Are We Successfully Training New Nurses to Think Like a Nurse?

April 1, 2021
April 1, 2021

This blog post is the first in a series about improving clinical judgment in newly hired nurses.

The challenge for nursing schools to teach their learners how to think like a nurse is a significant one. This was one of the focus areas during a recent HealthStream webinar, Improving Clinical Judgment in New Nurse Hires to Improve Patient Outcomes. The presenters for this webinar were Dr. Linda Caputi, a nursing education consultant, and Elease Caracci, Senior Product Manager at HealthStream. Caputi has over 30 years of teaching experience at all levels of nursing education. She is a certified nurse educator and a fellow in the NLN's Academy of Nursing Education. Having published numerous books, articles, and book chapters, Caputi’s latest work is Think Like a Nurse: A Handbook, published in 2018. Elease Caracci joined HealthStream in 2016 with our acquisition of NurseCompetency and is now a senior product manager. Caracci's background in healthcare staffing, educational planning, and curriculum development, along with her management expertise, have made her a multi-faceted performer within the healthcare industry.

Caputi told listeners that “The message I have heard from healthcare throughout my 30 years in nursing education and continuing today is the request for schools of nursing to include teaching thinking in their programs.” She is accustomed to hearing this as yearly feedback from schools of nursing all over the country. Caputi added that this feedback is not just anecdotal—there are multiple sources that identify this need for nursing education.

As evidence, she cited 2005 research by nursing icon Dorothy Del Bueno that only “35% of new graduate RNs, regardless of their educational preparation as ADN, BSN, or diploma graduates, could think at entry levels required for safe practice.” Even though these candidates had already passed the NCLEX, 65% of them were deficient in their thinking ability.

Caputi went on to mention a 2009 study from the Nursing Executive Center, which identified thinking ability and related actions as new graduate competencies with the lowest scores. Here are some specific thinking skills measured in newly hired nurses and the low percentages of candidates nurse leaders found to be satisfactory:

  • New hires’ decision-making: 20%
  • Ability to conduct appropriate follow-up: 19%
  • Recognition of changes in a patient’s status: 19%
  • Ability to take initiative: 19%
  • Interpretation of assessment data: 19%
  • Ability to prioritize: 12%
  • Ability to anticipate risk: 11%
  • Delegation of tasks: 10%

Other research identifying this problem includes the National Council State Boards of Nursing (2013), which reported that 50% of new graduates had made errors, 65% of those errors were due to poor decision-making, and 80% of employers were not satisfied with the thinking abilities of new graduates. More current research from the Cleveland Clinic (2017) echoes Del Bueno, “finding that the percent of new graduates' thinking at entry levels required for safe practice is now down to 24%.” That number indicates an even larger deficit and an 11% drop in ten years.

Caputi ended her discussion of needing to improve how nurses are taught to think by mentioning that the studies identifying these deficits involved thousands of new graduates, giving greater weight to their findings. Furthermore, if this problem is one identified over more than a decade, she asked that we “consider these results across time and their relationship to the current evidence on patient outcomes.” Caputi links the lack of judgment skills to the ability to “recognize clinical deterioration, which can result in compromised patient safety.”

Find the webinar recording here.