critical thinking nurses article

The Value of Critical Thinking in Nursing

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

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

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

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

How Do Nurses Use Critical Thinking?

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

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

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

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

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

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

Top 5 Ways Nurses Can Improve Critical Thinking Skills

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

Case-Based Approach

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

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

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

Practice Self-Reflection

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

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

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

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

Develop a Questioning Mind

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

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

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

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

Practice Self-Awareness in the Moment

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

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

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

Use a Process

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

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

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

Common Critical Thinking Pitfalls in Nursing

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

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

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

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

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

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

An Essential Skill for All Nurses

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

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

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

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

How does nursing school develop critical thinking skills?

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

Do only nurse managers use critical thinking?

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

Meet Our Contributors

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

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

Jenna Liphart Rhoads, Ph.D., RN

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

Nicholas McGowan, BSN, RN, CCRN

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

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The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice. Nurses’ ability to recognize and respond to signs of patient deterioration in a timely manner plays a pivotal role in patient outcomes (Purling & King 2012). Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events (Tomlinson, 2015). The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement. Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010). At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction.

The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.

As lifelong learners, nurses are constantly accumulating more knowledge, expertise, and experience, and it’s a rare nurse indeed who chooses to not apply his or her mind towards the goal of constant learning and professional growth. Institute of Medicine (IOM) report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice. American Nurses Association (ANA), Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice (p.26)

Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier

The future of nursing: Leading change, advancing health, (2010). https://campaignforaction.org/resource/future-nursing-iom-report

Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today. 30(6), 515-520.

NMC (2010) New Standards for Pre-Registration Nursing. London: Nursing and Midwifery Council.

Purling A. & King L. (2012). A literature review: graduate nurses’ preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23–24), 3451–3465

Thompson, C., Aitken, l., Doran, D., Dowing, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50 (12), 1720 - 1726 Tomlinson, J. (2015). Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Medical Education, 15(103)

Competing interests: No competing interests

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Critical thinking in nursing: an integrated review

Affiliation.

• 1 Summa Health System, Akron, Ohio 44304, USA.
• PMID: 15835580
• DOI: 10.3928/0022-0124-20050301-05

Critical thinking skills are essential to function in today's complex health care environment and to ensure continuing competence for the future. This article provides a review of various definitions and research studies related to critical thinking. Educators and researchers need to clearly define critical thinking, because there has been wide variation in definitions and descriptions of critical thinking. Research studies have shown inconsistent findings, and many have used a one-group pretest-posttest design over a single course or during the length of a nursing program. Studies have not shown an association between critical thinking and competence; rigorous research studies are needed to understand the process of critical thinking.

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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.

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CRITICAL THINKING

Strategies for clinical practice.

Bittner, Nancy Phoenix MSN, RN, CCRN; Tobin, Elizabeth MS, RN

Nancy Phoenix Bittner, MSN, RN, CCRN, is Lecturer and Clinical Faculty, Regis College, Weston, Massachusetts, and Critical Care Nurse, Neponset Valley Health Systems, Norwood, Massachusetts.

Elizabeth Tobin, MS, RN, is Lecturer and Clinical Faculty, Regis College, Weston, Massachusetts.

Address for reprints: Nancy Phoenix Bittner, MSN, RN, CCRN, Division of Nursing, 235 Wellesley Street, Weston, MA 02193-1561.

Critical thinking is an elusive concept. As a profession, nursing has yet to accept a universal definition of critical thinking. Despite the lack of consensus, nurse leaders in academia and practice settings overwhelmingly agree that critical thinking is essential. It is clear, considering the healthcare environment, nurses need to use critical thinking as a process for decision making in the clinical arena. This article clarifies critical thinking in practice by illuminating the imperative role it plays. Suggestions for fostering critical thinking, including specific strategies, provide a framework for practice.

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• Published: 26 June 2024

Cognitive influencing factors of ICU nurses on enteral nutrition interruption: a mixed methods study

• Huiling Pan 1 , 2 ,
• Chuanlai Zhang 1 , 2 ,
• Ruiqi Yang 1 , 2 ,
• Peng Tian 1 , 2 ,
• Jie Song 1 , 2 &
• Zonghong Zhang 1 , 2  

BMC Nursing volume  23 , Article number:  433 ( 2024 ) Cite this article

Metrics details

The incidence of clinically avoidable enteral nutrition interruptions is high. ICU nurses, as the implementers and monitors of enteral nutrition, have a close relationship between their cognitive level of enteral nutrition interruption and the incidence of enteral nutrition interruption. The level of ICU nurses’ cognition of enteral nutrition interruption and the key factors influencing the level of ICU nurses’ cognition of enteral nutrition interruption are not known.

This study aims to explore the cognitive level of ICU nurses on enteral nutrition interruption and delve into the key factors that affect their cognitive level from the perspective of management.

A sequential explanatory mixed methods research design was used.

With the convenience sampling method, an online survey questionnaire was distributed to ICU nurses in Chongqing, and 336 valid questionnaires were collected. After the survey, ICU managers were invited to participate in qualitative interviews, in which 10 participants from five hospitals completed face-to-face individual semi-structured interviews and were analyzed with thematic analysis.

The survey found that ICU nurses had a good level of cognition towards enteral nutrition interruption but poor knowledge about the definition, causes, and consequences of enteral nutrition interruption, as well as negative attitudes toward active learning, assessment, and communication. And the longer work time in the ICU, joining the nutrition team, receiving systematic training, and acquiring relevant knowledge from academic journals more frequently were favorable to improving ICU nurses’ knowledge level of enteral nutrition interruption. Personal interviews further identified the key factors affecting their cognitive level, including (1) lack of knowledge, (2) lack of proactive thinking, (3) lack of enteral nutrition management programs, and (4) lack of quality management tools for enteral nutrition interruption.

Although ICU nurses demonstrate a relatively high level of cognition, there is still room for improvement. ICU administrators must take specific measures to improve the knowledge of ICU nurses, especially in non-tertiary hospitals, in order to prevent nurse-induced enteral nutrition interruption in all ICUs and improve medical quality.

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Not applicable.

Peer Review reports

Introduction

Critically ill patients often experience physiological, pathological, and metabolic disorders that limit nutritional intake, and the prevalence of malnutrition is as high as 38–78% [ 1 ]. Malnutrition refers to a state of energy or nutrient deficiency caused by inadequate intake or utilization barriers [ 2 ], and it is a major factor contributing to adverse clinical outcomes for patients. Studies have found [ 3 , 4 , 5 ] that malnutrition in ICU patients increases the incidence of complications such as ICU length of stay, days of mechanical ventilation, infections and organ failure, and mortality. Therefore, nutritional therapy is particularly important in the management of critically ill patients.

Enteral nutrition (EN) has become the preferred nutritional support treatment for ICU patients due to its alignment with normal physiological metabolic processes [ 6 ]. Guidelines recommend [ 6 , 7 ] that ICU patients should receive 80–100% of their target feeding volume within 3–7 days of initiating EN. 60–75% of patients in the ICU, however, as shown in several studies [ 8 , 9 , 10 ], do not reach the target feeding volume. Research [ 10 ] has found that the feeding deficiency rates were 54% and 15% ( p  < 0.001) on trial days with and without enteral nutrition interruption (ENI), respectively, indicating a positive correlation between ENI and insufficient feeding.

Enteral nutrition interruption (ENI) [ 11 ] is defined as an interruption of EN lasting 1 h or more with continuous enteral feeding or if the patient does not receive the expected amount of nutrients within 30 min with intermittent enteral feeding. Studies have found [ 10 ] that the average ENI time for ICU patients is up to 12 (6–24) hours per day. The causes of ENI are underestimated target feeding volumes, feeding intolerance, medical procedures, etc., which can be divided into patient factors and subjective factors [ 12 , 13 ]. Among these, avoidable subjective factors related to medical operations account for approximately 72% of the total time of ENI [ 14 , 15 ]. This is related to multiple factors such as physicians, nurses, frontline administrators, and healthcare institution management. ICU nurses, as the primary role in EN screening, assessment, implementation, monitoring, and complication intervention, are closely related to the occurrence of ENI in patients [ 16 ]. Studies have shown [ 17 ] that nurses not starting EN in a timely manner after medical procedures or outpatient examinations are the primary cause of ENI.

The Theory of Reasoned Action [ 18 ] proposes that individuals make behavioral decisions through rational thinking, and this decision-making process is influenced by various factors such as knowledge, attitude, and social environment. Thus, nurse-induced enteral nutrition interruption may be related to their level of knowledge, beliefs, and consequent practice behaviors related to ENI. To explore the current situation of ENI caused by ICU medical staff, previous studies [ 19 ] have examined the cognition of ENI among ICU medical staff in Wuhan. Little study, however, has been found to explore the key factors that affect their cognitive status. Currently, ICU managers lack a unified and standardized EN management plan. Furthermore, ICU nurses and doctors have different levels of knowledge, and nurses interact with patients more frequently, so a questionnaire is needed to evaluate ICU nurses’ cognition of ENI.

ICU manager [ 20 ] refers to the doctor or nurse who is responsible for the daily operation, management, supervision, and improvement of the ICU. ICU managers, as one of the key personnel in the whole link management and quality control of enteral nutrition, usually view problems from an overall perspective, and their perspectives and observations are more objective, in-depth, and comprehensive, which helps us understand the difficulties and challenges of ICU nurses in practice. We, therefore, use a sequential explanatory mixed methods research design [ 21 ] to investigate the cognitive level and influencing factors of ENI among ICU nurses through a cross-sectional survey. Based on the results, we will develop an interview outline to delve into the key factors influencing ICU nurses’ cognition of ENI from the perspective of ICU managers. This will lay the foundation for developing targeted interventions aimed at improving ICU nurses’ cognition of ENI, and provide the basis for improving the EN management program, so as to avoid nurse-induced ENI and improve medical quality.

Methodology

Research design.

A sequential explanatory mixed methods research design [ 21 ] was used that included both quantitative and qualitative research. The interview guide for the qualitative research was developed based on the findings of the quantitative research and served to complement and explain the quantitative results.

Quantitative research

Participants.

Convenience sampling was used to conduct a cognitive survey on ENI among ICU nurses in Chongqing. The recruited object of this study was ICU registered nurses who had worked in general ICUs for at least one year. The first page of the questionnaire describes the purpose of this study and informed consent. Respondents can only access the survey questions after giving informed consent. After completing and submitting the survey, participants were considered to have given informed consent. In addition, researchers can judge according to the basic information filled in by participants to exclude those who do not meet the inclusion criteria. The sample size of this study was at least 193 according to previous similar studies [ 22 ].

Data collection

The scale used in this study is the “ICU Healthcare Providers’ ENI Knowledge, Attitude, and Practice Scale,” developed by the Yuanyuan Mi team in 2022 [ 22 ], which is used to understand the current level of knowledge, attitude, and practice of ENI among ICU medical staff. This scale comprised three dimensions: knowledge, belief, and practice, with 14, 10, and 17 items, respectively, and total score ranges of 14–70, 10–50, and 17–85. Items were rated using a Likert 5-point scale, with 1 indicating “not at all,” 2 “uncertain,” 3 “slightly,” 4 “fairly,” and 5 “completely.” Scores below 4 indicated poor cognitive levels of ENI among ICU nurses; scores equal to or greater than 4 indicated that ICU nurses have a good level of ENI awareness. Reportedly, the Cronbach’s alpha for the original scale was 0.953, the test-retest reliability was 0.795, and the total content validity coefficient was 0.975, indicating that the scale had good reliability and validity. In addition, the Cronbach’s alpha was 0.965 when the scale was retested using data from this study.

In this study, 10 demographic variables and the “ICU Healthcare Providers’ ENI Knowledge, Attitude, and Practice Scale” developed by the Yuanyuan Mi team [ 22 ] were converted into an online questionnaire. A cross-sectional survey was conducted among ICU nurses in Chongqing in October 2023. 366 questionnaires were distributed through the questionnaire star platform, and 366 were recovered, with a recovery rate of 100%. Two researchers checked the content of the questionnaire and the duration of the questionnaire, deleted 30 invalid questionnaires, and finally found 336 valid questionnaires, for an effective rate of 91.8%.

Data analysis

Data were downloaded from the Questionnaire Star platform and analyzed in SPSS 27.0. Statistical significance was set at p  < 0.05. Means (standard deviations) and frequencies (percentages) were used for descriptive statistics. Differences and associations between ICU nurses’ EN cognition scores and demographic variables were analyzed using t-tests, chi-square tests, and binary logistic regression. Pearson’s correlation was used to assess the relationship between the total cognition score and the scores of each dimension.

Qualitative research

Purposeful sampling was used to select ICU EN managers willing to participate in qualitative interviews from hospitals where the questionnaire was administered. Eligible participants included healthcare providers from general ICUs involved in EN management for at least three years and willing to participate in this semi-structured interview. A total of 10 ICU managers were included in this study for personal interviews. Information saturation [ 23 ] was reached at interview 8, meaning that no new themes emerged at the end of the interview process. Two further interviews were conducted to confirm the results.

Data were collected through semi-structured interviews conducted by the first and second authors with participants in December 2023. The interview guide (see to S1 ) was developed by the lead author, guided by the Theory of Reasoned Action [ 18 ], and based on questionnaire results, a review of domestic and international literature, and expert consultation. Participants were contacted by phone before the interview to explain the purpose and significance of the study, obtain informed consent regarding confidentiality principles, recording, and other issues. Interviews were conducted at mutually agreed-upon times, ensuring privacy and a quiet environment. The interview time should be controlled at about 30 min. During the interviews, non-verbal cues such as body language, facial expressions, and tone of voice were observed and recorded along with audio recordings. A pilot interview was conducted with two ICU managers meeting the inclusion criteria before the qualitative study’s implementation, but their data were not included in the final analysis.

Audio recordings and written notes were transcribed verbatim within 24 h of the interview’s conclusion and stored on a computer for backup. Data analysis was based on the Theory of Reasoned Action [ 18 ] and aimed to identify key factors influencing the improvement of ICU nurses’ cognitive levels regarding ENI. A deductive thematic analysis approach [ 24 ] was employed, involving the following steps: (a) familiarization with the data; (b) initial code generation; (c) theme search based on initial codes; (d) theme review; (e) theme definition and labeling; and (f) report writing.

Quality control

To ensure reliability, the research team met regularly, and team members reviewed the study data and analysis results. For the quantitative study, the online survey was anonymous. To ensure the authenticity and validity of the questionnaire results, each respondent was given only one chance to answer the questionnaire and was required to answer all the questions before submitting the questionnaire. To prevent the inclusion of low-quality questionnaires, it was assumed that each question would take no less than 2 s to answer, and in combination with the number of demographic characteristics entries (10) and scale entries (41), questionnaires with an answer time of less than 2 min were excluded from this study. The researcher observed and collected the filled-in data through the background of the questionnaire and double-checked the extracted information to ensure the completeness of the information. In the qualitative study, interview transcripts were collected by two research members trained in qualitative research, and one researcher organized the audio-recorded interviews into text within 24 h of the end of the interviews, which was then returned to the interviewees for confirmation by two researchers who repeatedly read and proofread the information. Participant recruitment, interviews, and data analysis were conducted simultaneously to help researchers determine information saturation. No repeat interviews were conducted.

Ethical considerations

Ethical approval was obtained from the ethics committee of the Second Affiliated Hospital of Chongqing Medical University (Ke Lunshen No. (139) in 2023). The front page of the questionnaire sent to potential participants during the quantitative phase had an “informed consent” option, which was clicked on to allow participants to access the electronic questionnaire. Participants who submitted the questionnaire were considered to have obtained their informed consent. Participants in the quantitative phase volunteered their participation, and the questionnaire’s demographic data did not include names. Each participant was assigned a numerical code to ensure the confidentiality of survey responses. In the qualitative phase, participants provided written informed consent, and their interview recordings were analyzed anonymously and reported solely for research purposes by the study team.

Quantitative phase

Demographic characteristics of icu nurses.

Among the 366 participants who completed the questionnaire, 336 (91.8%) were considered to have provided valid questionnaires. The mean age of the 336 study subjects was 31.24 ± 5.68 years, ranging from 22 to 59 years old. Among them, 192 (57.1%) nurse had junior professional title, a total of 285 (84.8%) held a bachelor’s degree or higher, and the average ICU working time was 6.88 ± 5.05 years. Most of the nurses worked in tertiary care hospitals [ N  = 212 (63.1%)], but a few were members of the nutrition team [ N  = 83 (24.7%)]. This survey showed that only 54 (16.1%) nurses had received systematic training on knowledge related to enteral nutrition, and only 25 (7.4%) nurses reported that they regularly obtained knowledge related to enteral nutrition from academic journals. (See Table  1 )

Cognitive level of ICU nurses regarding enteral nutrition interruption

As shown in Table  2 , the mean score of ICU nurses’ knowledge of enteral nutrition interruption was 165.04 (22.86), which was higher than 164 (41 × 4), i.e., the cognitive level of ICU nurses regarding ENI was better. On the knowledge dimension, the mean score of ICU nurses’ knowledge of the definition, causes, and consequences of ENI was lower than 4, which was poor in this area; while " Unless contraindicated, the head of the bed should be elevated by 30–45° during EN administration to critically ill patients " and “When the medical and nursing-related examination, diagnosis, and treatment procedures are completed, enteral nutrition feeding should be resumed in a timely manner” had the highest scores, which were both higher than 4, indicating better knowledge in this area. The mean scores of ICU nurses in the belief dimension of ENI were all higher than 4, indicating better beliefs. On the behavioral dimension, ICU nurses scored higher than 4 on all behaviors except for lower scores on active learning about ENI, active patient assessment, and communication with physicians.

Pearson’s correlation analysis among knowledge, belief, and behavior dimensions

As shown in Table  3 , there was a strong positive correlation between the total cognitive score and the scores for the knowledge, belief, and behavior dimensions ( r  = 0.830, 0.766, and 0.850, respectively, P  < 0.01). There was also a positive correlation between the knowledge dimension score and the scores for the belief and behavior dimensions ( r  = 0.487 and 0.549, respectively, P  < 0.01). Furthermore, there was a positive correlation between the belief dimension score and the behavior dimension score ( r  = 0.535, P  < 0.01).

Univariate analysis of knowledge, belief and behavior against demographic characteristics

ICU nurses were deemed to have a low cognitive capacity about ENI if they received a single-item score of less than 4. Therefore, a cutoff value of ≥ 4 was used to categorize the participants’ total cognitive scores, knowledge dimension scores, belief dimension scores, and behavior dimension scores into two categories: low (= 0) and high (= 1). These were used as dependent variables. Univariate analysis of ICU nurses’ demographics and cognitive scores showed that age, nutrition team membership, and frequency of acquiring relevant knowledge from academic journals were associated with ICU nurses’ level of cognition about ENI; professional title, nutrition team membership, systematic training, and frequency of acquiring relevant knowledge from academic journals were associated with ICU nurses’ knowledge scores about ENI; and frequency of acquiring relevant knowledge was associated with ICU nurses’ ENI belief dimension and behavioral dimension scores. A P-value of < 0.05 was considered statistically significant. (See Table  4 )

Factors associated with improving ICU nurses’ cognitive level

Variables with a P-value of < 0.10 from the univariate analysis were included as independent variables in a logistic regression model. The results showed that a high frequency of reading academic journals was a facilitating factor for improving ICU nurses’ cognitive level regarding ENI. Additionally, longer work time in the ICU, participation in nutritional groups, receipt of systematic training, and a high frequency of acquiring related knowledge about EN from academic journals were promoting factors for enhancing ICU nurses’ knowledge dimension scores regarding ENI (see Table  5 ).

Qualitative phase

Ten ICU managers with bachelor’s degrees or above, ages ranging from 40 to 53, took part in individual semi-structured interviews from five hospitals. The duration of the interviews was roughly 12–36 min (see to S2 ). Four key factors were identified from qualitative data analysis that influence ICU nurses’ cognitive level regarding ENI: (1) Lack of knowledge; (2) Lack of active thinking; (3) Lack of EN management plans; and (4) Lack of quality management tools for ENI.

Lack of knowledge

According to participants, ENI is common in the ICU and is related to ICU nurses’ lack of knowledge about it. Many nurses are unclear about the definition, causes, and consequences of ENI. As Participant 5 described, ‘Many nurses are not yet aware of the concept of ENI and do not know how long a sustained pumping pause is an interruption of enteral nutrition, so much so that they are not particularly concerned about the time of restarting EN after a pause in EN, which leads to an increase in the duration and frequency of ENI in patients’. Furthermore, many participants stated that many nurses believe that pausing EN for a few hours during continuous enteral feeding does not constitute an interruption because the gastrointestinal tract remains active, which can damage a patient’s gastrointestinal function. Therefore, pausing for a few hours is similar to intermittent enteral feeding, allowing the patient’s intestine to rest. ICU nurses have a vague understanding of the definition and causes of ENI. What’s more, Participant 9 added, ‘Many nurses directly suspend EN when the gastric residual volume (GRV) exceeds 200 mL! Sometimes, when the GRV is assessed to be below 200 mL, the returned nutrient solution is discarded without realizing the relationship between ENI and adverse outcomes related to inadequate feeding’.

Lack of active thinking

Participants believed that the limitations in ICU nurses’ cognitive level regarding ENI were related to their mechanical work and lack of active thinking. Various reasons for ICU nurses’ lack of active thinking were described. Notably, due to limited human resources, ICU nurses, apart from handling doctor’s orders and basic care, also need to deal with emergencies and adverse reactions among critically ill patients, such as resuscitation, vomiting, and diarrhea. At the same time, they need to dynamically assess patients and fill out numerous assessment forms, making their workload heavy. As Participant 5 explained, ‘For example, when ICU nurses administer a doctor’s order of 1000 mL of nutrient solution to a patient, they routinely adjust the feeding speed, mechanically fill out various forms, and habitually assess the patient’s enteral feeding intolerance. If the patient tolerates it, they simply finish the feeding and move on, rarely thinking about whether the patient’s EN feeding has reached their nutritional goals……If the patient is intolerant, they habitually discard the syringe return fluid when the GRV is greater than 200 mL or even 50 mL and directly suspend the patient’s EN!’ Participants felt that ICU nurses, as implementers and monitors of EN, had a diminished sense of active learning as their sense of active thinking weakened. Participant 6 stated, ‘ICU nurses lack knowledge of biochemical indicators related to EN (such as phosphorus), hemodynamics, patients’ total enteral nutrition target, calories, and protein, and believe that nurses do not need to master these, lacking active learning consciousness’. Although many hospitals have EN management teams, most participants stated that team members are not very motivated, often forced to accept tasks, and lack active learning consciousness, which may be related to their lack of demand, competition, and conflict of interest.

Lack of EN management plans

It was evident from the interviews that the management level varies among different medical units, and there is inconsistency in the quality of care provided by doctors and nurses. The absence of standardized EN management plans that can be referred to has limited the improvement of ICU nurses’ cognitive level regarding ENI. For example, there is a lack of solutions to address inconsistencies between theory and practice. Participant 4 described, ‘Nurses are confused about the different gastric residual volume thresholds recommended by multiple guidelines, resulting in behaviors such as suspending EN when the volume exceeds 200mL. There is a lack of regulations regarding GRV thresholds and guidance on how to adjust or reduce the feeding rate in our department’. Participant 1 stated, ‘Nurses are unclear about whether it is necessary to routinely aspirate gastric residuals every 4–6 hours’. Participant 6 added, ‘The department lacks an active feeding strategy for restarting enteral nutrition to promote early active venting of patients’. Furthermore, participants felt that the management of EN in ICU patients requires multidisciplinary collaborative management, but the triad of physicians, nurses, and nutritionists each had their own role and lacked a closely linked management process. Participant 7 described, ‘ICU doctors have better knowledge of nutrition, less consultation with the Nutrition Department is requested, and nutritionists are unable to dynamically assess the EN status of patients in a timely manner, to the extent that it is mostly left to the ICU doctors themselves to determine the problem of patients’ EN compliance’. And participant 3 said, ‘Currently, ICU nurses put a lot of effort into screening, assessment, implementation, monitoring, and complication intervention of EN, and their awareness is gradually increasing (smiled), while physicians are less involved in the management of the EN process!’ What’s more, participants described that the initial nutritional screening assessor varies from ICU to ICU, that some are nurses whereas others are physicians, that it is not yet known who leads the management of EN in ICU patients, and that there is a lack of a collaborative management process between the medical and nursing professions.

Lack of quality management tools for enteral nutrition interruptions

Participants noted that current clinical EN management primarily consists of EN guidelines, implementation procedures, nutritional screening tools, enteral nutrition tolerance assessment forms, and aspiration risk assessment forms. However, there is still a lack of quality management tools specifically designed for ENI. This makes it difficult for ICU nurses to identify avoidable causes of ENIs, which in turn hinders their ability to reduce the occurrence of such interruptions. Participants described some avoidable issues related to ENIs. Participant 6 described, ‘ICU nurses often pause EN when the amount of GRV exceeds 200 mL, lacking a standardized deceleration or reduction in volume’. Participant 2 described, ‘Clinical situations often arise where infusions are not completed within 24 hours……This is attributed to unreasonable infusion speed settings, excessive preoperative fasting durations, forgetting to report to doctors after suspensions, forgetting to restart infusions, and equipment malfunctions.” Although the EN management team has identified issues related to ENIs during the management process, they lack plans for implementation and problem-solving. They expressed a desire to use quality management tools to manage ENIs and reduce those caused by human factors.

Understanding the cognitive level and influencing factors of ICU nurses regarding ENIs is crucial, as their cognition has a direct relationship with achieving the nutritional targets for ICU patients’ EN [ 16 ]. This study helps ICU managers understand the key factors affecting the cognitive level of ICU nurses’ ENI in order to lay the foundation for ICU managers to develop targeted interventions aimed at improving the cognitive level of ICU nurses’ ENI. Analysis of the questionnaire revealed that ICU nurses generally have a good level of cognition regarding ENIs, with a poorer understanding of their definitions, causes, and consequences. Additionally, they exhibited a negative attitude towards actively seeking knowledge, assessing, and communicating. However, there is still room for improvement, such as by joining nutrition groups, receiving systematic training on EN, participating in related academic conferences, and regularly acquiring EN knowledge from academic journals. Based on this, ICU managers further explained the key factors influencing nurses’ cognitive levels: a lack of knowledge regarding ENIs, inactive thinking about achieving EN feeding targets, a lack of management processes for addressing inconsistencies between theory and practice, and a lack of quality management tools for ENIs. These findings provide a basis for ICU managers to improve EN management plans. Therefore, it is recommended that ICU managers accordingly develop targeted interventions aimed at improving ICU nurses’ cognition of enteral nutrition interruptions in order to avoid nurse-induced ENI and improve medical quality.

This study is consistent with the findings of Mi Yuanyuan [ 19 ] et al. that ICU nurses have a better level of ENI cognition. However, this study also found that the number of years working in the ICU and nutrition team members were the influencing factors for the ICU nurses’ ENI knowledge dimension scores. This may be related to the fact that only ICU healthcare workers in tertiary hospitals were included in the study by Mi Yuanyuan [ 19 ] et al. or to the fact that nutrition team members accounted for as much as one-third of the ICU nurses in the study by Mi Yuanyuan [19] et al. This is also a side effect of the unequal levels of ENI awareness among ICU nurses in different levels of hospitals. In the future, more ICU nurses in secondary hospitals can be included to explore the current status of ENI cognitive level of ICU nurses in different grades of hospitals. Furthermore, unlike previous studies [19] , this study conducted qualitative interviews with ICU managers on the basis of a questionnaire survey of ICU nurses, which explored the key factors affecting the cognitive level of ICU nurses’ ENI in more depth and laid the foundation for ICU managers to formulate targeted interventions aiming to enhance the cognitive level of ICU nurses’ enteral nutrition interruption.

In this study, we found that high years of working experience in ICU, joining the nutrition team, receiving systematic training, and a high frequency of acquiring knowledge related to enteral nutrition from academic journals were the contributing factors to increasing the level of ICU nurses’ knowledge of enteral nutrition interruption. The longer the working years, the richer the clinical experience and related knowledge of ICU nurses. However, as shown in this study, nearly half [ N  = 154 (45.8%)] of the ICU nurses had less than 5 years of working experience; therefore, there is an urgent need to improve the level of ICU nurses’ cognition of ENI in other ways in order to balance the level of cognition of ICU nurses with different years of working experience. For example, by joining a nutrition team and receiving relevant systematic training, ICU nurses can be helped to gain a systematic, comprehensive, and in-depth understanding of knowledge related to enteral nutrition and to increase nurses’ awareness of and interest in the interruption of enteral nutrition [ 25 ]. This is to promote proactive thinking by ICU nurses and to improve their scores in proactive learning about interruption of enteral nutrition, proactive assessment of patients, and communication with physicians [ 26 ]. Further, ICU nurses can also compensate for knowledge blindness by frequently acquiring knowledge related to enteral nutrition from academic journals. Academic journals, as authoritative repositories of academic knowledge, have the most cutting-edge knowledge in the field, such as clinical guidelines and original research with practical guidance, and ICU nurses’ frequent acquisition of enteral nutrition-related knowledge from academic journals is conducive to a systematic and in-depth understanding of the guidelines, consensus, original research, and the frontiers of enteral nutrition in order to enhance nurses’ knowledge of enteral nutrition interruption. Therefore, ICU administrators can encourage nurses to join nutrition teams and conduct multi-pathway training to promote nurses’ acquisition of knowledge from academic journals in order to improve ICU nurses’ level of knowledge about enteral nutrition interruptions, as well as to promote nurses’ proactive thinking in order to avoid unnecessary enteral nutrition interruptions.

Nurses are susceptible to the influence of external factors, and procedures and systems are fundamental to regulating nurses’ behavior. The development of enteral nutrition management protocols is beneficial to standardizing ICU nurses’ management of patients with enteral nutritional feedings in order to improve the level of ICU nurses’ perception of enteral nutritional interruption. A national survey [ 27 ] found that enteral nutrition is usually prioritized lower than other urgent care needs for ICU patients. Furthermore, there is a lack of uniform and standardized clinical protocols for enteral nutrition management in critically ill patients [ 28 , 29 ]. This has hindered the improvement of the level of ENI awareness among ICU nurses in different levels of hospitals to a certain extent and is not conducive to the homogenization of ICU healthcare personnel in various healthcare institutions. Enteral nutrition is critical to the recovery of ICU patients [ 4 ]. It is necessary to enhance ICU nurses’ knowledge of enteral nutrition management to facilitate the development of standardized enteral nutrition protocols [ 30 , 31 ]. Currently, the threshold for GRV is not uniform in clinical settings, with 200–500 mL being the most common [ 32 , 33 ]. This is not conducive to ICU nurses’ judgment of GRV thresholds, which may lead to some degree to nurse-induced ENI. Furthermore, guidelines have recommended that routine monitoring of GRV [ 7 ] during the EN may not be necessary, but most clinical nurses still habitually aspirate gastric residual to monitor patients’ gastrointestinal intolerance, which may be related to the ICU nurses’ fear of the risk of patients’ vomiting or aspiration [ 34 ] or to their insufficiently in-depth view of the problem. At the same time, there is currently a clinical controversy over whether the gastric residual aspirates should be returned or discarded [ 35 ]. This may explain, in part, why some ICU nurses currently choose to discard the gastric residual aspirates directly to avoid contamination, and some ICU nurses choose to tie back the gastric residual aspirates to minimize the risk of fluid and electrolyte imbalance in the patient. Therefore, there is an urgent need for the development of standard enteral nutrition management protocols to address the currently controversial issues and to standardize ICU nurses’ behavior regarding enteral nutrition management.

The formulation of the scheme is conducive to standardizing the behavior of nurses, but the optimization of the implementation effect of the scheme requires the application of quality management tools. Currently, there is a lack of quality management tools in clinical practice to monitor the rate of implementation of EN measures [ 5 , 6 ]. Previous studies have shown [ 12 , 13 ] that the reasons for ENI in ICU patients include hemodynamic instability, high GRV, and medical procedures. It is difficult to avoid ENI, but as shown by Kagan et al. [ 36 ], the use of nutritional management feeding platforms (such as the smART + platform) can monitor ICU patients’ ENI in real-time, calculate the amount of compensation needed when restarting, and ultimately help patients reach their EN goal. In other words, most ENIs caused by ICU nurses can be avoided through the use of management tools28. As a fine and process management method, the Plan-Do-Check-Act (PDCA) cycle method is a continuous quality management tool that targets clinical weaknesses, proposes countermeasures, and improves the implementation rate of measures. It has been widely used in ICU quality management [ 37 ]. Therefore, in the future, ICU managers can use quality management tools to dig deeper into the reasons for enteral nutrition interruption, promote the development and implementation of related plans, and solve the problem at the source in order to reduce avoidable enteral nutrition interruption, standardize nurses’ behaviors, and maximize the application of enteral nutrition management programs.

Strengths and limitations

This study boasts both strengths and limitations. Leveraging the advantages of mixed methods research, we delved into the key factors influencing ICU nurses’ cognition of ENI from both the nurses’ and management’s perspectives. This lays the foundation for targeted interventions aimed at enhancing ICU nurses’ understanding of ENI, ultimately aiming to prevent such interruptions caused by the nurses themselves. Rather, we must acknowledge its limitations. Our use of sequential explanatory mixed methods means our ability to explore the critical factors influencing ICU nurses’ cognition of ENI is somewhat limited, but this could be addressed through alternative mixed methods designs. Furthermore, our study sample was limited to a geographical region, potentially limiting the generalizability of our findings. Future research could expand the scope of the investigation. Nevertheless, this study provides novel insights and valuable perspectives for ICU managers to improve their department’s EN management strategies.

Overall, the level of ICU nurses’ cognition of enteral nutrition interruption is good, but there is still room for improvement. ICU nurses can improve the level of knowledge related to ENI and increase their proactive thinking about the management of enteral nutrition target feeding compliance by joining the nutrition team, participating in the systematic training of knowledge related to enteral nutrition, and frequently acquiring knowledge from academic journals. Furthermore, ICU managers should apply a quality management tool for enteral nutrition interruptions and develop targeted interventions aimed at improving ICU nurses’ cognition of enteral nutrition interruptions in order to provide a basis for improving the department’s enteral nutrition management program, so as to avoid nurse-induced ENI and improve medical quality.

Data availability

All data generated or analyzed during the study are available from the corresponding author [Chuanlai Zhang] on request.

Abbreviations

• Intensive care units
• Enteral nutrition
• Enteral nutrition interruption

Gastric residual volume

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Acknowledgements

We would like to thank the nurses who participated in this study.

This work was supported by the Medical Quality (Evidence-Based) Management Research Program (Award No.: YLZLXZ23G107) in 2023 of National Institute of Hospital Administration, National Health and Health Commission of the People’s Republic of China, Kuanren Talents Program of The Second Affiliated Hospital of Chongqing Medical University and Chongqing Municipal Education Commission’s 14th Five-Year Key Discipline Support Project.

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Huiling Pan, Chuanlai Zhang, Ruiqi Yang, Peng Tian, Jie Song & Zonghong Zhang

School of Nursing, Chongqing Medical University, Yuzhong, Chongqing, People’s Republic of China

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Conceptualization, ZCL; Methodology, PHL, ZCL, YRQ, TP, SJ and ZZH; Data curation, PHL, YRQ, TP, SJ and ZZH; Investigation, PHL, ZCL, YRQ, TP, SJ and ZZH; Formal analysis, PHL and YRQ; Writing- Original draft preparation, PHL; Funding acquisition, ZCL; Supervision, ZCL; Resources, TP, SJ and ZZH; Validation, TP, SJ and ZZH; Writing –review & editing, ZCL and YRQ.

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Pan, H., Zhang, C., Yang, R. et al. Cognitive influencing factors of ICU nurses on enteral nutrition interruption: a mixed methods study. BMC Nurs 23 , 433 (2024). https://doi.org/10.1186/s12912-024-02098-2

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Election latest: Rishi Sunak accused of 'behaving badly' in final debate - as he and Keir Starmer get brutal audience question

Follow reaction and fallout from the final head-to-head between the prime minister and Labour leader ahead of polling day on 4 July.

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Thanks for joining us for an extremely busy night here in the Politics Hub, including for the final debate between Rishi Sunak and Sir Keir Starmer before the general election next Thursday.

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And we'll be back from 6am with all the very latest.

Until then - read all the latest from Sky News below:

By  Tim Baker , political reporter, in Nottingham

One of the more amusing moments of the debate tonight was Robert, who told Rishi Sunak he was a "mediocre" prime minister and said Sir Keir's strings were being pulled by senior members of the Labour Party.

He is brought into the spin room by BBC production staff for journalists to talk to.

He tells us that he is a life-long Conservative voter - but at the moment is undecided.

Robert says he has recorded the debate and will be watching it again when he gets home.

However, he reckons he is leaning towards the Conservatives - believe Sir Keir has an "undeclared agenda".

Daisy Cooper, the deputy leader of the Liberal Democrats, has said the UK "deserves so much better" than the leaders' debate held tonight.

Reacting to the clash between Rishi Sunak and Sir Keir Starmer, she said: "Tonight the audience spoke for the nation when they asked: is this really the best we've got?

"Our country deserves so much better than what we watched this evening.

"Liberal Democrats are listening to you and fighting hard for the issues that matter to people. 

"From the NHS to tackling the cost of living, we want a fair deal for our country.”

A Conservative win would mean "five more years of chaos" and Rishi Sunak has shown tonight "just how out of touch he is", Labour's campaign coordinator has said.

Reacting to the leader's debate, Pat McFadden said Sir Keir Starmer "exposed the Tory manifesto as unfunded".

"Keir Starmer and Labour will return politics to public service, putting country before party in stark contrast to partygate and dodgy COVID contracts," he said.

"On 4 July, we have a chance to turn the page and start to rebuild with Labour."

Tonight was an "important moment" for Rishi Sunak as he put his opponent "on the spot", says our deputy political editor Sam Coates .

Coates says he thinks the prime minister would have been "very happy" with his performance - and adds that some of his aides were even "punching the air" after the debate.

It was a performance Mr Sunak "desperately needed earlier in the campaign", he adds.

He says Mr Sunak had a "clear strategy... to demand answers from Keir Starmer on tax and whether it will go up, on welfare and how you get people off benefits, on 'smashing the gangs' and whether the Rwanda policy is needed..."

Coates says Sir Keir provided a "range" of answers as the prime minister sparred with him.

"Sometimes he had specifics, sometimes he did not," he says.

"That strategy, although executed in a way I think that the Conservative Party tonight is very happy with, has nevertheless been judged not decisively in Keir Starmer or Rishi Sunak's favour," says Coates, referring to the YouGov poll showing there was no winner in the final debate of the election (see 21.38 post).

The final TV clash of the election campaign was an ill-tempered shouting match, at least from Rishi Sunak. 

Sir Keir was more measured. More prime ministerial, perhaps?

As he had to as the underdog, Mr Sunak went on the attack from the start until the very end and unveiled a new campaign slogan: "Don't surrender…"

He said it no fewer than 15 times during the 75-minute debate. That’s once every five minutes.

But just like the England-Slovenia Euros match 24 hours earlier, the result was a draw: 50%-50% exactly, according to pollsters YouGov.

At the outset, the PM served notice that he wanted to talk about tax, while Sir Keir wanted to talk about politicians gambling. 

As Mr Sunak read out prepared lines, it was a smart ad lib from Sir Keir that won the first round of applause.

"If you listened to people in the audience a bit more you might not be so out of touch," he said, in a familiar Labour attack line.

But the PM was strong and came out on top in exchanges on illegal migrants crossing the Channel.

One of the best moments came when a member of the audience, Robert, asked a devastating question: "Are you two really the best we’ve got to the next prime minister of our great country?"

By the end, the debate closed out as it began - with Mr Sunak shouting over the Labour leader. It wasn't a good look.

And as the debate ended, there was no handshake between the pair, which is unusual for these TV clashes. 

At least party leaders pretend to be civilised towards each other usually.

There's clearly no love lost between these two - and it showed.

Darren Jones, shadow chief secretary to the Treasury, is among the Labour representatives in the spin room this evening.

He's asked first about his leaked comments that Labour's target for decarbonising the economy will cost "hundreds of billions" of pounds.

Sir David Davis, who sticks around for this encounter, asks why Mr Jones's party "downgraded" their net zero plans.

"Because you guys crashed the economy," the shadow chief secretary responds.

Sunak 'behaved badly' in debate

On the leader's debate, Mr Jones says Sir Keir Starmer came across as "clearly more prime ministerial" - and adds that he thinks Rishi Sunak behaved "quite badly".

"He didn't answer questions that were put to him and was constantly speaking over Keir and Mishal [Husain, the BBC host]."

He denies Sir Keir's remarks that Mr Sunak is out of touch were "below the belt".

"Rishi Sunak is going around the country telling everyone that they've never had it so good... they crashed the economy, people at home know that because they paid the price for it."

Up to spin for the Conservatives is ex-minister David Davis.

"This debate was very important," he says, noting it's the final one before the public decides who to back.

He was a fan of Rishi Sunak's new attack line - the repeated pleas to voters not to "surrender" their borders or finances to Labour. 

"[Sunak has] faced a once-in-a-generation issue in terms of a war in Europe, he's faced a once-in-a-century issue in terms of a pandemic, and he did it with an economy from which we'd inherited massive debts in the past," he adds.

After all that, "he managed to get inflation down from 11% to 2% in six months". 

"The public will look at this and say: 'We've got a difficult world, all sorts of disruptions at home and abroad, who will deal with it the best of these two'?" he says.

"I know who I'll be voting for."

With minutes to go, a group of smiling Labour spinners arrived to watch the final summations.

Darren Jones - under fire for his comments about the cost of going for net zero, revealed in The Telegraph - tells Sky News it's clear who was more prime ministerial during the debate.

He and the other Starmer backers then burst away to the various cameras and microphones to talk up their leader.

Meanwhile, serious faced Conservatives enter from the other end of the room to give their verdicts. 

Tory candidate - and former minister - David Davis says he thinks Rishi Sunak's repetition of the "surrender" phrase will have gone down well.

This just in from YouGov - which has found there was no winner in tonight's BBC leaders' debate, the last of the general election campaign.

Asked who performed best - the results came in exactly 50/50.

Our deputy political editor Sam Coates says there will likely be disappointment in the Conservative ranks over this result.

"Neck-and-neck polling doesn't seem to me like it's going to change the race," he says.

"I think there's a really interesting question about Rishi Sunak's tactics, in my view, watching that, he was effective in highlighting the choice - the policy difference between the two men.

"I wonder looking at that poll whether that's what the public are really looking for."

However, there were distinctions when viewers were asked who performed better on certain topics.

Rishi Sunak came out on top on immigration and tax, while Sir Keir Starmer performed better on welfare and the UK's relationship with the EU.

Labour also just edged ahead on the economy - with 47% saying they performed better, and 43% backing the Tories.

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Reflective and critical thinking in nursing curriculum

O pensamento crítico-reflexivo nos currículos de enfermagem, el pensamiento reflexivo y crítico en los currículos de enfermería, maría antonia jiménez-gómez.

1 Universidad Nacional de Colombia, Facultad de Enfermería, Bogotá, Colombia.

Lucila Cárdenas-Becerril

2 Universidad Autónoma del Estado de México, Facultad de Enfermería, Toluca, México.

Margarita Betzabé Velásquez-Oyola

3 Universidad Nacional José Faustino Sánchez Carrión, Facultad de Medicina Humana, Huacho, Lima, Peru.

Marcela Carrillo-Pineda

4 Universidad de Antioquia, Facultad de Enfermería, Medellín, Colombia.

Leyvi Yamile Barón-Díaz

5 Universidad Nacional de Colombia, Facultad de Medicina, Bogotá, Colombia.

to evaluate the teaching of transversal competence of the Reflective and Critical Thinking that is fundamental in the decision-making and solution of nursing problems, in degree programs of public and private institutions in the Andean region.

multi-center, cross-sectional, exploratory-descriptive study, with mixed approach in 5 countries.

76 nursing programs participated in the study. The Reflective and Critical Thinking was found as a subject, subject content and didactic strategies. Of the 562 subjects reviewed, this type of thinking is found in 46% of the humanities area and 42% in the area of research and professional discipline. It is important to train teachers to achieve coherence between the pedagogical model approach, teaching strategies and evaluations.

Conclusion:

nursing programs in the Andean region contemplate the critical thinking as cognitive and personals skills of communication. They also use real situations analysis, supervised practice, simulation labs and specifically learning based in problems to develop the capacity to solve them, decision-making and develop communication skills, including analysis, synthesis and evaluation.

avaliar o ensino da competência transversal do pensamento crítico-reflexivo, fundamental na tomada de decisões e solução de problemas de enfermagem, nos programas de graduação de instituições públicas e privadas da região Andina.

Método:

estudo multicêntrico, transversal, exploratório-descritivo, com abordagem mista em cinco países.

Resultados:

76 programas de Enfermagem participaram do estudo. O pensamento crítico-reflexivo foi constatado como disciplina, conteúdo de disciplina e estratégias didáticas. Das 562 disciplinas revisadas, este tipo de pensamento se encontra em 46% da área de humanidades e 42% na área de pesquisa e profissional-disciplinar. Existe a necessidade de capacitar os docentes para obter coerência entre a proposta do modelo pedagógico, as estratégias didáticas e a avaliação.

Conclusão:

os programas de enfermagem da região Andina contemplam o pensamento crítico como habilidades cognitivas, de comunicação e pessoais. Da mesma forma, utilizam a análise de situações reais, estágio supervisionado, laboratórios de simulação e, principalmente, a aprendizagem baseada em problemas, com a finalidade de desenvolver a capacidade para solucionar problemas, tomar decisões e desenvolver habilidades comunicativas, incluindo análise, síntese e avaliação.

evaluar la enseñanza de la competencia transversal del Pensamiento Reflexivo y Crítico, fundamental en la toma de decisiones y en la solución de problemas de enfermería, en los programas de grado de instituciones públicas y privadas de la región Andina.

estudio multicéntrico, transversal, exploratorio-descriptivo, con abordaje mixto en 5 países.

76 programas de Enfermería participaron en el estudio. El Pensamiento Reflexivo y Crítico se encontró como asignatura, contenido de asignatura y estrategias didácticas. De las 562 asignaturas que han sido revisadas, este tipo de pensamiento se encuentra en el 46% del área de humanidades y el 42% en el área de investigación y profesional disciplinar. Está la necesidad de capacitar a los docentes para lograr coherencia entre el planteamiento del modelo pedagógico, las estrategias didácticas y la evaluación.

Conclusión:

los programas de enfermería de la región Andina contemplan el pensamiento crítico como habilidades cognitivas, de comunicación y personales. Asimismo, utilizan el análisis de situaciones reales, la práctica supervisada, los laboratorios de simulación y, principalmente, el aprendizaje basado en problemas, con la finalidad de desarrollar la capacidad para solucionar los problemas, tomar decisiones y desarrollar habilidades comunicativas, incluyendo el análisis, la síntesis y la evaluación.

Introduction

Globalization brought with it changes in all aspects of life: social, political, economic and cultural. Moreover, the nursing profession is evolving, so that it is increasingly moving away from the biomedical model of care, focused on the instrumental, to focus on people’s health care, with primacy of dialogue and agreements between the professional and the person under care. As part of a multiprofessional team, this requires changes in the curricular proposal and, in turn, a qualifying teacher for a new profile of graduate, whereby reflection, self-criticism and professional responsibility are developed ( 1 ) .

Therefore, it is necessary to work intensely to reduce the dichotomies that are present in nursing programs, namely: between theory-practice; training and the reality of professional practice; and the student as a passive part of the teaching-learning process and the professional who is required, active, proactive, creative, analytical, with contextual perspective, flexible, with logical thinking, able to carry out a permanent and continuous search for information, able to contribute with his profession to the solution of health problems.

The General Conference of the United Nations Educational, Scientific and Cultural Organization (UNESCO), at its 38th session, held in Paris from 3 to 18 November 2015, “Recommendation about Adult Learning and Education” states in one of its objectives the need to develop people’s capacity to think critically and to act with autonomy and a sense of responsibility ( 2 ) .

Critical thinking (CT) is a process and a learning outcome ( 3 - 4 ) and the clinical judgment is the result of this process. The development of the clinical judgment (clinical reasoning skills) is one of the most important and challenging tasks of being a nurse. Clinical reasoning precedes clinical judgment and the decision-making that is important in professional and personal life.

In order to achieve professionals with reflective and critical thinking (RACT), it is necessary to make deep changes in the educational dynamics, in the teaching and student roles, in the use of pedagogy and didactics to transmit knowledge, the curricular structure, the strategies of teaching-learning. These changes are expected to be centered on the student, who must actively participate in the learning process in order to achieve greater development of his or her capacities for reasoning, self-learning, self-evaluation, self-management and self-regulation. Likewise, it is expected that teachers to be critical and creative, attending to individual ways of learning, encouraging the development of good thinking in the student ( 3 ) .

Literature points out that critical thinking is the “essential foundation for education, since it is the basis for adaptation to the individual, social and professional demands of daily life in the 21st century and beyond” ( 4 ) . The world changes fast and new realities arise, so there is a fundamental need of people to develop capabilities that allow them to respond and adapt themselves to these changes.

Critical thinking is “the process of seeking, obtaining, evaluating, analyzing, synthesizing and conceptualizing information as a guide, to develop self-conscious thinking and the ability to use this information by adding creativity and taking risks” ( 4 ) .

Authors pointed out one of the first definitions of critical thinking: “knowledge, skills and attitudes” ( 5 ) and, since the end of 1980, various strategies for its teaching have been discussed at all school levels ( 4 ) . On the other hand, authors point out the importance of generating opportunities to develop RACT in students. Therefore, some authors emphasize the importance of developing it in all health situations in favor of the patient ( 4 , 6 - 7 ) . The nursing professional developing RACT will know where, when and how to use their knowledge, skills, values and attitudes.

The motivation for nurse training in the Andean region became evident in the 1960s. In particular, Colombia generated the first degree program in 1958, which was approved in 1961. In the same period, Venezuela, Ecuador, and Peru initiated undergraduate programs; in the case of Bolivia, it happened only until 1970 ( 8 ) .

The 1980s were marked by the rise of postgraduate programs, increased development of research and the generation of knowledge. The 1990s saw a boom in graduate, specialization, masters, and doctoral programs, the latter especially in education. However, there were also more options for the qualification of nursing professionals for the teaching role. On the other hand, the Higher Education Quality Assurance System ( Sistema de Aseguramiento de la Calidad de la Educación Superior ) was implemented, as well as the Accreditation of the programs and the own regulations or nursing law emerged in each country of the region.

The first decade of the 21st century brought the development of the highest level of nursing education, the doctorate, and, with it, the generation of nursing knowledge in the region and its progress towards consolidation as a discipline ( 8 ) .

Throughout this journey, there was a permanent motivation for balance and congruence between the graduation profiles and the reality of the job, based on the permanent motivation for the adaptation of the curriculum, the teaching-learning strategies, the evaluation processes, and the teacher qualification to respond to this constantly changing context.

The literature ( 9 - 11 ) shows the need to expand the research in the area of education, to achieve greater development of research and to work in education and nursing policies and practices. On the other hand, the latter shows the need to implement and evaluate pedagogical and didactic strategies that help the student to develop a critical judgment, justified decision making, comprehensive memory and communicative competence ( 11 ) .

For its part, the Ibero-American Network for Research in Nursing Education ( Red Iberoamericana de Investigación en Educación en Enfermería - RIIEE), in 2011, identified as a research priority, “The development of RACT in nursing students”, within the tree of the problems detected in its research line Higher Education and Nursing. For the development of this research purpose, the Network suggested a multicenter macroproject with the theme “Strategies to develop the RACT in nursing students: situation in Latin America”. In fact, the conceptual paradigm refers to “critical theory and constructivism, since RACT is an analytical, cyclical, broad and systematic process, but not rigid; its analysis and interpretation allows to have elements for decision-making, as well as to make informed choices” ( 8 - 12 ) .

The project involves five of the six regions that make up the RIIEE: the Andean region (Bolivia, Colombia, Ecuador, Peru and Venezuela), Brazil, the Southern Cone, Europe, and Mexico and the Caribbean. The investigation is planned in three stages: 1. Diagnose; 2. Planning and implementation of interventions; and 3. Evaluation. The diagnostic stage includes: 1. The state of the art on scientific production in RACT and teaching strategies for its development; 2. Characterization of educational strategies for teaching the RACT collected in nursing literature; 3. To determine the development of the RACT competence in the different nursing curriculum; 4. To identify the educational strategies used by teachers to develop the competence of reflective critical thinking in nursing students; 5. To identify levels of critical thinking in nursing students according to the classification of Paul and Elder (unreflective thinker - master thinker). Objectives 4 and 5 are currently being developed.

The analysis of the “Scientific Production in RACT in Nursing in 1990-2012 in Ibero-America” produced among others the following conclusion: the formation of a critical reader and the investigative process are strategies that help university students to be critical and autonomous and to access more critically to the knowledge of the disciplinary area. For this, teachers are required to make of each moment and situation in the teaching-learning relationship an open forum for reflection, debate, questioning and contrasting of the different perspectives around the area of professional training and society’s problems ( 8 ) .

After reviewing the literature on the web of science by using the descriptors critical thinking and nursing, education and curriculum, it was not possible to find studies that analyzed the presence of RACT in the curriculum of nursing degree programs. However, it is very striking the motivation to analyze the importance of its development and studies that demonstrate its value, as well as the use of different and combined teaching-learning strategies to achieve the formation of RACT in nursing students.

This study was done with the purpose of to evaluate the teaching of transversal competence of the Reflective and Critical Thinking that is fundamental in the decision-making and solution of nursing problems, in degree programs of public and private institutions in the Andean region.

The coordinating group of RIIEE developed the research project from which the research groups of each country and region of the Network were made up, integrated by members of the Network and researchers in education and nursing, who are also teachers in Higher Education Institutions (HEI), and mostly with PhD academic level. The HEI in Nursing (HEIN) were identified through the Ministries of Education, the Associations of Schools and Universities of Nursing of each country and the Latin American Association of Schools and Universities of Nursing ( Asociación Latinoamericana de Escuelas y Facultades de Enfermería - ALADEFE).

The project was benefited from the Declaration of Helsinki (Ethical principles for medical research on human subjects) and the current ethics legislation in each country, was approved by the Ethics Committee of the University of Antioquia, Colombia, by Act No. CEI-FE 2015-25 on July 31, 2015. The respect for privacy and confidentiality were ensured to each Program Director, with the informed consent signed by each participant. The project was also sent to them and their understanding was guaranteed. In turn, we conceded the right to choose what information they wanted to share. Confidentiality was maintained by institutional coding. Finally, was given a deadline of 15 days to obtain the response of acceptance to participate.

The target population of this research were 187 undergraduate nursing programs in the Andean region: Bolivia (47), Colombia (47), Ecuador (21), Peru (62) and Venezuela (10). We considered only the nursing curriculum of the HEI, recognized by the Associations of Schools and Colleges of Nursing of each country or its counterpart, regardless of whether they were public or private. Resulting in the nursing curriculum of 76 Institutions that correspond to the 40.64% HEIN that teach undergraduate nursing in the Andean region: Bolivia (7), Colombia (38), Ecuador (11), Peru (14), and Venezuela (6). Due to the difficulty in obtaining the information, we checked web pages, contacted HEIN members, made contacts by telephone, in some cases, we made personal visits and, finally, the complete program was requested in PDF format for the complete the instrument of the research group. In addition, the HEIN did not refused to participate, but some institutions did not respond to the invitation. The result of this process: 30 institutions accepted to participate and provided the complete information, and out of 46 partial results were obtained. An HEIN database of the names, telephone numbers and e-mail addresses of the authorities in charge of managing the programs was created in order to follow up on their responses.

After identifying, during 2011 and 2012, the theoretical and conceptual framework of RACT from different authors and different perspectives (education, pedagogy, psychology and nursing), despite the abundance of literature about the subject, we concluded that the concept is very unclear from a nursing point of view ( 13 - 14 ) .

However, it was necessary to establish a concept that was accepted by the research group of the Network, that allowed to determine a starting point or consensus to carry out this work and, without detriment to seek some level of fidelity to the multiple approaches of the scholars of this research object, that was understandable for the group and reflected what was intended to be done in its research phases and stages.

The Network took as a theoretical framework the approaches made by Paul ( 15 ) and Paul; Elder ( 16 ) , the elements of the CT and the attitudes of the Critical Thinker proposed by these authors. With the material analyzed, RIIEE constructed the following concept: “Reflective and critical thinking is a complex, systematic and deliberate process of reasoning, self-directed and action-oriented. It is primary purpose to choose, based on intellectual and affective processes (cognitive, experiential and intuitive), the best response options that favor the solution of nursing problems, in well-defined contexts and in accordance with the ethical postulates of the profession that allow it to act with rationality and professional autonomy” ( 8 ) .

The research process included the conceptual and theoretical analysis of the curriculum, the updating of the context of research development in nursing education in each country of the region, the characterization of the HEIN and, finally, the results of the state of the art on teaching strategies for the development of the RACT 1990-2012, Andean region.

Once the exhaustive bibliographic review was carried out, the instrument was designed based on the concept of Stenhouse ( 17 ) , the curriculum as a macro concept that encompasses the socializing function of the school is at the same time pedagogical ideas, structure of contents in a particular form, precision of them, reflection of educational aspirations more difficult to translate in concrete terms and skills to promote in the students ( 16 ) . In Posner ( 18 ) , who raised the great number of phenomena involved in the curriculum; Gimeno-Sacristán; Pérez-Gómez ( 19 ) , there is five categories in which the definitions of curriculum can be articulated: as an organized knowledge structure, production technology system, instructional plan, set of learning experiences and problems solution.

Based on the aforementioned, the specific instrument for this investigation was constructed with three parts. The first with 10 items, with general information from the HEI or University. Each University is subdivided into Centers that are parted into Colleges and these are divided into programs: name, geographic location, type of institution, accreditation data, mission, vision, objectives, curricular guidelines for degree programs, web page, and data about who completed the instrument. The second, 28 items, for the College, School, Department or Nursing Program (typology to identify HEIN in the region), with the following subsections: general aspects of the nursing program, character within the institution, number of sites where the program is offered, accreditation data (date, resolution, and time of accreditation), program justification, mission, vision and objectives of the program, evaluation process, graduation profile, pedagogical model, number of hours and credits, curricular structure (nursing program subjects that correspond to each area or component). Finally, the general characteristics of the teachers: kind of affiliation with the institution, time worked, and maximum educational level achieved. The third, 9 items, for specific information about each of the subjects: name, component or area to which it belongs, number of hours and credits, type of subject (theoretical, practical and theoretical-practical), contents, teaching-learning methodologies and evaluation process.

The members of the research group carried out an analysis of the validity of the content of the instrument. Afterwards, the pilot test was conducted, starting with its implementation in each of the HEI in which the researchers worked; the results were analyzed and the corresponding adjustments were made in its structure. Subsequently, the adjusted instrument was tested with five members from the region, one from each country, but different from the research group. Because of this test, we decided to design a guide to facilitate the completion of the instrument and ensure objectivity in the collection of information, because of the language differences. It is possible to obtain the final version of the instrument from the authors of the project.

Each participant received the letter of invitation, the project, the informed consent, the instrument to collect the information and the corresponding guide for its completion in hands and by e-mail.

The information obtained was reviewed and, in some cases, it was necessary to request the complementation of some aspects of the instrument. Then we proceeded to codify the HEI or Universities and the HEIN. The information was included in Excel tables designed with the predetermined categories and subcategories, which were later incorporated into the SPSS statistical analysis program, version 19. The information was processed using descriptive statistics, with frequency distributions and average analysis, and analyzed by institution, by country and as an Andean region, according to the categories and subcategories determined, allowing comparisons between countries and conclusions to be drawn as a region.

The analysis of the information was carried out using the deductive-inductive method, considering the objectives of the project and the revised conceptual theoretical framework, with the aim of determining the presence of the RACT, explicit and implicit, in each categories, the coherence of the approaches between University-College-Program, the coherence between the objectives, contents, teaching-learning strategies and the evaluation process in each subject. In this sense, we analyzed the linearity or coherence with respect to what was proposed, developed and evaluated in relation to the RACT and, finally, the contradictions and inconsistencies found in the aforementioned approaches were pointed out. We considered national and international studies about the subject for the analysis and discussion of the results obtained, in addition to the documents mentioned above.

According to the information obtained by the research group, the Andean region has 2,552 HEI; 410 with character of universities and 160 are public, 220 are private and 14 are in special regime. There are 167 universities with nursing programs, 146 affiliated and recognized by the respective Associations of Schools and Colleges of Nursing in each country. The number of accredited nursing programs in the Andean region is 43: Colombia (20), Peru (20) and Bolivia (3). Precisely, of the 20 accredited institutions in Colombia, 11 already have their certifications renewed, which are of 8, 6 and 4 years; 5 and 6 years for Ecuador and 3 years for Peru. Bolivia is just beginning the process and Venezuela has no information about it.

The total population of HEIN by country was Bolivia 47, Colombia 42, Ecuador 21, Peru 62 and Venezuela 10. A total of 76 HEIN answered: Bolivia 7; Colombia 38; Ecuador 11; Peru 14 and Venezuela, 6. These institutions constituted the sample of the study.

Twenty-one of these institutions are certified: in Colombia 20 and in Bolivia 1; 12 did not include this information and 41 were not yet certificated. Of the total number of institutions that provided the information, 47 are public, 26 private and three do not know the information. Administratively, 36 are programs; 22 Colleges; 21 Schools and one Department.

The number of hours and credits of the programs showed considerable heterogeneity: the average number of hours was 5,552.3, corresponding on average to 232.11 credits. Regarding the number of hours per credit, the lowest is in Peru, which has 13 hours per credit, and the highest is in Colombia, with 48 hours corresponding to one credit. There are institutions that do not work with credits, especially in Bolivia; others did not included this information, among them Ecuador and Venezuela.

The main characteristics of the 912 teachers developing nursing programs in the Andean region are: 501 (54.9%) with a Specialist degree; 634 (69.51%) with a Master’s degree and 58 (6.35%) with a PhD; 249 (27.3%) with a postgraduate degree in Education.

From a general perspective, it should be noted that of the five countries in the region only Venezuela and Peru explicitly present the RACT in their Organic Law (OL) or Higher Education Law in terms of integral and permanent formation of reflective critical citizens (LOE, 2009, or Organic Law of Education, in Venezuela) ( 20 ) and (Law 30220, 2014, or University Law, in Peru) ( 21 ) .

The results of RACT’s presence are presented below: Universities or HEI; in Colleges, Programs, Schools and Departments, that is, in HEIN; and in the subjects.

When analyzing the information of the Universities or HEI, we found the RACT as direct mention, indirect mention and evidence of traditional positions was found. Directly, it was found as a training purpose in Bolivia, Colombia and Peru: receptor and analytical constructor, with critical conscience; as methodology to achieve it, in Colombia and Peru: “ promoting reasoning, the CT and creative”; as a result of learning in Ecuador and Venezuela: capable of solving problems, CT promoter.

The indirect mention was found as result in the five countries of the Region, as a strategy in Bolivia, Ecuador, Peru and Venezuela: integral formation, relation practical theory; and as objective in Colombia: future graduates with ethical conscience, autonomy, democratic spirit and highly qualified.

There are still traditional postures: teaching, evaluation as a final product, training in instrumental action, the educational process as providing knowledge.

By going a little deeper into the HEI, we found that 88% (38) consider the RACT: 63% (27) in the mission; 7% (3) in the vision; 51% (22) in the objectives and 30% (13) in the curricular guidelines. Among these, three defining categories were identified. The first, as a training purpose: prepare professionals and leaders with CT and social conscience . The second, as a methodological strategy to achieve its development: to develop and implement pedagogical methods that encourage reasoning, CT and creativity, and that encourage habits of discipline and productive work . And the third, as a result of the formation process that includes the subject: Training of critical, self-managed, creative and proactive men and women; and, moreover, refers to the projection and utility: with the promotion of CT and the generation of knowledge, thanks to the strengthening of critical analysis, anticipation and vision of the future and development of viable alternatives to the problems.

At HEIN, RACT is expressed in the graduation profile, objectives, curricular guidelines and mission. Table 1 shows the data summarized in relation to the number and percentage in which the RACT is presented in the subcategories and with regard to the total. The information recovered allows us to identify that the RACT ranks first with 38.3% in the graduation profile, followed by 35% both in the curricular guidelines and in the objectives; thirdly, is in the mission, 26.7%, and finally, with 11.7% it is in the vision. Bolivia has the highest percentage of presence in its curricular guidelines, followed by Colombia in its graduation profile, objectives, and mission, while Venezuela is in one before the last place with a 28% of presence in its mission and is not present in the profile or in the curricular guidelines. Peru has the last place and presents it only in the objectives of the programs.

In a cross-sectional view of what is proposed by curricular programs, three categories were identified to be highlighted. The first, the development of cognitive and personal skills, expressed as the training of professionals with scientific, technical, critical, analytical and reflective knowledge, as well as communication, oral and written expression skills; and referred to a critical, creative, participative, supportive, innovative and sensitive attitude towards social change.

The second, the way in which its development could be achieved, among which the research stands out: promote and develop research, generating knowledge in the different areas of nursing that contribute to universal science and the solution of health problems; and the use of technologies: learns permanently developing the capacity of abstraction, analysis, synthesis and using information technologies . The third, its finality, related to the ability of individuals, families and community groups to interfere and make decisions in the solution of health problems, to provide comprehensive care with the capacity to solve health problems in changing and emerging environments.

Concerning the pedagogical models expressed in the HEIN, a variety was found in the denomination. First of all, the constructivist approaches are highlighted in eight (8) Institutions, with some connotations as the model social-critical-constructivist and second, the cognitive - humanistic in four (4). Other models or approaches were also identified, among them: dialectic, technological, psychological, the problematic schools, the Active, Reflective, Dialectic, Innovative and Critical . Finally one institution works with the model based on the pillars of education , in which learning to know, learning to do, learning to be and learning to live together, which includes, educating for life, educating for life, educating for work, educating in society and for society ( 22 ) .

The RACT in the subjects of the programs of Nursing in the Andean region

Only 29 of the 76 HEIN participants in the study were able to obtain information on subjects (38.15%), and 22 (75.86%) of these in nursing programs, RACT was present in different elements of the subjects. 562 subjects were reviewed, 159 (29%) of which have no information about teaching strategies or evaluation. Moreover, some programs record the same teaching and assessment strategies for all subjects in the program, 45 (8%).

Table 2 presents the results by subcategory and the total presence of RACT in the different groups of subjects, basic area or foundation subjects (which introduce and contextualize the student in the field of knowledge), Research, Humanities (the study of the behavior, conditions and performance of the human being), disciplinary professional area (gives the basic grammar of the profession and discipline) and those of the flexible area (the student chooses them according to personal interests, allow to the learner to approach, contextualize and study in depth aspects of the profession and discipline, allowing to learn tools and other kinds of knowledge, leading to develop interdisciplinarity, flexibility and diversity).

The information provided makes it possible to indicate RACT as a subject: Workshop of Critical Thinking and Introduction to CT ; second, as a subject content: CT in Nursing, and, third, RACT is evidenced in teaching-learning strategies.

The highest percentage of subjects in which RACT is evident correspond to the area of humanities, with 46% (55), in which analysis of real situations, group work, concept maps, role playing and seminars are predominant.

In second place, it is in the professional-disciplinary area with 42% (307) subjects with the predominance of the following strategies: supervised clinical practice, clinical case, problem-based learning, simulation laboratories, and the nursing process. The research is in the same place, 42% (41) subjects. The most commonly used strategies are: critical discussions of research reports and articles, project development, workshops, and problem-based learning.

In the last place, subjects from the basic or foundation area 144 (24%). Including discussion workshops, concept maps and case studies.

A great variety of strategies have been identified, among them are: presentation and discussion of clinical case, group work, clinical practice, flipchart, observation guides, debates, discussion about specific topics, resolution of case studies, support of the nursing care plan, investigative reports , workshop development.

What is evaluated: the development of competencies, the acquisition of skills, the development of superior cognitive processes, the professional spirit and the development of processes and independence.

Finally, in some of the subjects, the intentionality of the evaluation of the RACT is explicitly presented: written works about the topics of each seminar in which the proper handling of the bibliography is evidenced, the capacity for criticism, analysis and synthesis, evidence of problem solving, case analysis and Nursing Based in Evidences , didactic relationship analysis and fundamental elements of the RACT, conceptual knowledge, written and oral reflections, group work, practical reflections and group discussions.

It is evident that traditional evaluation techniques still exist: evaluating procedural aspects, dexterity, motivation and initiative in the procedures, memory evaluation, participation in class, oral and written interventions and, finally, the replication of the topics studied in classes.

Therefore, the analyzed programs show interest in including as an important element in their future graduates the development of the RACT. This aspect is vanishing in the development of the subjects. It is evident in the pedagogical strategies, but it is lost until disappearing in most of the evaluative processes.

The analysis results of the plans and programs of the HEI and HEIN allow to conclude that the proposes of the Law of Higher Education to develop the RACT in the students does not guarantee that it is included in the subjects and evaluations.

What is stated in HEI and HEIN allows us to infer that epistemological and theoretical contradictions are present in the Institutions and among them. It makes necessary an epistemological, theoretical and methodological consideration in order to achieve alignment and coherence between the purposes in the curricular guidelines and what is programmed in the curricular plans for the concrete work with the students. This matter goes against comprehensive training, since it is demonstrated that critical and reflective skills contribute to train professionals with greater ability to care for patients ( 23 ) .

It should be noted that it is the University or HEI that determines the philosophical bases that will guide the academic units that compose it, so that they, in turn, incorporate these principles into their academic programs. The results show that there is no linearity between the proposals of the university with respect to its mission, vision, objectives, graduation profile, curricular guidelines, and what is proposed in the nursing degree programs. There is more linearity in Institutions with a longer trajectory and development, private and public ones.

The analysis of the areas in which the subjects are grouped made it possible to identify that the subjects of the humanities area have the highest percentage of presence of the RACT. This result can be explained by the strategies used, but even more by the subjects under study, since it has been demonstrated that the teaching-learning strategies based on the humanities have a significant impact on the development of skills such as clinical reasoning ( 24 ) . The subjects in the professional area use strategies such as case study, supervised clinical practice and other relatively new ones as problem-based learning and simulation laboratories. Strategies that, by involving simulation or potential practical actions, contribute to enhance critical skills and make decisions that lead to the future professional committing fewer errors during the care of patients ( 25 - 26 ) .

By contrast, it is not the same with the subjects of the foundation or basic area in which it is necessary to return to some knowledge aspects that already exists, such as anatomy, physiology, anthropology, psychology, statistics, among many others. For some students these topics are very difficult and involve, on several occasions, an excellent dose of memory. However, the teaching strategies that develop the RACT are not so frequent. It is important doing more research on this point to sustain if it is true.

On the other hand, for the majority of HEIN, training is conceived as qualification and progress achieved by people and as a principle of theories, concepts, methods, models, strategies and courses of pedagogical action that aim to understand and qualify the teaching. In some cases, the transfer of knowledge is approached, but it still underlies the concept of learning as acquisition of knowledge built and finished; the teacher is the one who has the knowledge and the student is who learns what teacher knows.

The curricula of the Andean region include explicit elements that contribute to the development of the RACT, such as reading, writing and reasoning, allowing to the future professional to know how to learn, reason, think creatively, generate and evaluate ideas, make decisions and solve problems ( 24 ) . It includes as proposals the development of social skills, with emphasis on oral and written communication, cognitive skills including problem solving, establish different alternatives, understand the consequences of actions, make decisions and critical thinking ( 16 ) . Also, intend to achieve in the student some characteristics of the critical thinker like to be creative, innovative, proactive, analytical, participatory, entrepreneurial, self-critical, supportive, humanistic, ethical and scientific ( 27 ) .

Regarding the pedagogical models proposed by the HEIN, inconsistencies between the approach of constructivist approach and meaningful learning are evident. The axis is the student and the repetitive approach in the subjects with master class methodology, reading guides and analysis made by teacher, but not by the student. It shows a traditional model centered on the teacher, with an emphasis on memory, comprehension and the application of concepts. Some subjects focus learning on the acquisition of concepts, despite using the integrating project as a teaching-learning strategy, workshops and practice as evaluation. The pretense for the development of the RACT is not in line with the evaluation, with the examination, in the application of contents, since it is centralized in aspects of memory and knowledge, in an asymmetric theory-practice relationship.

Although significant learning is intended and the importance of integrating it into the formation of learning approaches with the intention of promoting critical thinking, added with successful learning experiences ( 28 ) , it is not really concrete how it could be achieved. Strategies such as simple repetition and teaching for the acquisition of concepts show the persistence of the traditional educational models.

This study found there is no a clear structure to operationalize the theories of the proposed pedagogical models, even though there are expressions that point to RACT. Thus, the elements important for its development are presented in the teaching and learning strategies in a more remarkable way.

The curricular guidelines express the intention to transcend technical rationality and behavioral objectives ( 29 ) , from the positivist, rationalist or empirical analyst paradigm, to the humanist and critical curriculum ( 30 ) to the socio-critical paradigm and critical thinking based on hermeneutic processes ( 31 ) . The social and contextual (political, economic and cultural) aspects that influence and determine the health behaviors of the people are still incipient in the curricula ( 32 ) .

According to what has been demonstrated, it is possible to state that there is no predominance of a pedagogical model, but a mixture of several models in the same program with varied influences. The presence of the following models was identified: Traditional Pedagogical, Behavioral, Cognitive, and Social Pedagogical, the latter being very tenuous ( 33 ) .

There are four fundamental elements to forming critical thinkers: first, the question; second, the creation of continuous opportunities to participate in dialogue, debate, research, and critique; third, self-evaluation and hetero-evaluation; and fourth, teachers as models of critical thinkers ( 32 ) . Considering these elements, we can assure that the creation of opportunities is present with more intensity in some curricula, and self-evaluation and hetero-evaluation have begun to be implemented especially in public institutions.

Mentioning the subjects, it is not evident that the thought is motivated by complex kind of questions that encourage exploration, generate evaluation, create concepts and knowledge ( 33 ) .

The literature points out that the Socratic questions stimulate the student to use existing knowledge, since they promote a greater understanding and integration of new knowledge, they foment the habit of thinking critically ( 8 , 34 ) . Other authors suggest, for the reports, questions about the purpose, information, concepts, assumptions, implications, points of view and the questions, as elements that favor analysis, the evaluation of ideas and reasoning ( 24 , 35 ) .

Like other researches, this study found that the most used strategies in the progress of the professional area that promote the development of RACT are the case study ( 24 , 36 ) , problem-based learning ( 24 ) , supervised clinical practice ( 37 ) , the nursing process ( 4 , 38 ) and simulation laboratories ( 34 , 37 - 38 ) . In this article, we only refer to two of these strategies, which were selected because of the great advance of information and communications technologies. The growing need to access this kind of infrastructure as a fundamental part in the training of future professionals and as an example of a single teaching and learning strategy is not sufficient to achieve the RACT, rather, the use of different techniques enhance its development, as we will see below.

We agree with the conclusion of authors who suggest that Problem-Based Learning and simulation labs are active strategies that develop RACT in nursing students ( 37 ) .

The case study, moreover, promotes active learning, helps to solve clinical problems, promotes the development of critical thinking skills ( 34 - 35 ) , in addition, it allows to integrate knowledge, to think as a professional, to analyze individual situations in specific contexts from different angles, to use theoretical concepts in the delimitation of a concrete problem ( 36 ) . It also stimulates collaborative and team work, the work with different points of view. The question-problem is the motivator in the search for alternative solutions, is useful in simple and complex situations, allows to apply theory in practice, promotes the exchange of ideas, teaches students to learn to control their own thinking and promote the exchange of ideas and intellect ( 37 ) . In addition, it helps to incorporate time management and take responsibility. It also facilitates the integration of the four elements of the Nursing metaparadigm: the person receiving the care, health as purpose, the nature of the nursing and the context or environment.

The case study allows the simultaneous implementation of other strategies that further enhance the development of RACT, such as concept maps, the analysis and selection of scientific evidence, the nursing process, nursing history, role-playing, argued discussion and debate.

In contradiction to all the positive aspects of the case study in the development of RACT, the dichotomy between theory and practice in a large number of the curricula reviewed is an obstacle to achieving all the benefits pointed out. Since some teachers are in charge of the development of the theoretical subject in the classroom, others are in charge of their practical part in other spaces that require this care.

Regarding the practice based on simulation models, a study ( 38 ) shows how the promotion of RACT is relevant. In this connection, it highlights the importance of including simulation as a key element in curricula, because it ensures skills in this kind of thinking ( 38 ) and gives students the opportunity to show their ability in decision-making, critical thinking and other skills ( 39 ) . Other authors emphasize its importance when students reflect it on their thinking process and show how it guided their actions ( 34 ) .

There is efficiency of simulation laboratories when accompanied by active strategies, such as the conceptual map before each laboratory session, a visual aid that allows the concepts, objectives, justification, expected results and possible complications to be described in a logical manner if the procedure is not carried out in the appropriate manner ( 34 ) . The same author suggests the use of high-level questions to stimulate reason more than memory. He also suggests assigning an observer, who will ensure analysis and reflection on patient safety, communication, teamwork and leadership, among others ( 34 ) . The reflection of the group around the whole process carried out will be the end of the laboratory ( 15 , 34 ) .

Another study concluded that simulation as a pedagogical method allows students to recognize, interpret and integrate new information with previous knowledge in order to make decisions about the best direction to follow. The authors state that simulation, as an educational method, provides an opportunity to systematically structure learning to help students acquire deep content knowledge and to facilitate the development of thought processes; that simulation experiences stimulate students’ RACT skills and help them become more competent in caring for patients in complex conditions ( 37 ) .

We agree with what has been found in other studies emphasizing that simulation laboratories by themselves do not guarantee the development of RACT skills, but if combined with other strategies and implemented with adequate pedagogy, the results will be much more effective in terms of CT skills ( 34 , 37 - 38 ) .

It is also possible to find correspondence with that was discovered in the State of the Art of scientific production in RACT in the Andean region. The students perceive that “Clinical simulation is a valuable strategy for the acquisition, complementation and integration of the theoretical part with the practical part, because it seeks to make decisions according to the CT” ( 38 ) .

The evaluation of the subjects is cumulative and formative. In some cases, a diagnosis of the level of the student’s participation in the subject is made; it is evaluated in the intermediate and at the end with the objective of promotion to another level. In other cases, a teaching-learning balance is done to verify the fulfillment of the objectives and competences. Self-evaluation and heteroevaluation are increasingly used, implying a process of reflection, analysis and self-criticism.

Precisely, evaluation appears as one of the weakest points when analyzing the presence of RACT in curricula. Therefore, we agree that the “best teaching practice begins by establishing learning outcomes and continues with a focus on helping the student to achieve satisfactory results”. If the proposal is to achieve a higher order thinking, the evaluation will be oriented towards the synthesis, analysis and evaluation of knowledge ( 40 ) .

Overall, the strong approaches to RACT training formulated at HEI, HEIN, as evidenced by some of the teaching and learning strategies presented in the subjects, become much weaker in the evaluation process, with predominance of traditional evaluation models, and in some cases, the intention to evaluate RACT is outlined.

The curricula of Colleges and Schools of Nursing in the Andean region explicitly contemplate reflective and critical thinking in their mission, vision, objectives, graduation profile and didactic strategies, and implicitly as integral formation. However, there is a tension between what is proposed by the HEI and HEIN and what is implemented and evaluated in the subjects. The presence of RACT in the proposed didactic strategies is much more evident, but it is not sufficiently objective or explicit in the evaluation processes.

Despite the great diversity of pedagogical models, there is a clear intention to facilitate the development of RACT. In addition, although a constructivist model is proposed centered on the student, dialogical, active, reflexive, innovative and critical, this model is more centered on the teacher than on the student; on knowledge over a relationship between equals; more on results than on the learning process. Likewise, knowledge is considered as something finished, fixed and the ultimate truth.

In order to be able to teach the RACT to the nursing student it is necessary to include it in the nursing curriculum, teachers who are professionals in the areas of Education and Nursing and with RACT in their training. Teachers should create spaces for the development of RACT, know and implement the different and complementary didactic strategies that facilitate its learning and that analyze the students in relation to the level of RACT achieved.

The authors of this article suggest that the projects currently developed with teachers and students in Ibero-America should be finalized and retaken with the implementation and evaluation of strategies that value the development of RACT.

RACT is considered an indispensable element in personal and professional development, in order to have autonomy, confidence, the ability to make decisions, reach clinical judgment and, the most important, provide individualized, comprehensive and human nursing care. In summary, graduates should be able to work as members of the health team with sufficient clarity of the role and identity they should have, because they have to integrate and experience the four paradigms of the Nursing.

The limitations of the study are

The complexity of the project due to the number of participating countries and the different research groups;

The large number of public and private nursing schools and colleges in the Andean region;

The limitation in accessibility to the complete information of the curricula of each institution;

The minimal presence of information on the official web pages of each institution, school or nursing college;

No response and lack of interest from different schools and nursing colleges, public and private, to participate of this project;

Limited access of current and recent updates of the curricula of nursing colleges to develop this project.

The research group made efforts to reduce these limitations and devised multiple options that were proposed to the institutions, in order to facilitate the provision of information and its complementation when necessary.

Applications for practice

The innovation and contributions expected with this research are based fundamentally on documenting and analyzing of the diverse existing evidences about if RACT is contemplated in the nursing curricula or not, the strategies used by teachers to create and promote it in nursing students and the evaluation processes employed. It provides insights about how RACT’s competence in nursing is addressed in the context of the Andean region and other regions of Ibero-America, its weaknesses and strengths, as well as the improvements that can be made. The final intention of the research is to offer, as a network and collegial body, proposals for teaching, learning and evaluation that will enable the empowerment of new generations of nurses, using RACT as a center of innovation and development.