NURSE EDUCATOR
Volume 30, Number 3, pp 133-136
N ursing faculty have a historical tra-
dition of teaching their students to
think like a nurse as originally de-
scribed by Florence Nightingale. “If
then, every woman must, at some
time or other of her life, become a
nurse, i.e., have charge of somebody’s
health, how immense and how valu-
able would be the produce of her
united experience if every woman
would think how to nurse” (see pref-
ace of reference 1). Notably, thinking
critically like a nurse is becoming a
benchmark of professional compe-
tence and student performance.2,3
Hence, the ability to think critically, to
improve clinical systems, and de-
crease errors in clinical judgments is
ever the vision of historic and futuris-
tic nursing practice.4
Critical Thinking
Creative thinking, smart thinking,
high-quality, and in-depth thinking
are semantic representations of the
concept that is widely labeled as criti-
cal thinking. The famous adage by
Descartes “I think, therefore I am,”
has contributed much worth to the
idea that thinking plays a key role in
the very existence of man. In evaluat-
ing critical thinking models from 1912
to 1992,5 Gendrop and Eisenhauer
found the common elements of
process (active, explicit, purposeful),
cognitive skill (inquiry, interpretation,
reflection, analysis, creativity, infer-
ence, conceptualization, evaluation),
data source (reality, evidence, theo-
Author’s Affiliation: Site Coordinator/
Associate Professor of Nursing, Langston
University-Tulsa School of Nursing and
Health Professions, Tulsa, Okla.
Correspondence: Langston University-
Tulsa, 700 N Greenwood Ave, Tulsa, OK
74106 (pdivito-thomas@mmind.net).
NURSE EDUCATOR Volume 30, Number 3
© 2005 Lippincott Williams & Wilkins, Inc.
Nursing Student Stories on
Learning How to Think Like
a Nurse
Pam Di Vito-Thomas, PhD, RN
The ability to think critically, improve clinical systems, and decrease
errors in clinical judgments are ever the vision of nursing practice. The
author describes the thinking processes of nursing students as they
make clinical judgments and the most important teaching/learning
strategies that help develop their clinical judgment.
ries, contexts, criteria, empathy, expe- Ausubel’s Assimilation Learning The-
rience), and outcome (judgment, ory. Ausubel’s theory includes the in-
novel idea, novel response). terrelationships of subsumption (an
Scheffer and Rubenfield6 support interactive process between newly
the idea that critical thinking in nurs- learned material and existing concepts
ing comprises 11 affective components: [subsumers]), progressive differentia-
perseverance, open-mindedness, flex- tion (refinement of a concept with
ibility, confidence, creativity, inquisi- more precision and specificity), and
tiveness, reflection, intellectual in- integrative reconciliation (crosslinking
tegrity, intuition, contextual, and of concepts; similar but not always
perspective); and 7 cognitive skills: in- exact). These conceptual interrelation-
formation seeking, discriminating, an- ships are evident in concept mapping,
alyzing, transforming knowledge, pre- where understanding is characterized
dicting, applying standards, and by the nature and structure of knowl-
logical reasoning). Nearly all defini- edge, how facts are organized, and
tions of critical thinking emphasize the relationships between superordi-
logic and reasoning. nate concepts.10
Importantly, “learners first may
Teaching/Learning learn the higher-order concept and
Strategies That Facilitate then subsume the lower-order con-
cepts, or learners may learn the
Critical Thinking lower-order concepts and then relate
Nursing education involves adult them to the higher-order one.”11(p43)
learners as students. Knowles7 theo- The ability to visualize conceptual in-
rized that adult learners are capable terrelationships in a hierarchical and
decision makers who need to be ac- causal manner is useful to many disci-
tive participants in the learning plines, and provides the learner with
process. The adult learning environ- an opportunity to practice both induc-
ment reflects a relaxed and informal tive and deductive thinking. The dis-
climate where process activities and tinction of the organizing techniques
collaboration are encouraged and in concept mapping is evidence that
evaluation is by the teacher, oneself, concept maps are not flow charts or
and peers.8 Adult learners construct outlines.
knowledge by linking concepts to- In many aspects, the use of con-
gether in meaningful ways based on cept maps in nursing education
former learning and life experiences. demonstrates the shift in nursing edu-
Research by Novak9 on meaning- cation from “an information-driven
ful learning led to his adoption of approach in teaching to a process that
May/June 2005 133
promotes higher level thinking and
clinical judgment.”12(p182) The shift em-
phasizes that nursing education is not
just a fact-loading process.13 This has
stimulated interest and research into
other innovative teaching/learning
strategies that facilitate the develop-
ment of critical “in-depth” thinking in
nursing students. Several studies iden-
tified teaching/learning strategies that
facilitate the development of critical
thinking in clinical judgments.12,14-21
The teaching/learning strategies
are self-directed learning activities, in-
teractive discussion, role playing,
problem-based learning, mastery
learning, case studies, clinical rounds,
reflective logs (journaling), and reflec-
tive practice groups.
The skill of metacognition,
thinking about thinking, is a strategy
that promotes the use of reflective
writing in clinical logs. Reflective writ-
ing provides the student with the op-
portunity to define and express the
clinical experience in his or her own
words. An analysis of reflective logs
by faculty permits individual student
instruction and creates a potential
arena for personal dialogue between
faculty and student for an optimal
learning experience.
Another teaching/learning strat-
egy that promotes open communica-
tion is student-led clinical rounds.
During clinical rounds, students have
the opportunity to communicate as-
sessment data, collaborate ideas, cre-
ate plans for patients, and view the
situation from multiple perspectives.19
During rounds, nursing faculty have
the opportunity to engage themselves
in the thinking processes of their stu-
dents and present themselves as
superior in their critical thinking abili-
ties. “This externalization of the think-
ing process and the fair-mindedness
in thinking is what is meant by ‘mod-
eling critical thinking’ in our teaching
of clinical judgment.”22(p135)
The Students
To understand nursing students’ per-
spectives about the phenomenon of
critical thinking and what they believed
are the most helpful teaching/learning
strategies in developing those thinking
skills, I mailed a cover letter, an
abridged proposal, and documents of
the study protocols to 6 deans I knew
134
at baccalaureate schools of nursing.
The cover letter requested that they in-
vite all junior and senior nursing stu-
dents in clinical nursing courses to par-
ticipate in the study. Four deans
volunteered to act as the study coordi-
nator at their institution. The purposive
sample of 134 nursing students came
from 3 private and 1 state university.
The students voluntarily read, signed,
and dated the informed consent form
and participated in the study. None of
the students were licensed healthcare
providers. There were 59 (44%) junior
and 75 (56%) senior nursing students,
whose ages ranged from 18 to 54.
There were 5 ethnic groups repre-
sented, with the primary ethnic group
being European-American.
The students responded in writ-
ing to the following questions: (1)
How would you describe how you
think (the thinking process that you
go through) when making clinical
judgments? and (2) What were the
most important teaching/learning
strategies in the development of your
clinical judgment? Upholding confi-
dentiality, I collected the responses
and analyzed the data using the con-
stant-comparative approach devel-
oped by Glaser and Strauss.23 The
general process involved bringing to-
gether provisional categories that re-
late to the same content, have specific
properties and dimensions, and are
internally consistent and mutually ex-
clusive.24,25 The findings in this study
describe the experience of junior and
senior nursing students in response to
the study questions. The results of the
data analysis are expressed in narra-
tive statements of the story that is
grounded in the data.
The Student Responses on
Critical Thinking
The students described their thinking
as a cognitive process that was devel-
oping through experience in practice.
Often, the responses reflected a simi-
lar understanding that the process of
critical thinking was not polished but
would improve in time with the op-
portunities to practice using those
skills in a clinical setting. Broader
ways of thinking are learned by work-
ing in the field, and although one’s
experience may be limited, it becomes
clear that education is an essential first
NURSE EDUCATOR
step. However, education without ex-
perience lessens the capacity of an in-
dividual to think critically in a situa-
tion where lives are at stake.
Education and experience must go
hand in hand so that the knowledge
gained in the classroom becomes sec-
ond nature in practice. While a lot can
be learned from books, the best expe-
riences come from real-life situations.
Critical thinking in clinical judg-
ments goes beyond what is seen,
heard, and presently known; it re-
quires discipline and a willingness to
round everything up and put it all to-
gether. How the thinking process
comes together can be likened to a
television screen without an antenna,
where things are scrambled, con-
fused, and hazy. Attach the antenna
and you get a perception—the light
goes on and you can put things in
their proper place. Also, thinking is
clarified when reasoning skills are
used to figure out what is wrong, what
is right, and what could have caused
the problem. By thinking through dif-
ferent options and weighing each op-
tion according to the best interest of
the patient, family, and community,
what should be done first to improve
patient outcomes is realized.
During the thinking process, the
thinker may integrate different con-
cepts and relate them to each other
while recollecting facts, situations, and
patients he or she cared for in the past.
This reflective processing is like a mind
picture, a concept map of the patient’s
varying problems. By going back to
the earliest recognizable contributing
factor then forward to the patient’s cur-
rent disease, the correlations and the
evolution of the disease process are
recognized. Then, by prioritizing and
grouping information, the thinker may
see how the factors connect to each
other and realize their influences on
the patient and his or her condition.
Notably, deductive and inductive
reasoning enter into the thinking
process. Deductively, it begins with
the most obvious whole picture and
works toward minute details, and in-
ductively, one puts 2 and 2 together,
step by step, and thinks it through.
Both types of reasoning involve cal-
culating assessment information gath-
ered from both the healthcare and
patient point of view. Finally, when
the thinking is unsuccessful the
Volume 30, Number 3 May/June 2005
process should be open to the exper-
tise of nursing faculty and other re-
sources. This ensures the soundness
of choices when making clinical judg-
ments for the patient and family.
Student Exemplar 1
I look at a situation and follow
through by doing a little research, be-
fore actually planning or implement-
ing decisions. For instance, a patient’s
BP has been low, 100/50, but the pa-
tient has a history of HTN. Do I hold
the drug? I’ll look in the chart at yes-
terday’s vital signs and whether the
drug had been given. If the drug was
not given yesterday or the day before,
I question myself as to whether I hold
the drug or call the doctor regarding
the situation. By thinking through dif-
ferent options and weighing each op-
tion, what should be done first to im-
prove patient outcomes is realized. I
know it is hard to put all the knowl-
edge learned in school into practice,
but I know it will come with practice.
The Student Responses on
Important Teaching/
Learning Strategies in
Developing Clinical
Judgment
Clinical experience is the most impor-
tant learning strategy in developing
clinical judgment. You cannot learn that
skill from a book. Moreover, the clinical
experience provides opportunity to ob-
serve other healthcare professionals in
the healthcare field who are known for
their competence and ability. In the
clinical environment, other healthcare
workers influence clinical judgment;
students have the opportunity to watch
others and see how they respond. This
contributes greatly to knowing what to
do in a given situation.
Learning by example and hands-
on experiences require more clinical
time to be immersed in the environ-
ment and to practice, practice, and
practice interventions that have been
learned. Some of the interventions in-
clude completing assessments, giving
reports, providing patient care and
developing a therapeutic relationship
through a fuller awareness of individ-
uals and their family. Clinical time is
most important because performing
NURSE EDUCATOR Volume 30, Number 3
an activity or procedure allows one to
understand and remember.
Clinical experience and interac-
tion with direct care nurses provide
models for different approaches to
care: nurses who care, are very excel-
lent, helpful, encouraging, and facili-
tate learning; these nurses are willing
to help and provide more in-depth
teaching. However, nurses who are
impatient, unkind, and lack enthusi-
asm hinder learning. Fortunately,
there are many people in the clinical
setting to draw knowledge from like
clinical instructors who make students
think and are open to suggestions. For
example, students felt instructors who
questioned the thinking behind as-
sessment findings until the most
sound clinical choice is made are
most helpful.
Apart from clinical and classroom
work, linking concepts using maps is
helpful. The maps display the interre-
latedness of all aspects of patient care
and how that work together to create
optimal health outcomes. Notably,
case studies allow students to focus,
think critically, make learning real,
and tie things together. Case studies
can also be visually displayed on a
concept map.
Student Exemplar 2
The most important teaching/learning
strategies in the development of clini-
cal judgments have been observing
procedures being done, then having
to do them myself, and then basic
repetition from there. Each time that I
perform procedures, and take care of
patients, I have seen new things and
learned more. So, my judgment has
become more in tune and accurate
from this. You see I can read it in a
book a thousand times but until I see
it demonstrated and implement it my-
self, it is just a bunch of words. I
would definitely say that having more
clinical experience would help de-
velop better critical thinking skills in
regard to clinical judgments.
Conclusion
The teaching and learning strategies
that students described as facilitating
development of clinical judgment are
as follows: case studies that can be
displayed on concept maps; having
May/June 2005
in-depth discussion with instructors
while observing clinical dynamics;
and making joint decisions on care.
The development of these strategies is
critical in the learning environment
and lies heavily on the quality and
quantity of the interactive discussions
students have with faculty and other
nurses who openly reflect what they
know, how they know it, and who
they are in nursing.
However, no strategy was per-
ceived as more important from the
data than the desire for “more clinical
time and experience.” The challenge
for faculty is identifying appropriate
clinical facilities despite the chal-
lenges often encountered in the
evolving healthcare environment.
Hence, seeking out exemplary direct-
care nursing role models who actively
demonstrate their critical thinking
processes is paramount for nursing
students at all levels on learning how
to “think like a nurse.”
These nurses’ demonstration of
their critical thinking processes is
paramount to nursing students of all
levels.
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Volume 30, Number 3 May/June 2005