importance of problem solving in nursing

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.

ANA Nursing Resources Hub

Search Resources Hub

Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

Images sourced from Getty Images

Related Resources

Item(s) added to cart

Account Management

Log in to manage your policy, generate a certificate of insurance (COI), make a payment, and more.

Log in to your account to update your information or manage your policy.

Download a Certificate of Insurance (COI) to provide to your employer.

Make a Payment

Make a one-time payment, set up autopay, or update your payment information.

Submit a notice of an incident or claim in just minutes.

Topics on this page:

Why Critical Thinking in Nursing Is Important

8 examples of critical thinking in nursing, improving the quality of patient care, the importance of critical thinking in nursing.

Jul 24, 2024

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.”

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.

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.

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 Jul 24, 2024. Originally published on Aug 25, 2021.

• Career Growth

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

The product descriptions provided here are only brief summaries and may be changed without notice. The full coverage terms and details, including limitations and exclusions, are contained in the insurance policy. If you have questions about coverage available under our plans, please review the policy or contact us at 833-242-3794 or  [email protected] . “20% savings” is based on industry pricing averages.

Berxi™ is a part of Berkshire Hathaway Specialty Insurance ( BHSI ). Insurance products are distributed through Berkshire Hathaway Global Insurance Services, California License # 0K09397. BHSI is part of Berkshire Hathaway’s National Indemnity group of insurance companies, consisting of National Indemnity and its affiliates, which hold financial strength ratings of A++ from AM Best and AA+ from Standard & Poor’s. The rating scales can be found at  www.ambest.com  and  www.standardandpoors.com , respectively.

No warranty, guarantee, or representation, either expressed or implied, is made as to the correctness, accuracy, completeness, adequacy, or sufficiency of any representation or information. Any opinions expressed herein are subject to change without notice.

The information on this web site is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment, and does not purport to establish a standard of care under any circumstances. All content, including text, graphics, images and information, contained on or available through this web site is for general information purposes only based upon the information available at the time of presentation, and does not constitute medical, legal, regulatory, compliance, financial, professional, or any other advice.

BHSI makes no representation and assumes no responsibility or liability for the accuracy of information contained on or available through this web site, and such information is subject to change without notice. You are encouraged to consider and confirm any information obtained from or through this web site with other sources, and review all information regarding any medical condition or treatment with your physician or medical care provider. NEVER DISREGARD PROFESSIONAL MEDICAL ADVICE OR DELAY SEEKING MEDICAL TREATMENT BECAUSE OF SOMETHING THAT YOU HAVE READ ON OR ACCESSED THROUGH THIS WEB SITE.

BHSI is not a medical organization, and does not recommend, endorse or make any representation about the efficacy, appropriateness or suitability of any specific tests, products, procedures, treatments, services, opinions, health care providers or other information contained on or available through this web site. BHSI IS NOT RESPONSIBLE FOR, AND EXPRESSLY DISCLAIMS ALL LIABILITY FOR, ANY ADVICE, COURSE OF TREATMENT, DIAGNOSIS OR ANY OTHER SERVICES OR PRODUCTS THAT YOU OBTAIN AFTER REVIEWING THIS WEB SITE.

Want Berxi articles delivered straight to your inbox? Sign up for our monthly newsletter below!

" * " indicates required fields

How we use your email address Berxi will not sell or rent your email address to third parties unless otherwise notified. Other than where necessary to administer your insurance policy or where required by law, Berxi will not disclose your email address to third parties. Your email address is required to identify you for access to the Berxi website. You may also receive newsletters, product updates, and communications about quotes and policies.

Paul Dughi is a contributing writer for Berxi, as well as a journalist and freelance writer. He has held executive management positions in the media industry for the past 25 years.

Related Articles

Breaking Bad News to Patients: A Nurse’s Guide to SPIKES

Michael Walton Jul 24, 2024

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

Kristy Snyder Jul 24, 2024

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

Paul Dughi Aug 28, 2024

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?

• Subscribe to journal Subscribe
• Get new issue alerts Get alerts

Secondary Logo

Journal logo.

Colleague's E-mail is Invalid

Your message has been successfully sent to your colleague.

Save my selection

Nurse leaders as problem-solvers

Addressing lateral and horizontal violence.

Anthony, Michelle R. PhD, RN; Brett, Anne Liners PhD, RN

Michelle R. Anthony is a program coordinator at Columbia (S.C.) VA Health Care System. Anne Liners Brett is doctoral faculty at the University of Phoenix in Tempe, Ariz.

Acknowledgment: The authors acknowledge the support of the University of Phoenix Center for Educational and Instructional Technology Research.

The contents of this article do not represent the views of the US Department of Veterans Affairs or the United States Government.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

For more than 126 additional continuing-education articles related to management topics, go to NursingCenter.com/CE .

Earn CE credit online: Go to http://nursing.ceconnection.com and receive a certificate within minutes .

Read about a qualitative, grounded theory study that looked to gain a deeper understanding of nurse leaders' perceptions of their role in addressing lateral and horizontal violence, and the substantive theory developed from the results.

The issue of lateral and horizontal violence (LHV) has plagued the nursing profession for more than 3 decades, yet solutions remain elusive. The significance of LHV isn't lost on nurse leaders because it creates an unhealthy work environment. Research literature worldwide has continued to report the prevalence of disruptive behaviors experienced by nursing students, novice nurses, and seasoned nurses in the workforce. The World Health Organization, International Council of Nurses, and Public Services International have recognized this issue as a major global public health priority. 1

LHV, also called nurse-on-nurse aggression, disruptive behavior, or incivility, undermines a culture of safety and negatively impacts patient care. 2,3 This experience, known to nurses as “eating their young,” isn't only intimidating and disruptive, it's also costly and demoralizing to the nursing profession and healthcare organizations. 4,5 Although the impact of LHV can be dreadful for both the institution and its staff, little is known about the reasons for these behaviors among nursing professionals. 2

LHV encompasses all acts of meanness, hostility, disruption, discourtesy, backbiting, divisiveness, criticism, lack of unison, verbal or mental abuse, and scapegoating. 6 The sole intent of bullying behaviors is to purposefully humiliate and demean victims. Bullying behaviors also taint healthcare organizations; cause irreparable harm to workplace culture; breakdown team communication; and severely impact the quality of the care provided, thereby jeopardizing patient safety. 7,8 Researchers have reported that acts of LHV are used to demonstrate power, domination, or aggression; for retribution; to control others; and to enhance self-image. 9-12

Previous studies have shown that the frequency of LHV in healthcare organizations is quite severe, with about 90% of new nurses surveyed reporting acts of incivility by their coworkers. 13 Sixty-five percent of nurses in one survey reported witnessing incidents of despicable acts, whereas another 46% of coworkers in the same survey reported the issue as “very serious” and “somewhat serious.” 13

LHV poses a significant challenge for nurse leaders who are legally and morally responsible for providing a safe working environment. 2,6 The purpose of this qualitative, grounded theory study was to gain a deeper understanding of nurse leaders' perceptions of their role in addressing LHV and develop a substantive theory from the results.

Literature review

A paucity of evidence exists in the literature regarding how nurse leaders perceive their role in addressing LHV. 14 Studies have shown that this phenomenon is attributed to heavy workloads, a stressful work environment, and lack of workgroup cohesiveness, as well as organizational factors such as misuse of authority and the lack of organizational policies and procedures for addressing LHV behaviors. 15

In one study, one-third of the nurses reported that they had observed emotional abuse during several of their work shifts. 16 Another study indicated that 30% of survey respondents (n = 2,100) stated LHV occurs weekly. 17 A third study revealed that 25% of participants noted LHV happened monthly, and a fourth study of ED nurses reported that about 27.3% of the nurses had experienced LHV perpetrated by nursing leadership (managers, supervisors, charge nurses, and directors), physicians, or peers in the last 6 months. 18

In a survey completed by members of the Washington State Emergency Nurses Association, 27% of respondents experienced acts of bullying in the past 6 months. 19 Another study reported that 27% to 85% of nurse respondents had experienced some form of uncivil behavior. 20 Other data have shown that those more vulnerable to violent, disruptive, and intimidating behaviors are newly licensed nurses beginning their careers. 21

Although nurse leaders can be perpetrators of LHV, they play an essential role in addressing LHV behaviors and creating a safe work environment. 22 The literature suggests that, in many cases, a lack of awareness and response by nurse leaders adds to the prevalence of LHV. 23 This may be due, in part, to nurse leaders being aligned with the perpetrators who are creating the toxic work environment. 6 The literature suggests that an environment where staff members feel safe to practice results in a culture that decreases burnout and promotes nurse retention and quality outcomes. 24,25

This qualitative, grounded theory study focused on nurse leaders' perception of their role in breaking the cycle of LHV for staff members whom they supervise. Two research questions guided the study: 1. How do nurse leaders perceive their role in addressing LHV among nursing staff members under their supervision? 2. What substantive theory may emerge from the data collected during interviews with nurse leaders?

A grounded theory methodology was used to explore the nurse leader's role in addressing LHV with the intent of developing a substantive theory through the meaningful organization of data themes to provide a framework to address the phenomenon of LHV. Purposive sampling was used to recruit a total of 14 participants for this study from a large healthcare system in the Southeastern US. The participants were chosen because of their experience with LHV and their ability to discuss and reflect on those experiences. Informed consent was obtained before the start of the study, which included explaining the reason for the study and what to expect. In addition, permission was obtained from the Institutional Review Board.

Data collection and analysis

Demographic data collected to describe the sample included gender, age range, number of years holding a management position, supervisory responsibility, and highest degree obtained. (See Table 1 .)

Semistructured, in-depth interviews were the primary mode of data collection. The recorded interviews were conducted face-to-face and lasted about 60 minutes. Data collection continued until saturation was achieved. Data saturation occurred when no new descriptive codes, categories, or themes were emerging from the analyzed data. The interviews were transcribed verbatim and verified through a member check process.

During the data analysis process, themes and patterns were identified. Data from each participant's interview were examined to determine if the responses were aligned with the identified themes. Analysis of the data included coding at increasingly abstract levels and constant comparison. Qualitative software assisted in coding the information and uncovering subtle trends.

Four themes emerged from core categories developed during the qualitative data coding process.

Theme 1: Understanding/addressing LHV . In question one, participants were asked to describe their understanding of LHV. Five subthemes emerged from the data collected with this question. (See Table 2 .)

Theme 2: Experience addressing LHV . In the second question, participants were asked about their experience with addressing incidents of LHV. Six subthemes were identified. (See Table 3 .)

Theme 3: Role perception in addressing LHV . In the third question, participants were asked what they perceive their role to be in addressing LHV. Six subthemes resulted from this question. (See Table 4 .)

Theme 4: Organizational impediment to addressing LHV . In question four, participants were asked to describe the factors within the organization that influence or impede their role in addressing LHV. This question yielded nine subthemes. (See Table 5 .)

Substantive theory

As a result of the themes that emerged from the data, a substantive theory was developed. This is especially important for the nursing profession to develop as a scientifically based practice. Theories help guide research and provide the expansion, generation, and validation of the science of nursing knowledge. 26 The substantive theory will help nurse leaders become more cognizant of the role that effective leadership plays in preventing or intervening in incidents of LHV in the workplace. The analysis revealed that nurse leaders are aware that the quality of patient care and staff well-being can be adversely affected by the impact of LHV.

Data themes were used to formulate the following theory: Nurse leaders address LHV affecting their staff members by solving problems, creating a safe work environment, and reducing institutional barriers that impede addressing LHV in a timely fashion. Nurse leaders perceive their role as a problem-solver, which is a necessary step in advocacy. 27 Problem-solving is a process that contains the elements of decision-making and critical thinking. 28

The theory that emerged from the core categories explicitly focused on the central phenomenon of LHV in the nursing work environment. Figure 1 shows the interrelatedness of the themes to the resultant substantive theory.

Discussion and implications

The study results have several implications for both the nursing profession and nurse leaders. The nursing profession requires decisive and robust leadership, and the role of the nurse leader is to be a combination of nurturer, investigator, and judge to examine incidents of LHV. 26,29-32 Nurse leaders are responsible for setting the tone and expectations for a safe work environment. This includes modeling the expected ethical behaviors; for example, doing the right things for the right reasons, being collegial toward each other, and being respectful of other's differences. One participant remarked, “This is a different world based on how I was raised. I was raised to be respectful to people.”

In addition, nurse leaders are responsible for enforcing policies created to address disruptive behaviors and working with the administration as soon as an incident occurs. Past research indicates that a healthy and collaborative work environment fosters nurse engagement and patient safety. 25,30 Staff members and patients need a leader to protect them when necessary; thus, the nurse leader needs to “walk the walk” in providing a safe environment for all. Nurse leaders engaged in these kinds of behaviors are providing strong leadership and practicing strong decision-making, thus ensuring the continued robustness of their organizations.

Recommendations and limitations

Future research could replicate this study in a different geographic region to explore the causes of LHV by soliciting the views of nursing students, new graduate nurses, and nurse educators from unionized and nonunionized hospital systems and comparing the results to further understand this phenomenon. Additionally, developing a tool to test the substantive theory could substantiate the nurse leader's role as a problem-solver to address incidence of LHV in the workplace.

The decision to conduct this study in one type of healthcare organization limits the ability to compare the interviewed nurse leaders' experiences with nurse leaders in other healthcare organizations. The experiences of nurses in other healthcare organizations may be different; thus, overall generalizability of the study may be limited.

Say “no” to the status quo

The results of this study support the findings of previous researchers. 23,31,33,34 Accepting the status quo is unacceptable and can cause irreparable harm to organizational well-being if LHV isn't addressed. Collaboration between nurse leaders and administrators is essential to successfully reduce institutional obstacles that prevent the timely handling of LHV incidents. The role of the nurse leader as a problem-solver should be clear, defined, and well supported to seek resolutions to toxic behaviors that are hurting the work environment. But we must remember that creating a policy doesn't equal change. Every employee from the lowest level in the organization to the highest ranks of administration must model civil behaviors.

INSTRUCTIONS Nurse leaders as problem-solvers: Addressing lateral and horizontal violence

Test instructions.

• Read the article. The test for this CE activity is to be taken online at http://nursing.ceconnection.com .
• You'll need to create (it's free!) and login to your personal CE Planner account before taking online tests. Your planner will keep track of all your Lippincott Professional Development online CE activities for you.
• There's only one correct answer for each question. A passing score for this test is 14 correct answers. If you pass, you can print your certificate of earned contact hours and access the answer key. If you fail, you have the option of taking the test again at no additional cost.
• For questions, contact Lippincott Professional Development: 1-800-787-8985 .
• Registration deadline is June 3, 2022 .

PROVIDER ACCREDITATION

Lippincott Professional Development will award 1.5 contact hours for this continuing nursing education activity.

Lippincott Professional Development is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 1.5 contact hours, and the District of Columbia, Georgia, and Florida CE Broker #50-1223.

Payment: The registration fee for this test is $17.95.

• + Favorites
• View in Gallery

Readers Of this Article Also Read

Leadership strategies to promote frontline nursing staff engagement, nurse leader competencies: a toolkit for success, keeping the peace: conflict management strategies for nurse managers, principles for sustaining shared/professional governance in nursing, workplace incivility: nurse leaders as change agents.

Information

• Author Services

Initiatives

You are accessing a machine-readable page. In order to be human-readable, please install an RSS reader.

All articles published by MDPI are made immediately available worldwide under an open access license. No special permission is required to reuse all or part of the article published by MDPI, including figures and tables. For articles published under an open access Creative Common CC BY license, any part of the article may be reused without permission provided that the original article is clearly cited. For more information, please refer to https://www.mdpi.com/openaccess .

Feature papers represent the most advanced research with significant potential for high impact in the field. A Feature Paper should be a substantial original Article that involves several techniques or approaches, provides an outlook for future research directions and describes possible research applications.

Feature papers are submitted upon individual invitation or recommendation by the scientific editors and must receive positive feedback from the reviewers.

Editor’s Choice articles are based on recommendations by the scientific editors of MDPI journals from around the world. Editors select a small number of articles recently published in the journal that they believe will be particularly interesting to readers, or important in the respective research area. The aim is to provide a snapshot of some of the most exciting work published in the various research areas of the journal.

Original Submission Date Received: .

• Active Journals
• Find a Journal
• Proceedings Series
• For Authors
• For Reviewers
• For Editors
• For Librarians
• For Publishers
• For Societies
• For Conference Organizers
• Open Access Policy
• Institutional Open Access Program
• Special Issues Guidelines
• Editorial Process
• Research and Publication Ethics
• Article Processing Charges
• Testimonials
• Preprints.org
• SciProfiles
• Encyclopedia

Article Menu

• Subscribe SciFeed
• Recommended Articles
• PubMed/Medline
• Google Scholar
• on Google Scholar
• Table of Contents

Find support for a specific problem in the support section of our website.

Please let us know what you think of our products and services.

Visit our dedicated information section to learn more about MDPI.

JSmol Viewer

Factors influencing on problem solving ability of nursing students experiencing simulation practice.

1. Introduction

1.1. background, 1.2. study purpose, 2. methodology, 2.1. study design, 2.2. sampling strategy, 2.3. ethical considerations, 2.4. study methods, 2.5. data collection method, 2.6. data analysis, 3.1. general characteristics of study participants, 3.2. problem-solving abilities according to general characteristics, 3.3. correlation between subjects’ self-leadership, goal commitment, critical thinking, and problem-solving abilities, 3.4. influential factors on problem-solving abilities of nursing undergraduates with the experience of simulated practice training, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

• Victor, J.; Ruppert, W.; Ballasy, S. Examining the relationships between clinical judgment, simulation performance, and clinical performance. Nurse Educ. 2017 , 42 , 236–239. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Nelson, A.E. Methods faculty use to facilitate nursing students’ critical thinking. Teach. Learn. Nurs. 2017 , 12 , 62–66. [ Google Scholar ] [ CrossRef ]
• Yoon, J. Development of an Instrument for the Measurement of Critical Thinking Disposition: In Nursing. Cathol. Univ. 2004 , 26–28. Available online: https://scienceon.kisti.re.kr/srch/selectPORSrchArticle.do?cn=DIKO0011531717&dbt=DIKO (accessed on 30 August 2022).
• Li, S.; Ye, X.; Chen, W. Practice and effectiveness of “nursing case-based learning” course on nursing student’s criticalthinking ability: A comparative study. Nurse Educ. Pract. 2019 , 36 , 91–96. [ Google Scholar ] [ CrossRef ]
• Kelly, M.A.; Berragan, E.; Husebø, S.E.; Orr, F. Simulation in nursing education—International perspectives and cotemporary scope of practice. J. Nurs. Scholarsh. 2016 , 48 , 312–321. [ Google Scholar ] [ CrossRef ]
• Thabet, M.; Eman, E.; Abood, S.A.; Morsy, S.R. The effect of problem-based learning on nursing students’ decision making skills and styles. J. Nurs. Educ. Pract. 2017 , 7 , 108–116. [ Google Scholar ] [ CrossRef ]
• Park, C.-S.; Choi, E.-A.; Kim, M.-K. The Effects of Convergence Simulation Education Applying Problem Solving Process, Communication and Learning Satisfaction of Nursing. J. Digit. Converg. 2019 , 17 , 241–247. [ Google Scholar ] [ CrossRef ]
• Son, J.E.; Kim, S.H. The influence of job stress, self-esteem, and resilience on the field adaptation in newly graduated nurses. J. Korean Clin. Nurs. Res. 2019 , 25 , 151–160. [ Google Scholar ] [ CrossRef ]
• Haskvitz, L.M.; Koop, E.C. Students struggling in clinical? A new role for the patient simulator. J. Nurs. Educ. 2004 , 43 , 181–184. [ Google Scholar ] [ CrossRef ]
• Rhodes, M.L.; CURRAN, C. Use of the human patient simulator to teach clinical judgment skills in a baccalaureate nursing program. CIN Comput. Inform. Nurs. 2005 , 23 , 256–262. [ Google Scholar ] [ CrossRef ]
• Hur, H.-K.; Park, S.-M. Effects of simulation based education, for emergency care of patients with dyspnea, on knowledge and performance confidence of nursing students. J. Korean Acad. Soc. Nurs. Educ. 2012 , 18 , 111–119. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Min, E. The effects of simulation practice education on team-based on proactivity of problem-solving, communication ability, and problem solving process of nursing students. J. Learn.-Cent. Curric. Instr. 2019 , 19 , 71–85. [ Google Scholar ] [ CrossRef ]
• El-Gilany, A.-H.; Abusaad, F.E.S. Self-directed learning readiness and learning styles among Saudi undergraduate nursing students. Nurse Educ. Today 2013 , 33 , 1040–1044. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• O’shea, E. Self-directed learning in nurse education: A review of the literature. J. Adv. Nurs. 2003 , 43 , 62–70. [ Google Scholar ] [ CrossRef ]
• Lee, J.; Lee, Y.; Gong, S.; Bae, J.; Choi, M. A meta-analysis of the effects of non-traditional teaching methods on the critical thinking abilities of nursing students. BMC Med. Educ. 2016 , 16 , 240. [ Google Scholar ] [ CrossRef ]
• Seymour, B.; Kinn, S.; Sutherland, N. Valuing both critical and creative thinking in clinical practice: Narrowing the research–practice gap? J. Adv. Nurs. 2003 , 42 , 288–296. [ Google Scholar ] [ CrossRef ]
• Houghton, J.D.; Neck, C.P. The revised self-leadership questionnaire: Testing a hierarchical factor structure for self-leadership. J. Manag. Psychol. 2002 , 17 , 672–691. [ Google Scholar ] [ CrossRef ]
• Shin, Y.; Kim, M.-S.; Han, Y.-S. A study on the validation of the Korean version of the revised self-leadership questionnaire (RSLQ) for Korean college students. Korean J. Sch. Psychol. 2009 , 6 , 313–340. [ Google Scholar ] [ CrossRef ]
• Klein, H.J.; Wesson, M.J.; Hollenbeck, J.R.; Wright, P.M.; DeShon, R.P. The assessment of goal commitment: A measurement model meta-analysis. Organ. Behav. Hum. Decis. Process. 2001 , 85 , 32–55. [ Google Scholar ] [ CrossRef ]
• D’Zurilla, T.J.; Maydeu-Olivares, A. Conceptual and methodological issues in social problem-solving assessment. Behav. Ther. 1995 , 26 , 409–432. [ Google Scholar ] [ CrossRef ]
• Choi, Y. A study of the reliability and validity of the social problem solving inventory-revised (SPSI-R). Korean J. Clin. Psychol. 2002 , 21 , 413–428. [ Google Scholar ]
• Cha, K.-S.; Jun, W.-H.; Hong, S.-S. Problem solving ability and social anxiety in nursing students. J. Korea Contents Assoc. 2014 , 14 , 324–333. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Yang, S.-A. Critical Thinking Disposition and Problem Solving Ability in Nursing Students. J. Korean Acad. Nurs. Adm. 2010 , 16 , 389–398. [ Google Scholar ] [ CrossRef ]
• Chaung, S.-K. Critical thinking disposition, problem solving ability, and clinical competence in nursing students. J. Korean Acad. Fundam. Nurs. 2011 , 18 , 71–78. [ Google Scholar ]
• Aubé, C.; Brunelle, E.; Rousseau, V. Flow experience and team performance: The role of team goal commitment and information exchange. Motiv. Emot. 2014 , 38 , 120–130. [ Google Scholar ] [ CrossRef ]
• Han, Y.; Park, Y. Effects of self-leadership and job involvement on clinical competence in general hospital nurses. J. Korean Acad. Nurs. Adm. 2013 , 19 , 462–469. [ Google Scholar ] [ CrossRef ]
• Tucker, A.L.; Edmondson, A.C.; Spear, S. When problem solving prevents organizational learning. J. Organ. Change Manag. 2002 , 15 , 122–137. [ Google Scholar ] [ CrossRef ]
• Kim, J.-H.; Park, M.-K. Factors influencing the process of problem solving in nursing students during clinical practice. J. Korean Acad. Soc. Nurs. Educ. 2012 , 18 , 34–42. [ Google Scholar ] [ CrossRef ]
• Lee, K.E.; Kim, S.M.; Choi, E.H. Problem Solving Ability, Learning flow, and Debriefing Satisfaction according to Self-leadership of Nursing Students Participated in Simulation Training. Korean Assoc. Learn.-Cent. Curric. Instr. 2017 , 17 , 219–234. [ Google Scholar ] [ CrossRef ]
• Kim, J.; Kim, Y. The effects of simulation practice education applying problem-based learning on problem solving ability, critical thinking and learning satisfaction of nursing students. J. Korea Contents Assoc. 2016 , 16 , 203–212. [ Google Scholar ] [ CrossRef ]
• Kanbay, Y.; Okanlı, A. The effect of critical thinking education on nursing students’ problem-solving skills. Contemp. Nurse 2017 , 53 , 313–321. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Song, J.-H.; Woo, J.-H. The Effect of Simulation Practical Education of Nursing Students at University. J. Converg. Inf. Technol. 2021 , 11 , 75–84. [ Google Scholar ] [ CrossRef ]

Share and Cite

Jo, H.H.; Hwang, W.J. Factors Influencing on Problem Solving Ability of Nursing Students Experiencing Simulation Practice. Int. J. Environ. Res. Public Health 2022 , 19 , 11744. https://doi.org/10.3390/ijerph191811744

Jo HH, Hwang WJ. Factors Influencing on Problem Solving Ability of Nursing Students Experiencing Simulation Practice. International Journal of Environmental Research and Public Health . 2022; 19(18):11744. https://doi.org/10.3390/ijerph191811744

Jo, Hyun Hee, and Won Ju Hwang. 2022. "Factors Influencing on Problem Solving Ability of Nursing Students Experiencing Simulation Practice" International Journal of Environmental Research and Public Health 19, no. 18: 11744. https://doi.org/10.3390/ijerph191811744

Article Metrics

Article access statistics, further information, mdpi initiatives, follow mdpi.

Subscribe to receive issue release notifications and newsletters from MDPI journals

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Problem solving in nursing practice: application, process, skill acquisition and measurement

Affiliation.

• 1 King's College, University of London, England.
• PMID: 8320382
• DOI: 10.1046/j.1365-2648.1993.18060886.x

This paper analyses the role of problem solving in nursing practice including the process, acquisition and measurement of problem-solving skills. It is argued that while problem-solving ability is acknowledged as critical if today's nurse practitioner is to maintain effective clinical practice, to date it retains a marginal place in nurse education curricula. Further, it has attracted limited empirical study. Such an omission, it is argued, requires urgent redress if the nursing profession is to meet effectively the challenges of the next decade and beyond.

PubMed Disclaimer

Similar articles

• The perceived problem-solving ability of nurse managers. Terzioglu F. Terzioglu F. J Nurs Manag. 2006 Jul;14(5):340-7. doi: 10.1111/j.1365-2934.2006.00551.x. J Nurs Manag. 2006. PMID: 16787468
• Problem-solving skills of senior student nurses: an exploratory study using simulation. Roberts JD. Roberts JD. Int J Nurs Stud. 2000 Apr;37(2):135-43. doi: 10.1016/s0020-7489(99)00064-4. Int J Nurs Stud. 2000. PMID: 10684955
• Clinical problem-solving in nursing: insights from the literature. Taylor C. Taylor C. J Adv Nurs. 2000 Apr;31(4):842-9. doi: 10.1046/j.1365-2648.2000.01342.x. J Adv Nurs. 2000. PMID: 10759980 Review.
• Knowledge-driven problem-solving models in nursing education. Chowlowski KM, Chan LK. Chowlowski KM, et al. J Nurs Educ. 1995 Apr;34(4):148-54. doi: 10.3928/0148-4834-19950401-04. J Nurs Educ. 1995. PMID: 7782881 Review.
• Responsible education for today's professional nurses. Bartels JE. Bartels JE. J Prof Nurs. 1997 Jan-Feb;13(1):4. doi: 10.1016/s8755-7223(97)80018-x. J Prof Nurs. 1997. PMID: 9183104 No abstract available.

Publication types

• Search in MeSH

LinkOut - more resources

Full text sources.

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

• LOGIN / FREE TRIAL

‘The challenges facing nurse education must be tackled’

STEVE FORD, EDITOR

• You are here: Archive

Thinking your way to successful problem-solving

13 September, 2001 By NT Contributor

VOL: 97, ISSUE: 37, PAGE NO: 36

Jacqueline Wheeler, DMS, MSc, RGN, is a lecturer at Buckinghamshire Chilterns University College

Problems - some people like them, some do not think they have any, while others shy away from them as if they were the plague. Opportunities, in the form of problems, are part of your life.

The most difficult decision is deciding to tackle a problem and implement a solution, especially as it is sometimes easier to ignore its existence. Problem-solving takes time and effort, but once a problem has been addressed the nurse can feel satisfied that the issue has been resolved and is therefore less likely to re-emerge.

Nurses make clinical decisions using two different approaches. The first is the rationalist approach, which involves an analysis of a situation so that subsequent actions are rational, logical and based on knowledge and judgement. The second approach is based on a phenomenological perspective, where a fluid, flexible and dynamic approach to decision-making is required, such as when dealing with an acutely ill patient.

Types of problems

Problems come in different guises and the solver can perceive them either as a challenge or a threat. One of the most common types of problem is when the unexpected happens. As a nurse you plan and implement care for a patient based on your knowledge and experience, only to find that the patient’s reaction is totally different from that expected but without any apparent reason.

Another type of problem is an assignment where others set a goal or task. Throughout your working life you will be required to undertake duties on behalf of other people. For some this is difficult as they feel unable to control their workload. Others see it as an opportunity to develop new skills or take on additional responsibilities. Opportunities can be perceived as problems by those who fear failure.

A third type of problem is when a dilemma arises. This is when it is difficult to choose the best solution to a problem because the nurse is confronted with something that challenges his or her personal and/or professional values.

Diagnosing problems

The sooner a problem is identified and solutions devised, the better for all involved. So try to anticipate or identify problems when they occur through continuously monitoring staff performance and patient outcomes.

Listening to and observing junior staff will help you to detect work or organisational concerns, because when there are problems staff are likely to behave in an unusual or inconsistent manner.

Initial analysis

Remember that people view things differently, so what you perceive as a problem may not be one to anyone else. So before you begin thinking about what to do - whether to keep it under surveillance, contain it or find a solution - you should undertake an initial analysis. This will help you to understand the problem more clearly.

An analysis will also enable you to prioritise its importance in relation to other problems as problems do not occur one at a time.

Routine problems often need little clarification, so an initial analysis is recommended for non-routine problems only. Even then, not all problems justify the same degree of analysis. But where it is appropriate, an initial analysis will provide a basis from which to generate solutions.

Perception is also important when dealing with patients’ problems. For example, if a patient gives up reading because he or she cannot hold the book (objective), the nurse may assume it is because the patient has lost interest (subjective, one’s own view).

Generating solutions

It is essential for the problem-solver to remember that, where possible, solutions must come from those connected with the problem. If it is to be resolved, agreement must be owned by those involved as they are probably the best and only people who can resolve their differences. The manager should never feel that he or she must be on hand to deal with all disputes.

To solve a problem you need to generate solutions. However, the obvious solution may not necessarily be the best. To generate solutions, a mixture of creative and analytical thinking is needed (Bransford, 1993).

Creativity is about escaping from preconceived ideas that block the way to finding an innovative solution to a problem. An effective tool for assisting in this process is the technique of lateral thinking, which is based largely on the work of Edward de Bono, who regards thinking as a skill.

There are several ways to encourage creative decision-making. One method that works best for specific or simple problems is brainstorming. If the ground rules of confidentiality and being non-judgemental are applied, it will produce a free flow of ideas generated without fear of criticism (Rawlinson, 1986).

Time constraints and staff availability may make it difficult for all those involved in a problem to meet. In such cases an adaptation of brainstorming - where a blank piece of paper is given to those involved and each writes down four solutions to the problem - may be the answer. A similar technique is the collective notebook, where people are asked to record their thoughts and ideas about a problem for a specified period.

An alternative is where one person writes down a list of solutions in order of priority, which is then added to by others. This helps to prioritise the ideas generated. All these methods produce data that can then be analysed by the problem-solver.

When the problem affects people in different geographical areas, solutions can be generated by obtaining the opinion of experts through the use of a questionnaire, which is known as the Delphi technique (McKenna, 1994).

When an apparently insurmountable problem presents itself, it is often useful to divide it into smaller pieces. This is known as convergent thinking. Using divergent thinking - where you consider a problem in different ways to expand your view - may also help. 

A final alternative is the stepladder technique, which is time-consuming but effective if the issue is stirring up strong feelings. This requires the people involved in the problem to be organised into groups. First, two people try to solve the problem, then a third member is drawn in, to whom the solution reached by the first two is presented. All three then try to agree a solution. More people are added to the group, if necessary, in a similar way, until there is agreement of all involved. Provided the individuals are motivated to solve the problem, this technique creates ownership and commitment to implementing the agreed solution.

Analytical thinking, which follows a logical process of eliminating ideas, will enable you to narrow the range down to one feasible solution.

Although someone has to make the ultimate decision on which solution to implement, there are advantages to group decision-making: a greater number of possible solutions are generated and conflicts are resolved, resulting in decisions being reached through rational discussion.

This does, however, require the group to be functioning well or the individuals involved may feel inhibited in contributing to the decision-making. One individual may dominate the group or competition between individuals may result in the need to win taking precedence over deciding on an agreed practical solution.

As nursing becomes less bureaucratic individuals are being encouraged to put forward their own ideas, but social pressures to conform may inhibit the group. We do not solve problems and make decisions in isolation, but are influenced by the environment in which we work and the role we fulfil in that environment. If group members lack commitment and/or motivation, they may accept the first solution and pay little attention to other solutions offered.

Making a decision

There are three types of decision-making environments: certain, risk and uncertain. The certain environment, where we have sufficient information to allow us to select the best solution, is the most comfortable within which to make a decision, but it is the least often encountered.

We usually encounter the risk environment, where we lack complete certainty about the outcomes of various courses of action.

Finally, the uncertain environment is the least comfortable within which to make decisions as we are almost forced to do this blind. We are unable to forecast the possible outcomes of alternative courses of action and, therefore, have to rely heavily on creative intuition and the educated guess.

Taking this into consideration, you should not contemplate making a decision until you have all the information needed. Before you make your decision, remind yourself of the objective, reassess the priorities, consider the options and weigh up the strengths, weaknesses, opportunities and threats of each solution.

An alternative is to use the method that Thomas Edison used to solve the problem of the electric light bulb. Simply focus on your problem as you drift off to sleep, and when you wake up your subconscious mind will have presented you with the answer. But bear in mind that this is not a scientific way of solving problems - your subconscious can be unreliable.

If you are not sure about your decision, test the solution out on others who do not own the problem but may have encountered a similar dilemma. Once you have made your choice stick to it, or you may find it difficult to implement because those involved will never be sure which solution is current. They will also be reluctant to become involved in any future decision-making because of your uncertainty.

The next step is to ensure that all the people involved know what decision has been made. Where possible, brief the group and follow this up with written communication to ensure everyone knows what is expected of them. You may need to sell the decision to some, especially if they were not involved in the decision-making process or the solution chosen is not theirs.

Implementing the solution

Finally, to ensure the solution is implemented, check that the people involved know who is to do what, by when and that it has happened. Review the results of implementing your solution (see Box) and praise and thank all those involved.

- Part 1 of this series was published in last week’s issue: Wheeler, J. (2001) How to delegate your way to a better working life. Nursing Times; 97: 36, 34-35.

Next week. Part three: a step-by-step guide to effective report writing.

• Add to Bookmarks

Related articles

Christmas prize gave winner a head start in her studies

As we announce the winner of the Nursing Times Christmas Competition for 2017, we…

Competition winner goes the extra mile to put patients at ease

In December, Nursing Times invited readers to nominate a nurse who makes a real…

Inter-professional education: if we are working together, shouldn’t we be learning together?

As nurses, no matter what our field of practice, we always work…

Special recognition for nurses who treated terror attack victims

Nurses from the hospital trusts that treated the victims of this year’s…

Have your say

Sign in or Register a new account to join the discussion.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Int J Nurs Sci
• v.8(4); 2021 Oct 10

Second-order problem solving: Nurses’ perspectives on learning from near misses

a Peking Union Medical College, School of Nursing, China

Huaping Liu

Gwen d. sherwood.

b The University of North Carolina at Chapel Hill, School of Nursing, NC, USA

Associated Data

Authors declare the absence of shared data in the present study.

Near misses happen more frequently than actual errors, and highlight system vulnerabilities without causing any harm, thus provide a safe space for organizational learning. Second-order problem solving behavior offers a new perspective to better understand how nurses promote learning from near misses to improve organizational outcomes. This study aimed to explore frontline nurses’ perspectives on using second-order problem solving behavior in learning from near misses to improve patient safety.

A qualitative exploratory study design was employed. This study was conducted in three tertiary hospitals in east China from June to November 2015. Purposive sampling was used to recruit 19 frontline nurses. Semi-structured interviews and a qualitative directed content analysis was undertaken using Crossan’s 4I Framework of Organizational Learning as a coding framework.

Second-order problem solving behavior, based on the 4I Framework of Organizational Learning, was referred to as being a leader in exposing near misses, pushing forward the cause analysis within limited capacity, balancing the active and passive role during improvement project, and promoting the continuous improvement with passion while feeling low-powered.

Conclusions

4I Framework of Organizational Learning can be an underlying guide to enrich frontline nurses’ role in promoting organizations to learn from near misses. In this study, nurses displayed their pivotal role in organizational learning from near misses by using second-order problem solving. However, additional knowledge, skills, and support are needed to maximize the application of second-order problem solving behavior when near misses are recognized.

What is known?

• • Near misses present learning opportunities to improve safety, but organizational efforts to learn from near misses often fail.
• • Second-order problem solving behavior (SOPSB) offers a new perspective to understand how individuals promote organizational learning from errors, yet there is limited evidence exploring SOPSB in learning from near misses.

What is new?

• • SOPSB was recognized as actions to prevent the recurrence of near misses, including exposing the occurrence of near misses, pushing forward the cause analysis, trying out improvement projects, and promoting continuous improvement. Inherent in the four actions, nurses were feeling equal parts passionate and low-powered.
• • By using SOPSB, on the one hand, frontline nurses demonstrated their active and pivotal role in learning from near misses. On the other hand, nurses usually felt low-powered when conducting SOPSB due to the characteristics of near misses, scarcities of safety management knowledge and unsupportive working environment.

1. Introduction

Despite decades of focus, patient safety remains a primary health care concern due to the high rate of errors [ 1 ]. Beyond the negative aspect of patient harm, errors can serve as valuable learning resources for organizations by examining why they occur and how they should be prevented. Learning more about errors can help organizations work towards adjustments of strategies and behavior to restructure the system and increase safety [ 2 ]. Although adverse events have long been regarded as an important key to learning, near misses have attracted considerable attention recently. A near miss is defined as an incident which did not reach the patient by chance or timely intervention [ 3 ]. Near misses have garnered attention because they occur more frequently than adverse events -- as much as 7 to 100 times more frequently [ 4 ], allowing for a greater quantitative analysis and learning process. More importantly, near misses have remarkably similar causes with adverse events [ 5 ] and can shed light on system vulnerabilities and suggest preventative strategies without causing harm [ 6 , 7 ], showing great value in optimizing the cost/benefit ratio for investment in patient safety.

Organizational efforts to learn from errors often fail because the role of employees’ behavior in learning has not been fully appreciated [ 8 ]. Few organizations train their employees in effective problem solving behavior as a part of the organization’s approach to learning from critical safety events. Research showed that when faced with problems, “fixing and forgetting” was the predominant problem solving choice made by healthcare workers; those who took actions to solve problems for system-wide learning and solutions were less than 10% [ 8 ].

Based on the concept of organizational learning, Tucker [ 8 ] developed the second-order problem solving behavior (SOPSB) model to exhibit employees’ effort to promote learning from failures. According to Tucker, first-order problem solving behavior manifested as temporarily correcting or only “patching” a problem without any further actions. By contrast, SOPSB emphasized the individuals’ response to problems by investigating the underlying causes and searching for preventative countermeasures. SOPSB has been accepted as an effective approach to successful organizational learning and highlights the important role of the grass-roots employees in safety and quality management as well [ [9] , [10] , [11] ]. For near misses, SOPSB appears particularly practical because the distinctive features of near misses -- less visibility and harmlessness means that organizational learning relies on the problem solving behavior of frontline employees, who hold first-hand information of near misses. However, SOPSB in learning from near misses has received only marginal attention in the literature. Limited knowledge mostly comes from comments of managers or studies that have used quantitative [ 12 , 13 ] and qualitative [ 14 ] approaches to explore near-miss reporting. Although reporting is critical to organizational learning for lasting improvements, it is not enough to get a full sense of the learning efforts just like the SOPSB does. Jeffs indicated that only by reporting problems was to no avail for learning because the problems would go into a black hole without seeking further investigations [ 15 ].

In recent years, China has emphasized the importance of learning from errors, including near misses, by issuing the National Provisions on Medical Quality and Safety and establishing the nationwide adverse events reporting system, which makes the exploration of SOPSB in learning from near misses more necessary. As the last line of defense in preventing patients from being harmed, frontline nurses are in a position to experience more near misses [ 16 ]. They are a primary force of quality and safety management [ 17 ], which makes them an indispensable part in conducting SOPSB to promote organizational learning from near misses. Thus, it is important to understand the nurses’ perceptions and experiences of applying SOPSB to increase organizational knowledge about near misses based on a qualitative approach in pursuit of a naturalistic paradigm. Given this, the findings of this study are meaningful as basic data to develop a comprehensive educational and managerial program. Therefore, the aim of this study was to explore frontline nurses’ perspectives on using second-order problem solving behavior in learning from near misses to improve patient safety.

2. Theoretical framework

Theoretically, we drew on the 4I Framework of Organizational Learning proposed by Crossan [ 18 ]. The framework emphasizes four key steps (intuiting, interpreting, integrating, institutionalizing) and relations in determining how organizational learning happens in the multi-level dynamic process. It shows a range of activities that explain how knowledge produce, transfer and utilize from the individual level to the organizational level. For example, individuals recognize information-based triggers (intuiting), develop models for understanding, bring out the meaning in groups (interpreting), and eventually realize the organizational learning by translating a shared understanding into coordinated action (integrating) and embedded it into work routines (institutionalizing). We chose this particular framework to theoretically underpin the study because it has been well proved and empirically grounded in research of organizational learning [ [19] , [20] , [21] ]. More importantly, it emphasizes the dynamic process of learning and knowledge construction from the individual to the organizational level [ 18 ], which aligns with the aims of this study.

3.1. Study design

A qualitative exploratory design with semi-structured interviews and directed content analysis was employed.

3.2. Participants

Participants were recruited from 19 nursing units in three general tertiary hospitals in east China. Hospitals ranged in size from 1,300 beds to 2,500 beds. A purposive sampling of Registered Nurses was recruited using maximum variation sampling for working experience, educational level and unit. The inclusion criteria were for nurses with at least five-year work experience and have had the experience of near misses during their work. We deliberately recruited senior nurses because of their experience with near misses, relatively higher safety awareness and exposure to SOPSB. Head nurses and managers were not recruited because they do not work in direct care, where most near misses occur and their views on SOPSB may differ from those of frontline nurses. Potential participants were identified in discussion with the corresponding nursing department of the participating hospital. Letters explaining the purpose of the study were then sent to the target nurses who met our inclusion criteria. We obtained written consent from those who were keen to participate. We accepted the suggestion by Sandelowski that the sample size is a matter of quality rather than quantity, and decided the size by the saturation of data [ 22 ]. In this study, saturation was reached after 15 interviews, and a further four interviews were carried out to validate the saturation. Table 1 provides the detail of participants.

Table 1

Characteristics of participants.

3.3. Data collection

Data were collected between June and November 2015 through audio-recorded, face-to-face, and semi-structured individual interviews. Interviews were carried out by the first author, who was a Ph.D. candidate and had been fully trained of qualitative study. Each interview lasted between 45 and 96 min. The interviewer adopted a conversational and emphatic approach. The foci of the interviews began with a general question about near misses that nurses had experienced, followed by a series of questions related to the behavior he/she perceived as SOPSB. Probing questions were added to gain more detailed information, such as ‘please describe what you mean by reward on near-miss reporting’. Table 2 provides examples of frequently asked questions. Considering the participants’ unfamiliarity with the term ‘SOPSB’ might account for a bias, the interviewer first gave a brief introduction of SOPSB, namely, the behaviors that promote learning from working problems or failures. Towards the end of each interview, the participant was asked to state the role of frontline nurses related to the management of near misses, which gave them an opportunity to reflect on their efforts to assure patient safety and enhance their participation in SOPSB. During and immediately after each interview, the interviewer made field notes of the session.

Table 2

Interview guide.

3.4. Data analysis

This study used the qualitative directed content analysis to analyze data, which is a methodology that explores a phenomenon of interest using a theory as a guide [ 23 ]. In this study, Crossan’s 4I Framework of Organizational Learning was employed as a guide to describing the frontline nurses’ perceptions of SOPSB. All digital audio-recording of the interviews were transcribed verbatim (in Mandarin) within 48 h after each interview. After comparing transcripts with audiotapes for accuracy, relevant information such as emotional content was noted from the field notes. All interview transcripts were then analyzed following the suggestions provided by Assarroudi et al. [ 23 ]. The initial coding categories were based on the 4I Framework. The main steps of the directed content analysis included: reading transcripts as a whole to have a feel of the essence of participants’ descriptions of SOPSB; using the 4I Framework as the initial coding categories; selecting participants’ quotes supporting the particular code; reflecting on the central ideas extracted and synthesizing participants’ perceptions; converting participants’ perceptions of SOPSB into a written form.

3.5. Trustworthiness

In this study, method triangulation involving comparing data from transcripts and field notes was used. Throughout the process, two researchers analyzed the data to ensure the investigator triangulation, and any discrepancies were resolved through group discussion. To achieve peer debriefing, researchers discussed the analysis with experts in qualitative research and patient safety, and also applied the results to a group of nurses (including two quality managers and four frontline nurses) in January 2016. Moreover, three randomly selected nurses from the interviews were asked to review the data to reconfirm the accuracy of the results. To further achieve transferability, researchers provided raw quotations from the transcribed text for each category.

3.6. Ethical considerations

The study was approved by the Ph.D. research review board in the relevant Chinese university. Permission to perform the interviews was obtained from the managers of the selected hospitals. Nurses who agreed to participate signed an informed consent form and were informed that they were free to choose the location for the interview and had the right to withdraw at any time. Confidentiality and anonymity were stressed, and any identifying data of persons mentioned in the interviews were deleted from the transcriptions of the audiotapes. The interviewer and participants were mutual strangers before the interview.

4. Findings

In this study, 23 registered nurses were initially invited to participate, 19 agreed to be interviewed. More participants were female (18/19). The nurses’ age ranged between 29 and 40 years old; work experience ranged from six to 21 years.

Categorized according to the 4I Framework, each SOPSB is explained based on the framework and described from the nurses’ perspective ( Table 3 ).

Table 3

Example of the analysis process regarding the nurses’ perception of SOPSB in learning from near misses.

4.1. Intuiting: being a leader in exposing near misses

Participants related that exposing near misses to the responsible persons or departments is an essential part of SOPSB. According to them, only by disclosing the invisible near misses could further action possibly be taken at the organizational level.

“ If you do not expose the near misses that happened, others will never be aware of the problem, let alone take actions to prevent their recurrence. ” (N1, quality supervisor)

Different strategies were employed to expose near misses, which helped focus the managers’ attention on those issues that should be urgently addressed, as well as protected the nurses from being punished. For example, nurses tended to use formal ways like structural reports to disclose near misses of high risk or had other teams involved. Informal chats were commonly used to share near misses with low risk or share those that might cause punishment.

“ The bugs in electronic ordering system may result in serious medication error, so we report it through the official reporting system. ” (N3, RN)

“ If I am the person responsible for a near miss, the most I would do is to tell my colleagues I know well in private. ” (N4, RN)

However, since near misses were hard to gain attention in clinical work, several participants stated that they had taken extra effort to optimize the exposure effect, for example, by calculating the frequency of occurrence before reporting.

“ Near miss did not cause any harm, the managers will not take them seriously without any data about the potential consequence. ” (N1, quality supervisor)

4.2. Interpreting: pushing forward the cause analysis within limited capacity

Participants stated that for both near misses and adverse events, searching for an in-depth explanation of why it happened should be the very core of SOPSB. Only by recognizing the causes could the organization make purposeful and effective changes, especially when the causes come to the system level.

“ The SOPSB refers to my responses to the causes; when I experience a near miss, I look for the causes and then come out with measures. ” (N6, quality supervisor)

For near misses, the cause analysis was often perceived as part of the responsibility of frontline nurses. Self-reflection was reported to be the dominant way.

“ I was the only person who cares about this near miss; I have to think about by myself why this event happened to me rather than others .” (N2, RN)

To further exploit the due role of cause analysis, several participants mentioned that sharing causes with others, especially the stakeholders, was important. In clinical practice, ‘win-win communication’ is a good way to make the patients as well as nurses much safer.

“ We use the WeChat (a favorite instant-communication tool) to let everyone in the unit know why the near miss happened. It would be meaningless if the analysis goes into the black hole. ” (N15, quality supervisor)

However, it was difficult to complete a deep search for the underlying causes. Participants reported that while individual nurses lacked knowledge about causes analysis, near misses also rarely gained collective attention and got few chances to be discussed systematically. In fact, nurses tended to impute the causes of near misses to individuals rather than the flawed system.

“ I think most of the medication near misses are the results of individual carelessness, there is no reason to attribute them to similar look or medicine distribution system. ” (N14, RN)

To compensate for their deficiency in analyzing causes, some nurses were willing to ask for assistance, especially when the investigations of causes would not have detrimental effects on themselves.

“ Although the head nurse sometimes is unaware the near misses happened, I will seek help from her. After all, the cause is a time bomb. ” (N8, RN)

Furthermore, participants stated that the value of near misses has not been fully realized and causes analysis was more typically regarded as the managers’ business. They are concerned about how colleagues and managers treated them during the analysis.

“ Only when the working atmosphere emphasizes the learning from near misses will I do cause analysis, or else others may say you are trying to shift responsibility. ” (N12, RN)

4.3. Integrating: balancing the active and passive role during the improvement project

Suggesting and trying out countermeasures based on causes was reported as the best reflection of SOPSB. Participants expressed that no matter how detailed the analysis was, improving the current work process was the best sign of actually using what was learned from near misses at the organizational level.

“ I think the most critical aspect of SOPSB is changing. Only when the new measures are implemented could indicate our department indeed to learn something from near misses. ” (N1, quality supervisor)

Participants mentioned that due to the no-harm feature of near misses, nurses sometimes had to exert more effort for their ideas to be accepted. In general, the ideas presented with sound current evidence or surveys were more likely to be approved.

“ I prepared a simple payoff-risk report and suggested that the improvement project should focus on the near misses regarding patient identification. ” (N6, quality supervisor)

Although the majority of participants appreciated the chance to participate in the improvement activities, it was reported that showing an overly positive attitude was risky and nurses might be mistaken for those who swerved from the path of own duty.

“ My job is to implement medical orders correctly, and it is improperly to point a finger at the safety and improvement issue, which is beyond the scope of my authority. ” (N5, RN)

In fact, the frontline nurses’ improvement activities were usually limited to making suggestions. Participants mentioned that their autonomy and voice would inevitably be weakened once the countermeasures were applied.

“ Once the suggested measures are accepted, we are expected to complete the task as required, regardless of the personal willingness or idea, our first duty is to get the work done. ” (N3, RN)

4.4. Institutionalizing: promoting continuous improvement with passion while feeling low-powered

For clinical situations, it was unlikely to solve a problem fundamentally once and for all. According to the participants, taking follow-up actions such as giving feedback on the improvement effects was an indispensable part of SOPSB. Most nurses were willing to participate to completely prevent the events from happening again.

“ The value of nurses mainly reflected on the evaluation of the actual effects of countermeasures, because we are those who benefit most from the successful prevention of near misses. ” (N4, RN)

In practice, however, it was hard to evaluate accurately how well the improvement actions had been done. Participants emphasized that nurses were commonly satisfied with the instant effects of new measures; their enthusiasm for evaluating the long-term effects would fade away in busy work, especially for measures of preventing no-harm near misses.

“ As long as the countermeasures are implemented as planned, they indeed have some effects, I think it is enough, and it is unnecessary to dwell too much on the long-term effect. ” (N10, RN)

Besides, participants mentioned that defective improvement measures, such as those developed from inaccurate or ineffective cause analysis, also impede nurses’ participation in the continuous improvement.

“ The patient-missing near miss is caused by the incomplete handover procedure. It is meaningless to evaluate the effect of improving hospital entrance guard system. ” (N16, quality supervisor)

5. Discussion

This study provides a better understanding of SOPSB by showing how nurse individuals act to promote the use of knowledge gained from near misses at the organizational level, including exposing the occurrence of near misses, pushing forward the cause analysis, trying out improvement projects, and promoting the continuous improvement. Inherent in the four actions, nurses were feeling equal parts passionate and low-powered. These findings are congruent with the core idea of the 4I Framework, which holds that individuals’ activities lay the foundation of a successful organizational learning by recognizing and interpreting improvement triggers, as well as transferring knowledge with the purpose of institutionalization [ 18 ].

5.1. Being a leader in exposing near misses to initiate learning

The National Health Service indicated that adequate access to safety data is the basis of learning [ 24 ]. In this study, exposing near misses was recognized as the essential part of SOPSB and laid the foundation for the knowledge transferring to the organizational level, which has been described earlier [ 10 , 25 ]. Paparella held that the learning value of system-based failures remained unreachable without reporting [ 11 ]. Although most participants in this study lacked a deep understanding of the value of near misses and the improvement process, they commonly regarded the near misses as a deviation from normal and should be reported, which confirms the notion in 4I Framework that the individuals’ preconscious recognition of differences marks the beginning of organizational learning [ 18 ].

While it was generally reported that nurses held an inactive attitude towards error reporting [ 16 , 26 , 27 ], this study identified that frontline nurses have a leading role in exposing near misses, mainly reflected in their efforts to optimize the exposure effect. For example, nurses used different ways of exposing near misses based on the risk of near misses. This leading role can be explained by the nurses’ deeper understanding of the potential risks of near misses and the necessity of improvement since they are the last line of defense for safety. Another reason may be the less requirement of personal ability to expose near misses. However, as the international studies reported that the fear of punishment was a deterrent to nurses’ participation of error reporting [ 16 , 27 ], our study showed that a non-learning working climate, particularly the punitive management style and a dearth of support could reduce nurses’ willingness to take a leading role in exposing near misses, even for near misses with high risk. Cohen et al. [ 10 ] suggested that creating a work environment in which staff felt empowered, convenient and safe to report events was the key to promote SOPSB.

5.2. Pushing forward the cause analysis within limited capacity to validate learning

Cause analysis has been recognized as the critical step to generate knowledge from errors by identifying the potential risks and improvement opportunity [ 18 ]. This study found that recognizing the underlying causes was the core aspect of SOPSB and laid the foundation of the following activities, which has been described earlier [ 8 , 11 ]. Crossan et al. [ 18 ] indicated in the 4I Framework that developing explanations about learning opportunities is the sign of knowledge production and the real beginning of learning. Although the cause analysis was typically reported as the managers’ work, this study suggested that for near misses, cause analysis was sometimes recognized as an in-role duty of nurses. The main reason is that nursing work is more likely to be disrupted by near misses and nurses have first-hand access to the useful data regarding causes. Besides, as Sarvadikar et al. [ 28 ] reported, nurses had a higher expectation of being blamed than doctors when an error occurred, which may also inspire the nurses’ passion for cause analysis. The third reason might be that the selected hospitals in this study are well respected for their efforts in establishing patient safety culture; it has been reported that in organizations grounded in safety culture, the focus is on the how of errors rather than placing blame on who . Furthermore, the 4I Framework showed that a shared understanding of the interpretation of cause promotes learning at the organizational level. Likewise, this study demonstrated the nurses’ efforts in learning from near misses by communicating causes, such as discussing and transmitting the causes across the organization, which was consistent with earlier studies that sharing ideas about the causes of problems was the valuable part of SOPSB [ 8 , 9 ]. Therefore, an open and smooth cross-boundary communication channel is needed to facilitate organizational learning from near misses.

However, despite the nurses’ passion in cause analysis of near misses, there are still challenges, especially when it comes to system problems. The main barrier might be that since near misses do not cause actual harm, they rarely get chances to be discussed deeply within professional groups just like the adverse events, which makes the analysis mainly depends on individual ability rather than collective efforts. However, evidence suggests that most health employees including managers lack the necessary knowledge, skills and energy to search deeply and accurately into the underlying causes [ 29 ]. Besides, a dearth of support and the organizations’ overemphasis on individual vigilance to ensure safety might be another reason. The Chinese traditional culture typically encourages self-criticism rather than examining the system process when an error occurs, which also helps explain why self-reflection became the primary way of analysis in this study. These findings can be considered as part of recommendations for providing comprehensive system-based safety education to increase the nurses’ effective participation in cause analysis.

5.3. Balancing the active and passive role during improvement project to explicit learning

This study found that the trial on working improvement was viewed as the best reflection of SOPSB. Participants reported that only when the countermeasures were identified and brought into effect could the near misses be possibly prevented, which has been reported earlier [ 8 , 9 ]. This finding demonstrates the notion in the 4I Framework that identifying and implementing a coordinated action was the symbol of learning at the organizational level [ 18 ]. Although the nurses’ efforts in improving work have not been well documented in Chinese hospitals, several participants in this study expressed a strong desire for trying out countermeasures to fundamentally solve near misses. This enthusiasm might come from nurses’ being tired of the disruption of recurrent near misses and the fear of the potential consequences. But meanwhile, participants reported that nurses are mostly passive followers and have limited autonomy during improvement process, which may be a result of the traditional work pattern dominated by managers. The previous studies showed that nurses generally felt their role was unimportant in quality improvement projects and few were involved in any safety initiative [ 29 , 30 ]. Furthermore, this study showed that nurses were sometimes criticized for their high enthusiasm in improvement activities, especially by those with a more passive view. This has been rarely reported because the idea of fully participating in quality management has long been advocated. This finding is understandable in China since nurses are commonly viewed as the passive performers of physicians’ order, and the traditional culture advocates that people should know their distance or place, with low tolerance for employees who are perceived as horning in on management work. These findings raise the question of whether the failure of learning from near misses lies with the employees’ poor activities or the lack of management support, and a culture change may be needed.

5.4. Promoting continuous improvement with passion while feeling low-powered to achieve a successful learning

Results of this study showed that in complex clinical work, key elements of SOPSB are the continuous evaluation and improvement of measures. Other studies likewise confirm that promoting long-term change should be an important part of SOPSB [ 9 , 25 ]. Phimister et al. [ 31 ] indicated that only through continuous evaluation and feedback could practice be pushed to a higher level and fundamentally solve near misses. From a theoretical standpoint, the 4I Framework supports that embedding coordinated action into work systems acts as the symbol that learning really happened at the organizational level [ 18 ].

Due to the high risk of being involved in accidents caused by invalid countermeasures, many participants in this study appreciated the continuous improvement and voiced concern about how their suggested actions were integrated into work routines. However, the work of continuous improvement sometimes got bogged down in clinical work and did not realize the intended effect. Considering the characteristics of near misses and the current working environment, the ‘instant gratification’ and ‘discounted countermeasures’ might be the main reasons. On the one hand, the no-harm feature of near misses diminishes the overall concern about the necessity of continuously improving work. Additionally, the busy clinical work and limited authority perceived by nurses also make them feel content with the instant effect of countermeasures in the short run. White et al. [ 32 ] reported that nurses generally found it difficult to find time for improvement without additional resources. On the other hand, due to a lack of knowledge, skills, or resources, the planned improvement measures are sometimes inaccurately implemented or discounted, making it difficult to evaluate the real preventative effects and improve the work further. These findings emphasize the importance of setting up an effective evaluation and feedback mechanism, thus ensure the measures take place as expected and increase the nurses’ awareness of continuous improvement.

5.5. Limitations and future research

Participants in this study may have been excessively positive in their perceptions because no one else had previously asked them what they thought about near misses and SOPSB, and they seemed to expect some routes for their concerns to be taken seriously. Besides, to compensate for the nurses’ inaccurate understanding of near misses and SOPSB, this study selected participants in high-quality tertiary hospitals who had more chances to access the relevant content in staff training. However, on the other hand, the purposive sampling might influence the findings’ automatic extrapolation to the lower-level healthcare settings. Moreover, it is difficult to comment on our findings in relation to the previous literature as the absence of comparable studies.

Despite these limitations, the insights gained from this study still generated robust evidence for practice and provided a good foundation on which to build further studies. The findings provide evidence that validates the link between nurses’ practice of learning from near misses and the 4I Framework, which can be used as a foundation to further develop educational materials and management programs to implement the 4I Framework in clinical work, thus, to improve the learning effect from near misses. Besides, this study has pinpointed many particular items regarding the nurses’ sense of SOPSB in learning from near misses, which can be amalgamated into an instrument and lay the foundation for the quantitative study. Moreover, this study incorporated nurses as a whole rather than distinguishing them between have and have not truly experienced near misses; future studies are suggested to explore different perspectives on these two nurse groups.

6. Conclusion

Learning from near misses is a critical but challenging aspect of patient safety. This study underpinned theoretically by the 4I Framework to demonstrate how the front-line nurses promote organizational learning from near misses through the lens of SOPSB. Since nurses expressed equal parts passionate and low-powered regarding SOPSB in learning from near misses, this study highlighted the importance of developing a near-misses-based education and establishing learning, supportive working environment, thus improve the learning effect from near misses and promote patient safety.

Data availability statement

This work was supported by National Health Commission of the People's Republic of China, China [Number: 201502017] and the Peking Union Medical College, School of Nursing, China [Grant Number 2015002017].

CRediT authorship contribution statement

Yi Yang: Conceptualization, Investigation, Data curation, Software, Formal analysis, Writing – original draft. Huaping Liu: Supervision, Methodology, Validation, Data curation, Writing – review & editing, Funding acquisition. Gwen D. Sherwood: Methodology, Writing – review & editing.

Declaration of competing interest

The authors have declared no conflict of interest.

Acknowledgments

The authors gratefully acknowledge all the participants in this study for their time to participate in the study and providing valuable information. The authors would also like to acknowledge Prof. Xinjuan Wu for her professional assistance in conducting this research.

Peer review under responsibility of Chinese Nursing Association.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2021.08.001 .

Appendix A. Supplementary data

The following is the Supplementary data to this article: