the authors applied the TNA method to identify the core keywords from new nurses' critical reflective journals on their clinical experiences during their orientation period.

Research Sample and Data Collection

The authors analyzed the critical reflective journals written by 143 new nurses who joined a university hospital located in an urban area of Korea from March 2020 to January 2021. The nurses recorded their experiences in the critical reflective journals six times during the orientation period (8 weeks). The nurses were instructed to record, in the form of narration, the most memorable aspects of their nursing interactions with patients and list their performance strengths and shortcomings in each situation. The journal structure was configured to assist them in establishing and writing goals, as well as with developing plans to improve their shortcomings. The researcher obtained the nurses' consent to participate in the study after detailing the purpose and method of writing critical reflective journals for 30 minutes during the common orientation period. New nurses were introduced to critical thinking as a very important and necessary process for improving clinical judgment. In addition, clinical nurse educators prompted new nurses to reflect on the situations they experienced in the field when writing in their journals; in particular, they asked the nurses to contextualize these situations and consider alternative ways they may have solved problems they encountered in the field. The researchers explained to the new nurses that the journals would only be used to analyze basic data to uncover how best to help new nurses adapt to the field. Next, new nurses who voluntarily agreed to participate were provided with a journal before being assigned to a department. Research participants were notified they could withdraw from the study at any time, and they were asked to contact the clinical nurse educators with any difficulties or questions related to journaling. After orientation, the nursing education team collected the journals.

Data Analysis

In the analysis of the collected data, the main semantic structure was visualized as a sociogram through preprocessing and network analysis. Analysis was performed using NetMiner 4.4.3 (Cyram Co. Ltd., Gyeonggi-do, Korea).

Preprocessing Stages

The journals were transcribed to Microsoft Office Excel (Microsoft Inc., Redmond, WA, USA) and converted into databases. Four researchers divided the reflective journals, copied them, and then went through the process of reconfirming each other's work. The data were extracted from long texts and included only nouns identified using the morpheme analysis function of NetMiner 4.4.3. Using the NetMiner's “import unstructured text” menu, the database data were read and morphemes were extracted. A thesaurus was created to unify words with similar meanings. While examining the extracted morphemes, meaningful morphemes were extracted using the thesaurus, defined words, and excluded words, and word purification was performed using the extraction results.

The thesaurus grouped words (phrases) with similar meanings, and the researcher designated the representative words for each group. 22 In Korean alphabet (Hangeul), words with the same meaning are often presented differently, 23 so the authors paid attention to the selection of representative words and their registration in the thesaurus. For example, “alcohol cotton” was made to represent “alcohol swab,” “disinfection cotton,” “cotton,” and “alcohol.” Phrases consisting of two or more words were also added to the dictionary to establish that the multiple words comprising the phrase should be read as a unit. 24 For example, the words “intravenous” and “injection” were registered within the dictionary as comprising “intravenous injection.” The dictionary of excluded words went through a refining process to exclude stop words, such as pronouns and adverbs without important meanings. The process of word refinement involved several rounds of consultation between joint researchers to reduce subjective bias. In addition, “frequency of appearance” refers to the number of times a keyword appears in an entire document. In order to exclude commonly used words that appear frequently in all documents, words with a term frequency–inverse document frequency (TF-IDF) value of 0.5 or less were excluded by referring to previous studies. 25 The frequency of words appearing in one document is called “term frequency,” and the number of documents in which a word appears is called “document frequency.” “Inverse document frequency” is the logarithmic expression of the inverse of document frequency. A high term frequency value may be recognized as a keyword due to a high frequency in one document, but if the term frequency value is equally high in other documents, it is considered a commonly used word in several documents, even if it may not be necessarily a keyword. Therefore, it should be excluded when extracting keywords by calculating inverse document frequency values of words. For this purpose, TF-IDF, which represents the importance of any word in a particular document, is obtained by multiplying term frequency and inverse document frequency, and used for word extraction. The larger the TF-IDF value, the higher the importance of any word in the document. 26 In this study, five words with a TF-IDF value of 0.5 or less (eg, “teacher,” “patient,” “work,” “think,” and “confirm”) were included in the dictionary of excluded words.

Finally, 274 thesaurus, 301 defined words, and 1759 excluded words were registered in the user dictionary. As a result, a total of 453 words were extracted in the critical reflective journals written by the new nurses. In this study, the top 30 keywords' frequency of appearance was analyzed based on refined words to extract keywords. To intuitively represent keywords, frequency of appearance was generated by using NetMiner 4.4.3.

Process of Network Formation

The network formation process generated a keyword co-occurrence matrix to reflect that the two keywords appeared next to each other in one sentence or were located among the other keywords. 27 Repeated co-occurrence can be interpreted as forming a semantic structure between the words. The higher the degree of connection, the more co-occurrence exists across different types of keywords, which yields a semantic structure in various contexts. In the one-mode matrix of the “keyword × keyword” relationship, the degree value was 1 to 48, 70.4% (1649) for less than 1 and 85.4% (1999) for less than 2.

To grasp the main phenomenon in network analysis, only keywords with an appropriate level of connection are included, but the reference value for the connection degree is not presented, 28 and the study result is determined considering ease of interpretation and network visualization. 27 In this study, a one-mode matrix composed of 401 keywords with a connection degree of two or higher was generated and used for network analysis.

Network Statistical Analysis and Visualization

Statistical analysis was performed and visualized using a one-mode network to discover the core keywords in the journals.

The centrality of the network was analyzed for degree centrality, closeness centrality, and betweenness centrality, which are indicators of centrality, and the average and concentration of each centrality were confirmed. Centrality indicators show that words with high centrality are considered core keywords to the extent that words in the network are centered. 29 The value of the centrality indicator exists between 0 and 1; the larger the value, the higher the centrality of the word. 28 The average centrality indicator refers to the center value of the entire network centrality indicator, and centralization represents the degree to which a network is structurally concentrated or distributed across a specific word. Thus, an intensive link flow in a small number of words indicates that the network is highly concentrated. 29

Degree centrality refers to the degree of connection between nodes (in this study, keywords used in the analysis) in the network; this indicates co-occurrence between words and indicates the number of connections between nodes. 28 Keywords with high connection centrality are often connected to other keywords, which means that they are important keywords. Closeness centrality refers to the degree to which a node is located close to another node in the network. 28 Keywords with high proximity centrality may be interpreted as keywords that play a central role in the network while reaching other keywords the fastest. Betweenness centrality refers to the degree to which other nodes and intermediaries play a role in the network. 28 Keywords with high mediation betweenness centrality serve as bridges that interconnect sub-keywords between networks. The top 30 words with high degree centrality, closeness centrality, and betweenness centrality were visualized as sociograms. The larger the node size, the larger the centrality index, and the thicker the link, the higher the co-occurrence frequency.

Sub-theme Analysis

To identify the sub-theme groups, the authors first extracted the largest component based on cohesion in the NetMiner program and then performed an eigenvector community analysis. A component is a group in which keywords are connected without being broken. Communities refer to subgroups with relatively low modularity, high connection density inside the group, and relatively low connection density outside the group within the component structure. The modularity value is used to determine the optimality of the community structure; eigenvector community modularity can have a value between negative (−) infinity and “1”—the larger the value, the better the modularity. 30

Ethical Considerations

This study was approved by the institutional review board (CNUH-2020-247) of the university hospital located in an urban area of Korea to protect the participants, where the current study was conducted. Participants were informed about the purpose of the study, their rights to anonymity and confidentiality, and their freedom to withdraw from the study. Written informed consent was obtained from those who wished to participate in the study.

Keywords of the Critical Reflective Journal of New Nurses

The top 30 keywords by simple frequency, degree centrality, closeness centrality, and betweenness centrality were identified as core keywords in the journals (Table ​ (Table1). 1 ). The simple frequency appeared in following order: “medication,” “intravenous (IV) cannulation,” “preparation,” “incompetence,” and “explanation.” In this study, the means of the degree centrality, closeness centrality, and betweenness centrality of the word networks were 0.216, 0.501, and 0.037, respectively, and the concentrations were 24.9%, 30.2%, and 14.0%, respectively. Regarding degree centrality, “incompetence,” “explanation,” “preparation,” “medication,” and “properly” were the most important keywords. Regarding closeness centrality, “incompetence,” “preparation,” “explanation,” and “time” were the most important keywords. Regarding betweenness centrality, “incompetence,” “preparation,” “first try,” “understand,” and “explanation” were the most important keywords. In the analysis of the most memorable events during the orientation period for new nurses, words such as “incompetence,” “preparation,” “explanation,” and “injection” were high in both frequency and centrality. Regarding the simple frequency, “medication” was the most frequent keyword. Regarding the centrality analysis, “incompetence” was the most important keyword.

Top 30 Keywords That Emerged From the Reflective Journal of New Nurses

Visualizing the Main Semantic Structure

Figure ​ Figure1 1 presents a sociogram, a graph consisting of nodes and links, of the top 30 keywords. The size of a node indicates the degree centrality, and the thickness of a link indicates the strength of the connection, that is, the frequency of co-occurrence. The researchers examined the semantic structure by focusing on five core topics: “medication,” which is strongly tied with “study,” “explanation,” “examination,” and “remember”; “preparation,” which is part of a semantic structure with “injection,” “operation,” “medication,” “time,” and “fluid”; “time,” which is strongly tied with “nursing” and “performance”; and “explanation,” which is part of a semantic structure with “caregiver,” “incompetence,” and “nursing.” Finally, “IV cannulation,” “fluid,” and “organization” formed the semantic structures; “first try,” “IV cannulation,” “admission,” and “night” appeared as meaningful structures; and “properly” and “explanation,” “need,” and “study” appeared as meaningful structures.

Keyword network analysis of the reflective journal of new nurses.

Regarding degree centrality and closeness centrality, “night,” “operation,” “condition,” and “suction” showed low degree centrality and centered on “incompetent,” which demonstrated the highest centrality. Regarding betweenness centrality, “night,” “blood glucose management,” “fluid,” “condition,” “operation,” and “suction” showed low betweenness centrality and centered on “incompetent,” which again demonstrated the highest centrality.

Sub-thematic Groups

The component analysis and eigenvector community analysis based on cohesion in the keyword network yielded three sub-thematic groups with an optimal modularity of 0.257 identified with sociograms (Figure ​ (Figure2). 2 ). Group 1 was classified into “medication,” “preparation,” “IV cannulation,” “first try,” “administration,” “injection,” “examination,” “blood glucose management,” “operation,” “fluid,” “blood sampling,” “blood,” “night,” and “caregiver.” Group 2 was classified into “incompetence,” “time,” “nursing,” “properly,” “electronic medical record (EMR),” “understand,” “study,” “organization,” “performance,” “condition,” and “suction.” Group 3 was classified into “explanation,” “need,” “remember,” “situation,” and “admission.” The research topic groups were named based on the contexts in which the keywords of each subgroup were used. The three sub-themes were (1) basic nursing skills required for new nurses, (2) insufficient competency, and (3) explanation of nursing work.

Visualization of subgroup analysis from the reflective journal of new nurses.

This study sought to understand the work experiences of new nurses by using a TNA method to analyze the contents of the critical reflective journals they wrote during their orientation (the first 8 weeks after they began working in the hospital). The main semantic structure specifically showed the context of the core topic.

More specifically, the frequency and centrality analyses confirmed that, in terms of working directly with patients, the new nurses had the most difficulty with tasks related to medication. The contents of the analysis suggest that a new nurse must prepare drugs for patients and explain the medication to the patient while administering the drug through injection. The new nurses described their experiences with this process in their journals as follows: “When I went to the patient to inject the drugs, the patient asked a question about why the drug was being used, but I did not explain the reason properly” and “I don't know how to explain the efficacy and side effects of various types of drugs administered to patients.” These excerpts suggest that new nurses lack knowledge about medications and experience job stress and low confidence; if these problems are not resolved, they may lead to job turnover. 31 New nurses must learn to administer medications; this is a core basic nursing skill in nursing colleges. A practical training room in the hospital is necessary to provide systematic and sufficient opportunities for repeated practice to improve the confidence of new nurses in their core basic nursing skills and reduce work stress. 32

This study uncovered the following main semantic structures. First, new nurses experience a lack of clinical knowledge about medication and feel a need to study on their own. In addition, a lack of drug-related knowledge caused new nurses to feel burdened when teaching a patient or their caregivers about a medication before administering it. Additionally, new nurses felt that they should remember what they learned on their own and in clinical practice from their preceptors. They also felt the need to learn and study the drugs used in many tests. Medication errors are an important factor in patient safety and are the most frequent medical accidents. 33 Administering the correct drug to the correct patient, providing information about the drug to the patient, and confirming and reporting the side effects of a drug is necessary to reduce medication errors; therefore, it is crucial to emphasize this in nursing programs. 33 Because this study found that new nurses experienced many difficulties with medication, it is necessary to establish a protocol for clinical practice and improve systematic education through simulation. 34

Second, this study confirmed that new nurses must prepare to successfully give injections, oral medications, and fluids and to facilitate operations (eg, preparing dressing materials). 35 In addition, new nurses were frequently pressed for time while taking care of patients. The results were similar to those from a study in which new nurses reported that the confidence level for the item “I can completely care for a patient within the allotted time” was low at 20%–50%. 36 New nurses often work overtime at hospitals; for example, some nurses go to work 2 hours early and complete their records after work because they do not have enough time to complete their duties within their scheduled hours. 37 This suggests that nursing tasks should be more appropriately distributed. 36

Third, new nurses need skills to explain their care to patients or caregivers while working. Accordingly, new nurses need to have strong relationship and communication skills. 38 The journals revealed that new nurses feel their work requires them to be able to properly explain different elements of care to patients and their caregivers; however, they often felt that they did not have the knowledge or skills necessary to carry out this duty. Moreover, the new nurses themselves felt they needed to study to ensure that they were not ignorant in ways that may harm the patient. Therefore, a system should be established to help new nurses strengthen their skills by actively utilizing support resources at the hospital level; notably, this may reduce turnover. Along these lines, a simulation program related to communication should be used during orientation to increase the communication abilities of new nurses. 39

Fourth, new nurses reported difficulties with IV cannulation and their first inpatient admissions. They felt pressured to complete an IV cannulation for the first time and struggled to connect and arrange various fluids. Simulations that teach new nurses how to administer intravenous injections should be included in orientations in response to this trend. Most wards in this research institute use functional nursing, with different numbers of people per service. Therefore, new nurses completed different tasks during day and evening shifts, such as IV cannulation, injection, and vital sign and blood glucose testing during the former and overseeing patients, checking prescriptions, and entering records during the latter. Accordingly, they reported that night work was very complicated and that they felt that they were lacking in their skills to complete it successfully. Previous studies reported that new nurses in Korea experienced excessive workload, communication difficulties, and low confidence in their work, suggesting that active intervention is needed to improve clinical adaptation in new nurses. 36 Therefore, there is a need to develop various programs, such as communication programs and basic nursing skill simulations, for new nurses.

Finally, based on the analysis of the three sub-thematic groups, the first subject group was “basic nursing skills required for new nurses.” The ability to perform basic nursing skills is an essential element for new nurses to adapt to practice: when nursing skills are lacking, they experience overload in the clinical field; this leads to increased stress, which increases the resignation rate. 40 In 2019, Korean institutions began to ensure they were offering clinical nurse educator systems and training programs to reduce the resignation rate of new nurses by improving their competency. 41 Programs that intensively train new nurses in basic nursing skills at the initial stage of their employment are essential in hospitals to help new nurses adapt to practice. The second thematic group was “insufficient competency.” New nurses start clinical work with insufficient clinical experience and competency; experience difficulties in providing and selecting appropriate treatments for patients; and must cope with overload, which increases their role burden. 37 Therefore, it is necessary to reduce the amount of work assigned to new nurses and to develop educational programs that can identify problems by presenting various situations that can help them understand their work. The third topic group was “explanation of nursing work.” New nurses most frequently deal with patients and caregivers and thus feel pressured to properly explain things to them (eg, why patients are hospitalized, what medications they are receiving); this feeds their desire to remember what they have learned. In addition, new nurses often complain of communication difficulties 38 ; accordingly, clinical communication programs should be developed to overcome this problem.

Unlike previous studies, this study analyzed the experiences of new nurses by applying TNA to the critical reflective journals they wrote during orientation. However, the information was only collected over the course of a year, which limits the generalizability of the research results. In addition, the fact that the nursing manager reports and provides feedback on the journals may have limited direct expression. To overcome these limitations, a program for the in-depth analysis of new nurses' experiences should be implemented in the future. Ultimately, this study sets the foundation for further analysis of the experiences of new nurses by being the first to use a TNA to effectively explore the subjective experiences of new nurses.

This study applied a TNA to identify, group, and analyze core keywords in the critical reflective journals new nurses wrote during their orientation at tertiary general hospitals in Korea. New nurses' most memorable events during orientation were reflected by high-frequency and high-centrality words, such as “incompetence,” “preparation,” “explanation,” and “injection.”

This study's results can guide best practice for improving the field adaptability of new nurses and reducing their turnover rate. Currently, nursing students in Korea nursing mainly complete observation-oriented practicums; this increases the burden on their basic nursing skills. Being compelled to perform extensive duties beyond their competencies is causing exhaustion among new nurses. To mitigate these issues, changes should be made to the new nurse education system to better prepare new nurses and nursing duties should be more efficiently distributed.

This study was financially supported from Back Ui Association, Chonnam National University Hospital (2021).

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Ethical Approval: The study was approved by the Chonnam National University Hospital Institutional Review Board (approval number: CNUH-2020-247).

Hye Won Jeong: https://orcid.org/0000-0001-5664-8672

Shin Hye Ahn: https://orcid.org/0000-0002-1403-2711

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"Is autocracy actually compelling?": Jordan Klepper examines why we're falling for Russian misinfo

The "daily show" host asks whether americans are naive or drawn to strongmen, and what that would mean to the world, by melanie mcfarland.

Jordan Klepper ’s field pieces for  “ The Daily Show ” have taken him to places most progressives prefer to avoid. Trump rallies, mostly. “I’m this big, lanky, white guy. And I think people feel more comfortable and confiding some of these things to this person who they see, perhaps, as closer to an ally,” the correspondent told Salon in a recent interview conducted over Zoom.

That ease in his presence has netted Klepper a wealth of material for “Jordan Klepper Fingers The Pulse,” his regular journeys into the dark heart of the partisan divide . But some excursions produce broader examinations. 

"The Daily Show Presents: Jordan Klepper Fingers The Pulse: Moscow Tools ,"  his latest special, is a nimble dive into how effectively Russian propaganda has insinuated itself into our political discourse. Klepper's objective is stone-cold serious as always, even as he places a comedic spin on a topic that should scare all of us.

Similar to  his 2022 special on the far-right’s obsession with Hungary , “Moscow Tools” grew out of Klepper noticing the changing MAGA-world conversation around Russia.  When the same lies were used in Congress to slow down financial assistance to Ukraine, he realized this was a gateway to examining American gullibility.

“That's what I essentially cover,” Klepper said. “And I think there are these big questions there of like, why are we so gosh darn gullible? How much of it is us being a pawn to misinformation, and how much of this is revealing what we actually want? Are we just stooges? Or are there people in the MAGA movement who want these more autocratic desires, and these powerful players who limit LGBTQ rights and the power of the press? They’re kind of big questions and frankly, I think they’re scarier questions.”

“Moscow Tools” has the distinction of showing Klepper in conversation with two unlikely allies in this fight to maintain Western democracy. One is Estonian Prime Minister Kaja Kallas , whom Klepper visits in her home country to discuss what the stakes are should Donald Trump return to the Oval Office and do as he’s promised, withdrawing from NATO.

The other, former Trump administration National Security Advisor  John Bolton , sounded the alarm concerning his former boss’ threat to American democracy from a well-apportioned wine cellar. 

Spending a decade with “The Daily Show” has given Klepper a reputation for tangling up his subjects in their own webs of illogic, including among some of the conservatives who agree to speak to him on camera. Bolton is not immune to this, although perhaps he recognizes Klepper is on his side of this urgent debate. It probably also has something to do with Klepper’s ethos of, in his words, listening with curiosity.

That principle takes him to other places in “Moscow Tools” that are just as unexpected as his interview locations with former and present world leaders and, as he explained in our conversation, represents a truer interpretation of what patriotism means.

The following interview has been edited for length and clarity.

First of all, watching you talk to John Bolton in a wine cellar made me think to myself, “Oh, that's the nicest doomsday bunker I've ever seen.” Did you ever think that you would be in a situation where, to say nothing of the wine cellar-slash-bunker, you would be consulting him as a voice of wisdom?

Not at all. No. And I brought that up in the interview, although, it's not in the special but . . . The fact that I'm sitting down with the prime minister of Estonia and John Bolton, both people who are afraid about Russian propaganda and how it's affecting the GOP, to me is more just reflective of the weirdness of the time we're in. I can't say I had "wine cellar with John Bolton" on my bucket list, but you know, 2024 has a weird way of making strange bedfellows.

Your segment where you spent time with the Estonian militia is also enlightening, especially when the person you’re speaking to tells you he’s preparing to be a choir director while he’s armed and wearing fatigues and assorted camouflage. What was that moment like for you, and what are you hoping that the image of that moment will convey?

Yeah. As a Michigan boy, I always feel most at home hanging out with militia. So even when I go abroad, I'm keeping an eye out for them. These specials happened fairly organically, and so when we notice something in the field, we want to explore it more. 

This one provides some interesting opportunities for us to sit down with experts and try to use them to walk through Russian propaganda and show it in the field. And then when we started to hear the stories around Estonia — and more so, hearing stories in America, where there was just such a lack of actual information about what it meant to be threatened by Russia, and what it meant to be living underneath an oppressive Russian regime, we thought it was an opportunity for us to go there and talk to people.

So much gets lost in translation and social media and TikTok that when we decided we wanted to talk to the Estonian prime minister, we said we wanted to talk to real people as well. And the story comes up about the Estonian Defence League. 

Quite frankly, it's shocking to me to see people come together and fight a common enemy. This is what we were told about World War II, that there were these unifying moments where there was a larger enemy. When the enemy is at the gates, people put aside their differences, and they come together to battle for the common good. 

"I can't say I had 'wine cellar with John Bolton' on my bucket list, but you know, 2024 has a weird way of making strange bedfellows."

And I feel like America has faced some threats, COVID being the most recent worldwide threat, and we haven't seen this unifying moment where people come together. In fact, when I go out on the road and I talk to people, the biggest enemy that they see is usually their neighbor. It's not a foreign adversary. It's somebody on the left, it's somebody who's been too “woke,” somebody who wants to have a trans athlete in a middle school competition. That is their largest fear and threat. 

And so hearing the story about the Estonian Defence League, these are people who are coming together because they actually are afraid for their families. They actually can look across the border and see a threat. They have a recent history of living under that oppressive, autocratic regime. 

We need to talk to these people. We need to dispel some of these rumors and these images and lies that Tucker Carlson pushes on the MAGA faithful about like, this autocratic regime is beautiful. “Look at the subway, look at the baguettes!” No, look at the people in Estonia who have lived underneath this oppressive regime who are training — who are teachers, who are going to be choir conductors – who are putting their time aside because they are afraid. And they're not talking about partisan politics. They're talking about protecting democracy and freedom. 

To me, that was so inspiring and an opportunity for us to just get their story told. It's something that I felt was lost in this weird partisan American environment we're in. And it's surreal that it happens on a place like Comedy Central. But I think it's more important than ever to talk to people who are actually affected by this and show that there are people who have more at stake than the . . . culture wars that we have back at home.

It's also a powerful image when you think about when we see images of militias in the news. A lot of that is in the context of Jan. 6, right? There's all this whole idea of people kind of playing Weekend Warrior as if it's a concept that they want to execute in real life without truly understanding the consequences.

I was there on Jan. 6 —  working, to be clear. To be clear! And you're right, there's a lot of weekend warriors dressed in fatigues who train for one big issue and that issue was apparently to overthrow their own government.  They were angry at, again, their neighbors.

I did a special, “ Jordan Klepper Solves Guns ,” where I spent a weekend with the Georgia state militia training in the woods. And there's a lot of straw men they’re training to fight. Their heads are swimming with misinformation and these faux narratives of heroism. So getting to see in Estonia, all of that stripped away . . . they're not doing it for glory, or for clicks, or Instagram likes or to get away from their kids on the weekends. They're doing it because they want to protect their kids 365. 

It is a wake-up call when people have more on the line than you do, when people aren't getting caught up in what feels like fake arguments over the internet about stuff that actually isn't affecting people's lives, and it is just being used to have some sort of outrage competition. When you go into the woods, and you see people training for the things that actually could affect their family members, it really is a wake-up call. 

For me, it was also a reminder that patriotism could be defined in perhaps a more earnest and true way than what I've been privy to these last few years.

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I want to return to the idea of looking at this through the lens of comedy. I think that when Tucker Carlson went to Russia , afterward there was a lot of breaking down of all of the fallacies he perpetuated and Putin's reaction of basically calling him a soft target. There was a tendency, I think, to laugh at it. 

But I also think there's a tendency on the part of what I would call the mainstream media, and however you’d characterize Chris Cuomo , to understand what it was that he was thinking. The theory is that doing so will help us to understand the MAGA tribe, those people who are locked in this specific kind of information silo. And I'm wondering whether you think this might affect that audience, either positively or negatively.

I find comedy is a very effective tool to frame issues in a way that perhaps a general population might not approach. . . . The “Fingers the Pulse” pieces are a little bit unique in that we do look for humor, we look for hypocrisy. But I also find them to be revelatory, because more often than not, what I get to do that most journalists don't get to do is, I get to come in with a biased perspective. I get to ask follow-up questions, I get to say yes to their ideas to hopefully have them reveal more in the field than they normally would to somebody else, so that I can understand them a little bit more. 

"It's easy enough to sort of look at what's happening with Russia misinformation, and just look at the useful idiots . . . But the scarier question is the other side of it: Is autocracy actually compelling to many Americans?"

Like when we spoke to [journalist] Julia Ioffe, who walked us through what the Kremlin's talking points were, as far as how they wanted to get these narratives into American mainstream culture, how can I have that conversation, and then use my comedic skills and my fieldwork, to actually show the effects of Russian propaganda in conversation with the actual propaganda?  

And so for me, that was a really exciting part of using comedy as a way to ignite an audience interest, and to show a contradiction and hypocrisy, but hopefully also to evolve what we've been doing and use that as proof of the Kremlin’s success. And so I'm hoping that we're showing somewhat of a coherent narrative as to how that propaganda can find its way into the middle of Pennsylvania.

Want a daily wrap-up of all the news and commentary Salon has to offer? Subscribe to our morning newsletter , Crash Course.

Now, the effect that has on an audience is a much bigger conversation, I think. I don't know if it's getting inside the bubble of the people out there in MAGA world. I think we are in these silos in a way where I don't know if they're ingesting this comedy in any kind of a way and, more often than not, their knives are out. Because if it seems critical, then they won't engage whatsoever. But I think we approach it more so not as a way of converting people, but hopefully as a way of articulating some of the chaos and, frankly, manipulation that we see day in and day out. 

It's easy enough to look at what's happening with Russia misinformation, and just look at the useful idiots – and there are plenty of them in America, and that's part of what Putin wants. But the scarier question is the other side of it: Is autocracy actually compelling to many Americans? And do we pretend like democracy is this thing that will just always exist when frankly, there are folks who may desire something completely different? 

And maybe that is because of Russia's manipulation or outside manipulation. Maybe it's because of naïveté. Or maybe it's because that is a desire — a strongman, a conservative nation with a white leader might be something that people are actually pining for. Again: big, scary ideas, but hopefully, we can use whatever tools we have to kind of start to ask those questions because I think they are really percolating right now.

What you said about the difference between Estonia versus here is important, because in most cases when Americans are talking about their neighbor, they're talking about the concept of them. I don't think they're talking about anyone they actually know and fear.

I think that's 100% true. People are so angry about their neighbor, and they talk about bringing guns to their neighbor. The way in which people talk about the person on the other side of the aisle is so scary. And Jan. 6 was a goddamn s**tshow. The rhetoric got so high and there were a lot of bad actors there who had one goal in mind. And there are a lot of other people who had been talking about overthrowing the government and being so angry at their neighbor and then got caught up in something that was way beyond what they had expected. 

So I do think it's dangerous to have these conceptual talks about our anger and our fears, and where we want to seek vengeance. You look at this Trump campaign, it's all about vengeance. 

People are often like, “You went to Estonia?” Yes, we went to Estonia. There are other stories being told, where people are facing real consequences. Like, let's hear these out before we get lost in the world of concept.

"The Daily Show Presents: Jordan Klepper Fingers The Pulse: Moscow Tools" is streaming on Paramount+, the "Daily Show" YouTube channel, CC.com and video on demand.

about this topic

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Melanie McFarland is Salon's award-winning senior culture critic. Follow her on Twitter: @McTelevision

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