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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

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

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

What Is Critical Thinking in Nursing?

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

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

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

How Is Critical Thinking Important for Nurses? 

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

Elements of Critical Thinking in Nursing

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

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

How to Develop and Apply Critical-Thinking Skills in Nursing

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

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

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

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

Images sourced from Getty Images

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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.

What is Critical Thinking in Nursing? (With Examples, Importance, & How to Improve)

Successful nursing requires learning several skills used to communicate with patients, families, and healthcare teams. One of the most essential skills nurses must develop is the ability to demonstrate critical thinking. If you are a nurse, perhaps you have asked if there is a way to know how to improve critical thinking in nursing? As you read this article, you will learn what critical thinking in nursing is and why it is important. You will also find 18 simple tips to improve critical thinking in nursing and sample scenarios about how to apply critical thinking in your nursing career.

What Is Critical Thinking In Nursing?

4 reasons why critical thinking is so important in nursing, 1. critical thinking skills will help you anticipate and understand changes in your patient’s condition., 2. with strong critical thinking skills, you can make decisions about patient care that is most favorable for the patient and intended outcomes., 3. strong critical thinking skills in nursing can contribute to innovative improvements and professional development., 4. critical thinking skills in nursing contribute to rational decision-making, which improves patient outcomes., what are the 8 important attributes of excellent critical thinking in nursing, 1. the ability to interpret information:, 2. independent thought:, 3. impartiality:, 4. intuition:, 5. problem solving:, 6. flexibility:, 7. perseverance:, 8. integrity:, examples of poor critical thinking vs excellent critical thinking in nursing, 1. scenario: patient/caregiver interactions, poor critical thinking:, excellent critical thinking:, 2. scenario: improving patient care quality, 3. scenario: interdisciplinary collaboration, 4. scenario: precepting nursing students and other nurses, how to improve critical thinking in nursing, 1. demonstrate open-mindedness., 2. practice self-awareness., 3. avoid judgment., 4. eliminate personal biases., 5. do not be afraid to ask questions., 6. find an experienced mentor., 7. join professional nursing organizations., 8. establish a routine of self-reflection., 9. utilize the chain of command., 10. determine the significance of data and decide if it is sufficient for decision-making., 11. volunteer for leadership positions or opportunities., 12. use previous facts and experiences to help develop stronger critical thinking skills in nursing., 13. establish priorities., 14. trust your knowledge and be confident in your abilities., 15. be curious about everything., 16. practice fair-mindedness., 17. learn the value of intellectual humility., 18. never stop learning., 4 consequences of poor critical thinking in nursing, 1. the most significant risk associated with poor critical thinking in nursing is inadequate patient care., 2. failure to recognize changes in patient status:, 3. lack of effective critical thinking in nursing can impact the cost of healthcare., 4. lack of critical thinking skills in nursing can cause a breakdown in communication within the interdisciplinary team., useful resources to improve critical thinking in nursing, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. will lack of critical thinking impact my nursing career, 2. usually, how long does it take for a nurse to improve their critical thinking skills, 3. do all types of nurses require excellent critical thinking skills, 4. how can i assess my critical thinking skills in nursing.

• Ask relevant questions • Justify opinions • Address and evaluate multiple points of view • Explain assumptions and reasons related to your choice of patient care options

5. Can I Be a Nurse If I Cannot Think Critically?

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BSN Level Objectives

1. utilize critical thinking to synthesize knowledge derived from nursing, natural and behavioral sciences, humanities and arts in the practice of professional nursing..

• Utilize critical thinking to identify knowledge from the natural and behavioral sciences and humanities related to nursing practice with individuals within the context of health and wellness promotion.
• Identify the major concepts within the domain of nursing.
• Utilize critical thinking to apply knowledge from the sciences, humanities and arts to nursing practice with individuals and families with lived experiences of wellness/illness.
• Apply Watson’s, Benner’s and Rogers’ concepts to nursing.
• Utilize critical thinking to integrate knowledge from the sciences, humanities and arts related to nursing practice with individuals, families and communities within the context of life long lived experiences.
• Formulate practice principles based on Watson’s, Benner’s and Rogers’ view of nursing.

2. Practice professional nursing competently in diverse settings, utilizing caring, critical thinking and therapeutic nursing interventions with individuals, families, aggregates and communities, at any developmental stage, and with varied lived health experiences.

• Examine caring and the use of Nursing process to implement therapeutic interventions in professional nursing practice with individuals with varied lived experiences.
• Make guided clinical judgments with individuals according to their lived experience and within the context of health for the purpose of wellness promotion.
• Perform protective, enhancing and preservative interventions with individuals at various stages in the life span.
• Utilize caring and Nursing process to implement therapeutic interventions in professional nursing practice with individuals and families with varied lived health experiences.
• Make shared clinical judgments and decisions related to Nursing care of individuals and families with varied lived experiences.
• Demonstrate protective, enhancing and preservative interventions as a novice clinician with individuals and families with lived experiences of wellness and illness.
• Utilize caring and critical thinking to evaluate therapeutic interventions in professional nursing practice with individuals, families and communities.
• Make clinical judgments and decisions with individuals, families and communities according to their lived experiences of wellness and illness.
• Demonstrate protective, enhancing and preservative interventions as an advanced beginner with individuals, families and communities.

3. Utilize the requisite knowledge and skill to practice independently and collaboratively with other health professions as an advanced beginner professional nurse.

• Identify, as a learner, how collaboration with other health professionals contributes to the care of individuals.
• Examine, as a novice clinician, the information and process needed to work with health professionals within the context of caring for individuals and families.
• Apply, as a leader, knowledge and skills needed to practice nursing collaboratively with other health professions within the context of caring for individuals, families and communities.

4. Integrate research findings and nursing theory in decision making in professional nursing practice.

• Identify the need for research findings in nursing practice decisions.  Examine the relationships between nursing, human being, health and environment and the concepts of caring, power and empowerment, and autonomy and advocacy as they relate to nursing practice.
• Examine the research process and the concepts of validity and reliability and their relationship to decision making in nursing practice.
• Apply the concepts of caring, power and empowerment and autonomy and advocacy in nursing practice with individuals and families.
• Critique research findings that impact on decision making in nursing practice.
• Utilize nursing theory in decision-making when caring for individuals, families and communities.

5. Apply concepts of leadership, autonomy & management to the practice of professional nursing.

• Examine as a learner the concepts of power and empowerment and autonomy and advocacy as related to self development and nursing practice.
• Examine as a learner the concepts of power and empowerment and autonomy and advocacy as they relate to other providers of nursing care.
• Apply, as a clinician, the concepts of power and empowerment and autonomy and advocacy to nursing practice.
• Apply, as a clinician, the concepts of power and empowerment and autonomy and advocacy in relationships with other health care providers in the advancement of care of individuals and families.
• Evaluate as a leader, the concepts of power and empowerment and autonomy and advocacy in managing nursing practice.
• Evaluate own empowering and advocacy efforts in relation to other health providers in the provision of care to clients.

6. Integrate professional caring into practice decisions that encompass values, ethical, moral and legal aspects of nursing.

• Identify caring as an ethical and moral aspect of nursing.
• Identify legal factors which impact on the practice of professional nursing.
• Differentiate between values, ethics, and morals in nursing care and practice.
• Utilize caring in the clinician role as it relates to Nursing care of individuals and families.
• Utilize the ethical decision making process in resolving ethical dilemmas.
• Make clinical practice decisions that reflect professional values and knowledge of legal aspects.
• Evaluate Nursing care of individuals, families and communities from the perspective of caring reflecting a commitment to the humanitarian focus.
• Incorporate moral and legal perspectives into practice and evaluate how they contribute to professional values and ethical decision making in nursing practice.

7. Communicate effectively with clients, peers and other health care providers.

• Utilize a variety of caring interactions with individual clients, peers and other health care providers. Examine communication techniques and principles that reflect caring in Nursing process.
• Apply selected principles of caring interpersonal relationships and communication patterns in providing care for individuals and families with lived experiences of wellness and illness.  Evaluate communication patterns observed in families.
• Formulate strategies to enhance positive communication patterns of complex systems in providing care for individuals, families and communities.
• Evaluate effectiveness of own communication behaviors in terms of empowerment and advocacy for clients and providers.

8. Respect the dignity, worth and uniqueness of self and others.

• Examine, from the role of learner, personal values, beliefs, interests and needs and their contributions to the development of the professional self.
• Consider from a caring perspective the client’s beliefs, interests and needs in nursing practice.
• Relate personal beliefs, interests and needs to own value formation and openness to diversity.
• Incorporate beliefs, interests and needs of clients across the life span into the process of planning, implementing and evaluating nursing care.
• Analyze how one’s personal values and beliefs affect professional practice.
• Examine differences in beliefs, personal values and perceived needs between self and clients.
• Respect values, beliefs, diversity and needs of self and others while utilizing a caring approach in the praxis of nursing.

9. Participate in the advancement of the profession to improve health care for the betterment of the global society.

• Identify major professional, social, political, economic and technological issues confronting society that impact on human beings, environment, nursing and health.
• Discuss professional, social, political, economic and technological issues that affect the environment, health and the care of clients coping with the lived experience of health, and recommend strategies for dealing with these issues from the role of clinician.
• Examine the broad professional, social, political, ethical and technological issues impacting on the environment and nursing practice and propose solutions as a member of the profession.

10. Accept responsibility and accountability for the effectiveness of one’s own nursing practice and professional growth as a learner, clinician and leader.

• Identify the qualities of the humanitarian nurse in the learner role with moral, ethical, aesthetic, cognitive, intellectual, and interpersonal dimensions.
• Recognize the need for learning and socialization into professional nursing in the learner role as scholar, researcher and scientist.
• Develop as a novice professional nurse in the clinician role as care giver by accepting responsibility for individuals and families as clients.
• Participate as a critical thinker, teacher, collaborator and user of nursing theory in the clinician role as care giver.
• Evaluate the outcomes of own activities in enhancing effectiveness of the nurse leader role as a manager, coordinator of care, change agent and role model.
• Initiate a plan to present oneself professionally for entry into the profession for assuming responsibility for practice and for facilitating the delivery of health care needed by the public.

Revised 5/14/02 – 10/02/02

Reviewed 5/16/07

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Effective clinical learning for nursing students

Approaches that meet student and nurse needs..

• Direct care nurses serve as significant teachers and role models for nursing students in the clinical setting.
• Building critical thinking skills is one of the most important outcomes in the clinical setting for nursing students.
• Collaboration with nursing faculty during the clinical rotation can ease the burden on direct care nurses and facilitate a positive learning experience for the student.

The nursing profession continues to experience several challenges—some longstanding and exacerbated by the COVID-19 pandemic. The shortage of nurses at the bedside and reports of nurses planning to leave the profession soon place stress on the workforce and the healthcare system. The situation has put even more pressure on nursing schools to recruit and retain students who enter the workforce well-prepared for practice and capable of filling these vacancies. However, concerns exist surrounding students’ critical thinking skills and their readiness for a demanding career.

The challenge

A longstanding shortage of nursing school faculty and a reliance on new graduate nurses to serve as preceptors create challenges to properly preparing nursing students for a demanding role that requires excellent critical thinking skills.

What-Why-How? Improving Clinical Judgement

New nurses and clinical judgment

Nurse faculty shortage

Lack of interest and incentives lead to difficulty recruiting nurses from the bedside or practice to education. Many 4-year schools require a terminal degree to teach full-time in their undergraduate programs, but only 1% of nurses hold a PhD. In addition, according to the National Advisory Council on Nurse Education and Practice (NACNEP), the average doctorally prepared nurse faculty member is in their 50s, which means they may soon retire. The surge in doctor of nursing practice programs has helped to bridge this gap, but attracting advanced practice nurses to academia from their more lucrative practice roles continues to prove difficult.

Concerns about the practice readiness of new graduate nurses have existed for several years. Missed clinical experiences and virtual learning during the COVID-19 pandemic heightened those concerns. The National Council of State Boards of Nursing (NCSBN) addressed the calls from nurse employers to make progress in this area by revamping the NCLEX-RN and NCLEX-PN exams to create Next Generation NCLEX (NGN), which includes more clinical judgment and critical thinking items. Nurse educators are working hard to prepare students for both practice and the new exam items by incorporating more active learning into classroom, clinical, and lab activities and emphasizing the importance of clinical judgment skills.

In most areas of the country, clinical student experiences have returned to pre-pandemic arrangements. State boards of nursing mandate maximum faculty-to-student ratios for clinical experiences. Schools can choose to have faculty supervise fewer students than the maximum, but faculty and clinical site shortages may eliminate that option. In many cases, preceptor-style experiences (such as capstone or practicum courses) have higher faculty-to-student ratios, and preceptors may have to meet specific criteria, such as a certain amount of experience.

Nursing faculty who facilitate on-site learning and supervise and teach students during their clinical experiences face several challenges. Some faculty supervise students across multiple units because unit size can’t accommodate 8 to 10 students at one time. Faculty may or may not have access to the organization’s electronic health records or other healthcare information technology, such as medication dispensing cabinets or glucometers.

In such instances, direct care nurses play an important role in the student’s experience at the clinical site. Their familiarity with the unit, the patient population, and the organization’s technology facilitates learning.

Direct care nurses

Allowing nursing students into the hospital can improve the patient care experience and potentially recruit students to work at the organization in the future. However, precepting a student or new employee creates an extra burden on an already overextended bedside nurse. NACNEP identifies several challenges for obtaining qualified preceptors, including lack of incentives and limited preparation in clinical teaching and learning strategies. Many hospitals have nursing students on the same unit several days a week to accommodate multiple area schools. This means that staff nurses are expected to teach students on most of their workdays during a typical school semester.

Unit nurse experience creates another barrier to effective precepting of nursing students. A study by Thayer and colleagues reported that the median length of experience for inpatient nurses working a 12-hour shift was less than 3 years at an organization. Without a better alternative, new graduate nurses frequently teach nursing students, although they may still be in what Benner describes as the advanced beginner stage of their career (still learning how to organize care, prioritize, and make clinical judgments). It’s difficult for someone who’s still learning and experiencing situations for the first time to teach complex concepts.

A guide to effective clinical site teaching

The following strategies promote critical thinking in students and collaboration with nurse faculty to ease direct care nurses’ teaching workload. Not every strategy is appropriate for all student clinical experiences. Consider them as multiple potential approaches to help facilitate meaningful learning opportunities.

Set the tone

Nursing students frequently feel anxious about clinical experiences, especially if they’ve been told or perceive that they’re a burden or unwanted on the unit. When meeting the student for the first time, welcome them and communicate willingness to have them on the unit.

If you feel that you can’t take on a student for the day, speak to the nurse faculty member and charge nurse to explore other arrangements. Nurse faculty recognize that work or personal concerns may require you to decline precepting a student. Faculty members want to find the best situation for everyone. If the charge nurse or supervisor determines that the student still needs to work with you, talk to the nurse faculty about how they can help ease the burden and facilitate the student’s learning experience for the day.

Begin your time with the student by asking about their experience level and any objectives for the day. Understanding what the student can or can’t do will help you make the most out of the clinical experience. You’ll want to know the content they’re learning in class and connect them with a patient who brings those concepts to life. A student may have assignments to complete, but their focus should be on patient care. Help the student identify the busiest parts of the day and the best time to review the electronic health record and complete assignments.

If a situation requires your full attention and limits training opportunities, briefly explain to the student what will happen. If you have time, provide the student with tasks or specific objectives to note during the observation. Involve the nursing faculty member to help facilitate the learning experience and make it meaningful.

Be a professional role model

Students like to hear about the benefits and rewards of being a nurse, and about each nurse’s unique path. Students also enjoy learning about the “real world” from nurses, but keep in mind that they’re impressionable. Speaking negatively about the unit, patients, organization, or profession may discourage the student. If you must deviate from standard care, such as performing a skill differently than it’s traditionally taught in school, provide the rationale or hospital policy behind the decision.

Feel free to discuss the student’s nursing school experience but don’t diminish the value of their education or assigned work. Keep in mind that school assignments, such as nursing care plans or concept maps, aren’t taught for job training but to deliberately and systematically promote critical thinking. These assignments allow a student to reflect on how a patient’s pathophysiology and nursing assessment and interventions relate to one another.

Reinforce how concepts students learn in school provide valuable knowledge in various settings. For example, if the student is on a medical-surgical unit but says that they want to work in obstetrics, engage the student by pointing out links between the two areas, such as managing diabetes and coagulation disorders. Provide encouragement and excitement about the student’s interest in joining the profession at a time of great need.

Build assessment skills

Explain to students your approach to performing assessments and organizing patient care. Most students learn comprehensive head-to-toe assessments but, in the clinical setting, need to focus on the most relevant assessments. To promote critical thinking, ask the student what data they should focus on gathering based on the patient’s condition. Many students focus on the psychomotor aspect of assessment (performing the assessment correctly); ask them about the subjective data they should gather.

Allow the student to perform an assessment and then compare findings. For example, a student may know that a patient’s lung sounds are abnormal but not remember what the sound is called or what it means. Provide them with the correct terminology to help connect the dots. Discuss with the student when reassessments are warranted. If appropriate, allow a student to reassess the patient (vital signs, output, pain, other physical findings) and then confirm their findings and discuss what any changes mean for the clinical situation. If you don’t have time for these types of discussions following a student’s patient assessment, ask nursing faculty to observe and discuss findings with the student.

Discuss care management

Take advantage of opportunities to discuss concepts such as prioritization, advocacy, delegation, collaboration, discharge planning, and other ways in which the nurse acts as a care manager. Pointing out what’s appropriate to delegate to unlicensed assistive personnel or a licensed practical nurse will prove valuable and help reinforce concepts frequently covered on the NGN exam.

Promote critical thinking

The NCBSN has introduced the Clinical Judgment Measurement Model (CJMM) as a framework for evaluating the NGN exam, which incorporates unfolding case studies that systematically address six steps: recognize cues, analyze cues, generate hypotheses, generate solutions, take action, and evaluate outcomes. Each candidate encounters three case studies, with six questions, one for each step of the CJMM. Nursing faculty incorporate this framework and language into the nursing curriculum to help students think systematically and critically and prepare them for the exam.

Nurses with practice experience use this type of framework to gather information, make judgments, and take action. As a nurse approaches Benner’s competent stage of nursing practice, this type of thinking becomes intuitive, and nurses may not even be aware of the conclusions they draw and decisions they make based on their clinical judgment skills. To help students understand why something is happening, they should continue to work through a process like this deliberately. For example, many students view medication administration as a simple task and may say in post-conference discussion, “All I did was give meds.” You perform many assessments and make various judgments while administering medications, but you may not think to discuss them with students. Asking questions of students while they’re performing what may seem like repetitive tasks can help prompt critical thinking. (See Critical questions .)

Critical questions

Enhance self-efficacy

Many nurses believe that the student must follow them to every patient. This can be overwhelming for the direct care nurse and a barrier to agreeing to work with students. Other approaches can better facilitate learning. Most students will complete an assignment focused on one or two patients. Encourage the student to spend time alone with those patients to perform a more comprehensive history and assessment, help patients with basic care, and provide education. Select a patient who might enjoy the extra attention to ensure a mutually beneficial experience.

Also, consider asking the student to find information using available resources. Such inquiry can benefit you and the student. For example, prompt a student to answer one or more critical thinking questions using their textbooks or resources available on the hospital’s intranet. If time prevents you from explaining complex topics or helping the student problem-solve, ask the student to take the information they find to their faculty member to review. Nurse faculty won’t be familiar with the specific details of all patients on the unit, so identify the most appropriate questions for the student to consider to help the nurse faculty facilitate learning.

Allowing the student time to find answers themselves builds self-efficacy and confidence and also relieves some of the stress and anxiety associated with being asked questions on the spot. This strategy also models the professional approach of using evidence-based resources to find information as needed in the clinical setting.

To ensure a positive learning experience and reduce anxiety, provide the student with ample time to prepare for performance-based skills. For example, identify an approximate time that medications will be administered to one patient and ask the student to independently look up the medication information by that time. This is more beneficial for the student than observing every patient’s medication administration or participating only in psychomotor tasks, such as scanning and giving injections. This also can free up your time by setting the expectation that the student will have the chance to prepare for and be directly involved in one medication pass.

Similarly, if an opportunity exists for practicing a psychomotor skill, such as inserting a urinary catheter or suctioning a tracheostomy, ask the student to review the procedure with their instructor using hospital policy and resources. If time doesn’t allow for a review, have the student observe to ensure provision of the best care and efficient use of time and resources.

Opportunities in education

Nurses who enjoy working with students or new staff members may want to consider academic roles. Many advanced nursing degrees, available in various formats, focus on education. For those who want to try teaching or have an interest in teaching only in the clinical setting, opportunities exist to work as adjunct faculty or to participate in hospital-based professional development activities. Adjunct faculty (part-time instructors) teach a variety of assignments and workloads, including in clinical, lab, or classroom settings. Many clinical adjunct faculty are nurses who also work in the organization with patients and may teach one group of students one day a week. Clinical and lab assignments vary from 4- or 6-hour experiences to 12-hour shifts.

According to NACNEP, most nursing programs require that adjunct faculty and clinical preceptors have the same or higher level of educational preparation as the program; for example, a nurse with a bachelor of science in nursing (BSN) may be able to teach clinicals for associate degree in nursing or BSN programs, depending on the state’s requirements and the school’s needs. Educational requirements to work in nursing programs vary by school. In some cases, adjunct faculty who don’t have a master’s degree may be supervised by full-time faculty with advanced degrees.

Benefits for adjunct faculty can include extra income, professional development, personal reward, tuition discounts or remissions, and giving back to the profession. Locate opportunities on nursing school websites or by talking to the nursing instructors or administrators in the local area.

Everyone benefits

Applying teaching approaches that benefit students and nurses can help ensure a positive clinical learning experience for everyone. When you graciously accept and teach students you help create positive encounters that enhance student critical thinking skill development, aid program retention, and support organizational recruitment.

Jennifer Miller is an assistant professor of nursing at the University of Louisville School of Nursing in Louisville, Kentucky .

American Nurse Journal. 2024; 19(4). Doi: 10.51256/ANJ042432

American Association of Colleges of Nursing. Nursing faculty shortage fact sheet. October 2022. aacnnursing.org/news-information/fact-sheets/nursing-faculty-shortage

Benner P. From Novice to Expert: Excellence and Power in Clin­i­cal Nursing Practice . Menlo Park, CA: Addison-Wesley; 1984.

National Advisory Council on Nurse Education and Practice. Preparing nurse faculty, and addressing the shortage of nurse faculty and clinical preceptors. January 2021. hrsa.gov/sites/default/files/hrsa/advisory-committees/nursing/reports/nacnep-17report-2021.pdf

National Council of State Boards of Nursing. Clinical Judgment Measurement Model. 2023. nclex.com/clinical-judgment-measurement-model.page

Thayer J, Zillmer J, Sandberg N, Miller AR, Nagel P, MacGibbon A. ‘The new nurse’ is the new normal. June 2, 2022. Epic Research. epicresearch.org/articles/the-new-nurse-is-the-new-normal

Key words: nursing students, nursing education, critical thinking, precepting

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All nursing programs need to put in more clinical time. Students do not get the time in clinicals so they do not have the opportunities to develop their clinical judgement and thinking skills. Clinical time is what glues concept and theory together if they don’t get the clinical time they are less likely to develop these skills which contributes to errors, burnout and nurses leaving the field.

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Effectiveness of Problem-Based Learning on Development of Nursing Students’ Critical Thinking Skills

A systematic review and meta-analysis.

Wei, Baojian MD; Wang, Haoyu BS; Li, Feng MSc; Long, Yan MSc; Zhang, Qi MSc; Liu, Hang MSc; Tang, Xiujun MSc; Rao, Mingjun MD

Author Affiliations: Adjunct Professor (Dr Wei), School of Nursing, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian, Shandong, China; and Instructor (Messrs Wang, Li, Zhang, Liu, and Tang and Ms Long), Professor (Mr Tang), and Adjunct Professor (Dr Rao), Department of Plastic Surgery, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China.

Correspondence: Dr Rao ( [email protected] ) and Mr Tang ( [email protected] ) , Department of Plastic Surgery, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China.

This work was supported by the Research Program of Taishan Medical College Education and Teaching Research Project (No. XY2018051).

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website ( www.nurseeducatoronline.com ).

Accepted for publication: September 17, 2023

Early Access: November 16, 2023

Cite this article as: Wei B, Wang H, Li F, Long Y, Zhang Q, Liu H, Tang X, Rao M. Effectiveness of problem-based learning on development of nursing students’ critical thinking skills: a systematic review and meta-analysis. Nurse Educ . 2024;49(3):E115-E119. doi:10.1097/NNE.0000000000001548

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Background: 

Problem-based learning (PBL) is a student-centered approach to teaching that has been applied in medical and nursing education. The effectiveness of PBL in promoting critical thinking in nursing students has been studied extensively with mixed results.

Purpose: 

The meta-analysis aimed to investigate the impact of PBL interventions on critical thinking skills of nursing students.

Methods: 

PubMed, Embase, Cochrane, and CINAHL databases were electronically searched. Methodological quality was examined using the Newcastle-Ottawa Scale and version 2 of the Cochrane risk-of-bias tool. Data were analyzed with 95% confidence intervals based on random-effect models.

Results: 

Nineteen studies involving 1996 nursing students were included in the analysis. The results of the analysis demonstrated greater improvement in critical thinking skills compared with the control group (overall critical thinking scores: standardized mean difference [SMD] = 0.47, 95% CI = 0.33-0.61, P < .01).

Conclusions: 

The meta-analysis indicates that PBL can help nursing students to improve their critical thinking.

Nursing occupies a critical role in health care. The profession entails a myriad of responsibilities, including recognizing patients’ symptoms, taking measures to administer medications, providing other measures to help relieve symptoms, and collaborating with other health care workers to optimize patients’ comfort and families’ understanding and adaptation. 1 To effectively fulfill these responsibilities, nurses require professional knowledge across various aspects of health care. 2 , 3 Critical thinking, an essential cognitive capacity, plays a pivotal role in enabling nurses to make informed decisions and fulfill their diverse roles. 4 It involves a combination of cognitive skills and affective dispositions, as defined by the American Philosophical Association, and positively influences clinical practice, patient health, student education, and the growth of nursing science. 5 , 6

Problem-based learning (PBL) is an innovative teaching method that has gained widespread application among institutions worldwide, particularly in the fields of medical and nursing education. 6 , 7 As described by Zakaria et al, 8 PBL is a student-centered, outcome-based approach that has been proven to enhance the quality of learning across various disciplines and academic levels. PBL is described as a process-focused teaching strategy that employs small groups centered on solving well-integrated clinical problems. Unlike traditional instruction, which relies heavily on lectures and limited self-directed learning, PBL encourages active problem-solving and collaboration among students. 9 PBL has been hailed as the “most significant innovation in education for professions in many years,” a testament to its transformative impact on the field of education. 10-12 Indeed, PBL has emerged as a game-changer in medical education, and its effects on nursing education have also been studied extensively. 13

Numerous studies have shown that PBL significantly enhances critical thinking skills (CT skills) among medical students. 14 As Hajrezayi et al note, critical thinking involves purposeful, self-regulatory judgment that results in interpretation, analysis, evaluation, and inference, skills that are invaluable in the clinical setting. 15 PBL, as a teaching strategy, focuses on engaging students in group discussions to address complex and ambiguous clinical problems. This process involves analyzing problems, setting objectives, gathering information, summarizing ideas, and reflecting on problem-solving experiences. 16 Research has demonstrated that this teaching strategy effectively develops critical thinking abilities in medical students. 17

However, the efficacy of PBL as a teaching method for enhancing critical thinking in nursing students remains a topic of debate among researchers. Previous systematic reviews evaluating critical thinking in PBL have produced mixed results, with some studies supporting a positive relationship between PBL and critical thinking and others disputing it. 18-20

To address these inconsistencies and provide a more comprehensive understanding of the effectiveness of PBL in promoting critical thinking in nursing students, we synthesized the data of previous studies published and conducted a more comprehensive meta-analysis.

Methodology for Meta-analysis

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure a systematic and transparent process. The PRISMA statement comprises a 27-item checklist and a 4-phase flow diagram, which guide the analysis. 21 We carefully applied each item on the checklist to guarantee transparent reporting of our systematic review, while the flow diagram helped us visualize and track the different stages of our analysis. The review protocol was registered on PROSPERO (PROSPERO ID: CRD42023406592).

Search Strategy

We conducted a comprehensive search of the literature using electronic databases (PubMed via National Library of Medicine, Embase via Elsevier, Cochrane via Cochrane library, and CINAHL via EBSCO) from inception to September 9, 2023, supplemented by a manual search of reference lists of relevant articles. There was no limit to search date, language, and publication period. We used a combination of keywords and MeSH terms related to the topic to optimize the search results, detailed in the supplementary material (see Supplemental Digital Content 1, available at: https://links.lww.com/NE/B450 ).

Study Selection

Two reviewers (R.M. and W.B.) independently screened the titles and abstracts for eligibility. Articles that did not meet the inclusion criteria were excluded. The same 2 reviewers then independently reviewed full texts of remaining articles for inclusion in the meta-analysis. Discrepancies were resolved through discussion and consensus with a third reviewer (T.X.).

Included studies satisfied the following criteria: (1) participants were nursing students including graduate and undergraduate nursing students, (2) the intervention group used PBL, (3) the control group used traditional lectures, (4) trials evaluated critical thinking, (5) reported sample size, mean difference, and standard deviation of critical thinking scores. Excluded studies included nonnursing subjects, interventions other than PBL, no critical thinking evaluation, and incomplete/duplicate articles. Both randomized and nonrandomized controlled trials were included.

Data Extraction

Two reviewers independently extracted data from the included studies using a standardized data extraction form. The data extracted included study characteristics (author, year of publication, and country), participant characteristics (sample size and grade), description of PBL, teaching methods combined with PBL, research of design, and critical thinking tools (the mean difference from baseline to post-test, as well as standard deviation). Any discrepancies were resolved through discussion and consensus with a third reviewer.

Quality Assessment

Two reviewers independently assessed the quality of the included studies using a Newcastle-Ottawa Scale (NOS) for cohort studies, and version 2 of the Cochrane risk-of-bias tool for randomized trials. A study was considered as high quality if the NOS score was 7 or more, moderate quality if the NOS score between 4 and 7, and low quality if the NOS score less than 4. As for version 2 of the Cochrane risk-of-bias tool, when there are “some concerns” (or high risk of bias ratings) in some domains, the overall risk of bias is rated as “some concerns” (or high), respectively. Any discrepancies were resolved through discussion and consensus with a third expert.

Data Analysis

We used a random-effects model to pool the effect sizes across studies. To determine the significance of our findings, we set a threshold of a 2-sided P value less than .05 for all analyses. We assessed heterogeneity using the I 2 statistic and P value of Cochran's Q statistic, P value < .10 and I 2 > 50% were considered as heterogeneity. The I 2 statistic, which indicates the percentage of variation attributed to heterogeneity, was an easily interpretable way to assess the degree of heterogeneity. We considered an I 2 statistic of 25% to 50% to indicate low heterogeneity, 50% to 75% to indicate moderate heterogeneity, and more than 75% to indicate high heterogeneity. If there is heterogeneity, we explored potential sources of heterogeneity using subgroup analyses based on the duration of PBL intervention (hours or weeks), the grade of nursing students, and the assessment tools of CT skills. We conducted sensitivity analyses to examine the robustness of the findings and assessed publication bias using funnel plots and Egger's test. All analyses are conducted using R software.

Ethics Approval

As this study is a meta-analysis of previously published studies, no ethical approval was required.

We conducted a thorough review of available literature on PBL interventions for nursing students and ultimately obtained 19 studies (see Supplemental Digital Content 2, available at: https://links.lww.com/NE/B451 ).

Study Characteristics

All included studies were published between 2004 and 2021 and involved 1996 nursing students from Iran (n = 3), South Korea (n = 8), China (n = 6), the United States (n = 1), and Turkey (n = 1). The participants included first-year, second-year, third-year, fourth-year, and graduates with a work experience ranging from 1 to 21 years; 1876 participants were undergraduate nursing students while 120 participants were graduate nursing students with a work experience ranging from 1 to 21 years. The length of the PBL intervention period varied, with 7 articles lasting less than 12 weeks and 9 articles lasting 12 weeks or more. PBL interventions were integrated with various teaching methods, including simulation, case-based learning, teamwork, concept mapping, clinical practice, internet, and tutors as guides (tutors help clarify concepts and answer questions).

To assess the critical thinking, 18 included studies adopted different assessment tools including the California Critical Thinking Skills Test (CCTST, n = 6), California Critical Thinking Dispositions Inventory (CCTDI, n = 5), Assessment Technologies Institute Critical Thinking Test (n = 1), Watson-Glaser Critical Thinking Scale (n = 1), and critical thinking tools developed by Yoon (n = 2), Kwon (n = 2), Park (n = 1), McMaster University (n = 1). Among these assessment tools, the CCTST and CCTDI stand out as the primary tools utilized in the studies. The detailed characteristics were presented in Supplemental Digital Content 3, available at: https://links.lww.com/NE/B452 .

Risk of Bias

Nine of the 12 cohort studies had a low risk of bias (see Supplemental Digital Content 4, available at https://links.lww.com/NE/B453 ). However, all 7 randomized controlled studies had a high risk of bias (see Supplemental Digital Content 5, available at: https://links.lww.com/NE/B454 ). None of the randomized controlled studies specified whether the allocation sequence was concealed until participants were enrolled and assigned to interventions, nor were they able to conceal their allocation from the participants, the teachers, and the outcome assessors during the trial.

Meta-analysis Results

Nineteen studies involving 1996 participants (PBL group = 941, lecture group = 1055) reported overall critical thinking scores. The pooled effect size showed significant difference (standardized mean difference [SMD] = 0.47, 95% CI = 0.33-0.61, P < .001) in favor of PBL, compared with traditional lectures (see Supplemental Digital Content 6, available at: https://links.lww.com/NE/B455 ). There was moderate heterogeneity ( I 2 = 52%, P < .01).

Subgroup Analysis and Publication Bias

We conducted further subgroup analyses to explore the underlying sources of heterogeneity. Regarding nursing students of different grades, compared with second-year students, the critical thinking scores of the first- and third-year improved more, but there was no clear pattern of higher or lower critical thinking scores among higher grades (see Supplemental Digital Content 7, available at: https://links.lww.com/NE/B456 ). Additionally, we conducted subgroup analysis based on the different assessment tools used in the studies and discovered that nursing students who took the CCTST had higher scores compared with the CCTDI. Furthermore, the subgroup analysis based on intervention time showed that an intervention duration with fewer weeks and more hours had a greater improvement in critical thinking scores (see Supplemental Digital Content 7, available at: https://links.lww.com/NE/B456 ). This may suggest that nursing students who receive more intensive PBL course arrangements exhibited a higher improvement in critical thinking scores.

Furthermore, during the PBL process, nursing students who visualize the ideas, concepts, and terms using concept mapping show better improvement in critical thinking abilities (see Supplemental Digital Content 7, available at: https://links.lww.com/NE/B456 ). Additionally, students who receive help from teachers to clarify concepts and solve problems also demonstrate better improvement in critical thinking abilities. It is worth noting that among the 9 studies where teachers played a significant role in guiding students (clarifying concepts and answering questions rather than simply directing the slow of the PBL), all were published in 2008 or later. In contrast, among the 9 clinical studies where teachers only assisted in implementing PBL, 4 were published before 2008. This suggests that teachers play a more important role during the development of the PBL teaching strategy.

We conducted a funnel plot analysis to determine the degree of symmetry in our results and conducted Egger's regression test to determine publication bias (see Supplemental Digital Content 8, available at: https://links.lww.com/NE/B457 ). The results showed no publication bias, with bias = 0.7445 ( t = 0.6, df = 7, P = .5580).

In this meta-analysis, we found that PBL has a greater impact on CT skills of nursing students compared with traditional lectures. In the past 2 decades, there have been several meta-analyses published on this topic, but the earlier meta-analysis did not support our current conclusion, that the PBL teaching strategy can improve nursing students’ critical thinking ability compared with traditional lectures. 18 After incorporating more studies, our meta-analyses has new findings that differ from previous meta-analysis.

The discrepancy between our conclusions and those of earlier meta-analyses can be attributed to the continuous improvement of the PBL teaching strategy itself. 22 , 23 Our meta-analysis supported that teachers played a more important role in the development of the PBL teaching strategy. Teachers in the earlier studies mainly helped implement the PBL teaching strategy, teachers in the more recent studies encouraged students to think critically and gave timely feedback. Originally introduced as a novel teaching strategy in medical education, teachers primarily act as a procedural guide, our meta-analysis suggests that increased teacher engagement in the PBL teaching process can enhance nursing students’ critical thinking abilities. Although exhaustively providing students with answers to their questions as a directive lecturer is not conducive to fostering students’ critical thinking abilities, students might be dismayed when their teachers rarely directly answer a question, but instead ask questions back and let the student find the answer independently. 24

Throughout the ongoing improvement of the PBL teaching strategy, case-based learning has been integrated. Cases present clinical problems to nursing students in a fragmented manner, fostering their autonomy in constructing a knowledge framework to investigate the problems and address the presented challenges. 25 Furthermore, the assistance of concept mapping and teamwork during the PBL teaching process further improved the PBL teaching strategy. 26 , 27

Despite various advantages demonstrated by the PBL teaching strategy over the past few decades, it is imperative that we carefully evaluate both the benefits and drawbacks of adopting this teaching strategy over traditional lecture-based learning methods. One of the most celebrated aspects of the PBL teaching strategy is its ability to situate information within the context of real-life clinical problem-solving, bridging the gap between textbook knowledge and practical application. 23 On the other hand, PBL necessitates teachers to invest substantial effort in guiding students’ self-directed learning, while medical institutions should acknowledge adequate resources to support the PBL teaching strategy. 28 Nevertheless, it is worth noting that implementing the PBL teaching strategy effectively may pose challenges for teachers who are accustomed to traditional lecture-based strategy, necessitating additional training to ensure competence in the PBL teaching strategy.

Furthermore, we must acknowledge that clinical problem-solving through the PBL teaching strategy is a complex cognitive task that involves hypothesis generation from ambiguous clues. It requires reasoning based partly on fuzzy categorical knowledge, partly on probabilities, and partly on understanding the urgency and risk-benefit relationship of potential treatments. 29 In essence, for clinical problem-solving to become a meaningful experience, nursing students must possess knowledge and experience directly tied to the clinical problems. Traditional lecture-based learning methods afford teachers the opportunity to assist students in constructing knowledge frameworks based on their own expertise experience. 30 However, in the realm of PBL teaching, students, due to their limited foundational knowledge, may pose numerous seemingly inconsequential questions, potentially appearing chaotic, time-consuming, and misguided in the eyes of teachers. 31 To mitigate this challenge, some studies have leveraged concept mapping and the internet to facilitate rapid access to relevant knowledge, aiding nursing students in comprehending clinical problems. 32 , 33 Moreover, experienced PBL teachers play a pivotal role in helping nursing students build a robust knowledge base by promptly answering their questions. 34

Moreover, the current trend in PBL teaching involves employing cases as guides for learning in specific content areas. In this situation, nursing students typically only learn the definition of possible treatments when the clinical problems are presented. This approach often simplifies the complexities and exceptional aspects of clinical cases, which may serve as illustrative examples of important concepts, which may lack practicality in the actual practice of clinical problem-solving. 31 , 35 However, as nursing students engage in independent collection of background information, teachers help guide them in applying and refining their critical thinking skills to attempt to understand the reading materials, not limiting themselves to textbooks or the small world of their peers and teachers. They are quickly guided into a broader world, namely the current cutting-edge medical issues, by the latest medical articles as well as expert teachers. 25

Our meta-analysis indicates that the PBL teaching strategy can enhance critical thinking skills in nursing students.

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• Program Learning Outcomes

Nursing Learning Outcomes (NLOs)

Upon completion of the Jacksonville State University (JSU) School of Nursing (SON) programs, the student will be competent in and demonstrate critical thinking, therapeutic nursing interventions, effective communication, and professional behavior. 

• Critical thinking (CT) reflects skills in reasoning, analysis, evidence-based practice, and decision making relevant to the discipline of nursing. Critical thinking encompasses knowledge, skills, and values from the arts and sciences to provide safe and quality care to diverse populations.  Critical thinking integrates knowledge and skills in leadership, quality improvement, and safety in providing high quality health care. Critical thinking examines the role of financial and regulatory health policies and their effects on health care systems.
• Therapeutic Nursing Interventions (TNI) reflect the ability to safely perform theory and/or evidence-based patient centered nursing interventions reflective of professional knowledge, skills, and attitudes. TNI reflect the synthesis of evidence-based practice to improve patient outcomes and identify practice issues.
• Effective Communication (EC) reflects the students’ interpersonal relationship skills reflective of professional values/attitudes evidenced through effective written, oral, and nonverbal communication, group process, use of information technology, and the ability to adapt communication to needs of the patient/family, colleagues, health care team and situation. Effective Communication reflects synthesis of communication and collaboration as an interprofessional team member to deliver high quality, safe patient centered care. 
• Professional behavior (PB).  JSU SON embraces the professional values promulgated by the American Association of Departments of Nursing (AACN) and the American Association of Nursing (ANA) Code of Ethics.  Professional behavior expectations, in both classroom and clinical settings, include respect for all, a primary commitment to the patient, advocacy for the health, safety and rights of patients, responsibility and accountability for one’s own nursing practice, duty to self to maintain integrity, competence and professional growth, ownership of a healthy work/health care environment, contributions to the advancement of the profession, interprofessional collaboration, and the articulation of nursing’s values and the shaping of social policy. 

Program Learning Outcomes (PLOs) (undergraduate)

Based on the essentials of baccalaureate education for professional nursing practice (aacn, 2008), graduates of the baccalaureate nursing program will be able to:.

Synthesize knowledge, skills, and values from the arts and sciences to provide safe and quality care to diverse populations. (Critical Thinking and Therapeutic Nursing Interventions)

Integrate knowledge and skills in leadership, quality improvement, and safety in providing high quality health care. (Critical Thinking, Therapeutic Nursing Interventions, and Effective Communication)

Synthesize evidence-based practice to improve patient outcomes and identify practice issues.   (Critical Thinking, Therapeutic Nursing Interventions, and Effective Communication)

Synthesize knowledge and skills related to information management systems and patient care technology to deliver safe and effective evidence-based care. (Critical Thinking and Therapeutic Nursing Interventions)

 Examine the role of financial and regulatory health policies and their effects on health care systems. (Critical Thinking and Professional Behavior)

Synthesize effective communication and collaboration as an interprofessional team member to deliver high quality, safe patient care. (Effective Communication and Professional Behavior)

Analyze programs for health promotion, disease, and injury prevention across the lifespan to improve individual, family, and population health (Critical Thinking and Therapeutic Nursing Interventions)

Emulate core values associated with professionalism to ensure responsibility and accountability to the nursing profession. (Professionalism Behavior)

• Synthesize knowledge, skills, and values that ensure high quality, patient centered care. (Critical Thinking, Therapeutic Nursing Interventions, Effective Communication, and Professional Behavior)

Program Learning Outcomes (PLOs) (MSN-Population Health)

Based on the essentials of master’s education in nursing (aacn, 2011), graduates of the graduate nursing program will be able to:.

• Synthesize theories from the humanities and the natural, behavioral, and applied sciences which support advanced clinical practice and role development. (Critical Thinking, Therapeutic Nursing Interventions, and Professional Behavior); (MSN Essentials I and Essential II)
• Develop advanced practice expertise to affect positive health care outcomes for vulnerable populations. (Critical Thinking and Therapeutic Nursing Interventions); (MSN Essential IX)
• Assume accountability for ethical values, principles, and personal beliefs that acknowledge human diversity and influence professional practice decisions and nursing interventions. (Critical Thinking, Therapeutic Nursing Interventions, Effective Communication and Professional Behavior); (MSN Essential VIII)
• Employ effective communication and technology within the multidisciplinary collaborative context of advanced community health nursing practice. (Therapeutic Nursing Interventions, Effective Communication, and Professional Behavior); (MSN Essentials V and VII)
• Design cost-effective interventions/strategies collaboratively with multiple disciplines for the purpose of providing quality health care within the community. (Therapeutic Nursing Interventions and Effective Communication); (MSN Essential III)
• Evaluate research findings for the development and implementation of evidence-based practice guidelines. (Therapeutic Nursing Interventions and Effective Communication); (MSN Essential IV)
• Evaluate health care issues, trends, and policies for application to the health status of communities. (Therapeutic Nursing Interventions, Effective Communication and Professional Behavior); (MSN Essential VI)

Program Learning Outcomes (PLOs) (Doctor of Nursing Practice)

Based on the essentials of doctoral education for advanced nursing practice (aacn, 2006), graduates of the dnp program will be able to:.

• Practice nursing at the highest level, demonstrating knowledge, skills, and attributes essential to advanced practice in the designated pathway for advanced practice. ( Essential VI, VII, and VIII; DLOs CT, TNI, PB, and EC)
• Analyze, lead, and manage complex and diverse health care organizations and be responsive to a changing health care environment. ( Essential II, II, IV, VI, and VII; DLOs CT, PB, and EC)
• Function as nurse scholars to advocate and ensure quality outcomes-based care utilizing evidence to guide best practice. ( Essential I, III, IV, V, VI, and VIII; DLOs CT, TNI, PB, and EC)
• Apply information and patient care technology to transform patient care delivery. ( Essentials II, III, IV, VI, and VIII; DLOs CT, TNI, PB, and EC)
• Participate in development of health care policy and lead as an advocate for improvements in the health care system. ( Essentials II, V, VI, and VII; DLOs CT, PB, and EC)
• Participate in interprofessional teams as leader and consultant to deliver optimal, evidence-based care to patients and populations. ( Essentials II, III, IV, VI, VII, and VIII; DLOs CT, TNI, PB, and EC)
• Design and apply evidence-based strategies for clinical prevention and population health to improve the nation's health. ( Essentials III, IV, V, VI, and VII; DLOs CT, PB, and EC)

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Factors associated with the critical thinking ability among nursing students: An exploratory study in Iran

Affiliations.

• 1 Students Research Committee, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran; Student Research Committee, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran.
• 2 Students Research Committee, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran.
• 3 Department of Emergency Nursing, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran. Electronic address: [email protected].
• PMID: 37925833
• DOI: 10.1016/j.nepr.2023.103814

Background and objective: Critical thinking is a crucial skill in nursing that nursing students should apply in their work environment. It involves analyzing, evaluating, and interpreting information. It is used in various topics such as disease diagnosis, treatment planning and implementation, monitoring, and evaluation of results, problem-solving, and decision-making in emergencies. This study in Iran aimed to evaluate factors associated with nursing students' critical thinking ability.

Study method: Following the STROBE guidelines, an analytical cross-sectional study was conducted in Ardabil province, northwest Iran. The study collected data through convenience sampling at nursing schools in Ardabil province, with a sample of 246 nursing students participating. The data collected from a demographic information form and the Persian version of the Nursing Critical Thinking in Clinical Practice Questionnaire were analyzed using SPSS version 22.0 software.

Results: The study found that the overall mean score of clinical critical thinking among nursing students was 313.87 ± 25.80 (range = 109-436). Based on this score, most students reported low (63%) or moderate (37%) clinical critical thinking levels. The highest and lowest mean scores between dimensions were related to the intellectual and cognitive (127.99 ± 13.30) and technical (17.25 ± 3.43), respectively. Multiple linear regression analysis revealed that semester and college were predictors of clinical critical thinking among nursing students. The selected predictors accounted for 19.3% of the total variance in clinical critical thinking scores (F = 9.396, p < 0.001).

Conclusion: The study results showed that nursing students could have performed better in critical thinking ability. The study suggests that nursing education programs should prioritize teaching critical thinking skills in clinical settings as it is an essential subject in nursing education. With significant changes in nursing clinical environments, enhancing clinical critical thinking can improve nursing student performance clinically. Therefore, one of the crucial learning objectives in a clinical nursing course is to develop clinical critical thinking skills for nursing students.

Keywords: Clinical practice; Critical thinking; Iran; Nursing care; Nursing student.

Copyright © 2023 Elsevier Ltd. All rights reserved.

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Conflict of interest statement

Declaration of Competing Interest No conflicts of interest has been declared by the authors.

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• Published: 06 April 2023

Application of flipped classroom based on CDIO concept combined with mini-CEX evaluation model in the clinical teaching of orthopedic nursing

• Xinyang Su 1 ,
• Huaxiu Ning 1 ,
• Fang Zhang 2 ,
• Xiaoling Zhang 1 &
• Hongmei Xu 3  

BMC Medical Education volume  23 , Article number:  219 ( 2023 ) Cite this article

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After the COVID-19 epidemic, the state has paid more attention to the clinical teaching function of affiliated hospitals of colleges and universities. Strengthening the integration of medicine and education and improving the quality and effect of clinical practice teaching are critical challenges facing medical education. The difficulty of orthopedic teaching lies in the characteristics of a wide variety of diseases, strong professionalism, and relatively abstract characteristics, which affect the initiative, enthusiasm, and learning effect of nursing students. In this study, a flipped classroom teaching plan based on the CDIO (conceive–design–implement–operate) concept was constructed and practiced in the orthopedic nursing student training course to improve the effect of practical teaching, and it is convenient for teachers to implement more effective and targeted teaching in the flipped classroom of nursing education and even medical education in the future.

Fifty undergraduate nursing students who practiced in the Orthopedics Department of a tertiary hospital in June 2017 were enrolled in the control group, while 50 undergraduate nursing students who practiced in the same department in June 2018 were enrolled in the intervention group. The intervention group adopted the flipped classroom teaching mode of the CDIO concept, whereas the control group adopted the traditional teaching mode. After finishing the department practice task, the students in the two groups completed the evaluation of theory, operation skills, independent learning ability, and critical thinking ability. They completed the evaluation of clinical practice ability in eight dimensions, including four processes of nursing procedures, humanistic care ability, and evaluation of clinical teaching quality for two groups of teachers.

After teaching, the clinical practice ability, critical thinking ability, autonomous learning ability, theoretical and operational performance, and evaluation of clinical teaching quality in the intervention group were significantly higher than those in the control group (all p < 0.05).

The CDIO-based teaching mode can stimulate the independent learning ability and critical thinking ability of nursing interns, promote the organic combination of theory and practice, improve their ability to comprehensively use theoretical knowledge to analyze and solve practical problems, and improve teaching effectiveness.

Peer Review reports

Clinical teaching is a critical phase in nursing education that involves the transition from theoretical knowledge to practice. Effective clinical teaching can help nursing students master professional skills, strengthen their professional knowledge, and improve their ability to perform nursing activities. It is also the final stage in the transition of nursing students’ professional roles [ 1 ]. In recent years, many clinical teaching researchers have investigated problem-based learning (PBL), case-based learning (CBL), team-based learning (TBL), and situational learning in clinical teaching, scenario simulation teaching, and other teaching methods. However, different teaching methods have their own merits and shortcomings regarding the teaching effectiveness of the practice link, but they have not achieved the integration of theory and practice [ 2 ].

Flipped classroom refers to a new teaching mode in which students learn diversified learning materials independently before class with the help of a certain information platform, complete homework in the form of “cooperative learning” and other forms in class, and at the same time, teachers answer questions and provide individualized help [ 3 ]. The American New Media Alliance noted that the flipped classroom readjusts the time inside and outside the classroom and transfers students’ learning decisions from teachers to students [ 4 ]. Valuable time in the classroom in this teaching mode allows students to focus more on active problem-based learning. Deshpande [ 5 ] carried out a flipped classroom in the teaching of doctor assistant education, and concluded that flipped classroom can improve students’ learning enthusiasm and academic performance, and shorten the class time.Khe Foon HEW and Chung Kwan LO [ 6 ] examined the findings of comparative articles through a meta-analysis to summarize the overall effects of teaching with the flipped classroom approach, suggesting that the flipped classroom approach in health profession education significantly improves student learning compared with traditional teaching methods. Zhong J [ 7 ] compared the effectiveness of blended learning between a flipped virtual classroom and a flipped physical classroom on students’ knowledge learning and discovered that in a flipped classroom with a blended learning process of histology, enhancing the quality of online learning boosts student satisfaction and improves knowledge learning. Based on the above research, it is found that in nursing education, most scholars study the impact of flipped classrooms on classroom teaching effects and believe that flipped classroom teaching can improve nursing students’ academic performance, autonomous learning ability, and classroom satisfaction.

Therefore, to promote nursing students to internalize systematic professional knowledge in their hearts and externalize it in practice to improve their clinical practice ability and comprehensive quality, it is urgent to explore and construct a novel teaching method.CDIO (conceive–design–implement–operate) is an engineering education model developed in 2000 by four universities, including the Massachusetts Institute of Technology and the Royal Swedish Institute of Technology. It is an advanced engineering education model that allows nursing students to learn and acquire competencies in an active, hands-on, and organically linked way among courses [ 8 , 9 ]. On the subject of teaching, this model emphasizes "student-centered” students participate in the conception, design, implementation, and operation of the project and transform the theoretical knowledge they have learned into a tool for solving problems. Several studies have revealed that the CDIO teaching mode is conducive to improving the clinical practice ability and comprehensive quality of nursing students, enhancing the interaction between teachers and students, improving the teaching effect, and playing a certain role in promoting the informatization and optimization reform of teaching methods. Currently, it is widely used in the field of applied talent training [ 10 ].

With the transformation of the global medical model, the demand for health is increasing, and higher burdens of responsibility are also placed on medical personnel. The ability and quality of nurses are directly related to the quality of clinical care and patient safety. Recently, cultivating and evaluating the clinical ability of nursing staff have become hotspots in the nursing field [ 11 ]. Therefore, an objective and comprehensive evaluation method with high reliability and validity is vital for medical education research. Mini-clinical evaluation exercise (mini-CEX), an assessment method for evaluating the comprehensive clinical ability of medical students, has been widely used in the field of multidisciplinary medical education in China and abroad. It has gradually emerged in the field of nursing [ 12 , 13 ].

At present, several studies have reported the application of the CDIO model, flipped classroom, and mini-CEX in nursing education. Wang Bei [ 14 ] discussed the effect of the CDIO model on improving special nursing training oriented to the nursing needs of the new coronary pneumonia disease. The results demonstrated that using the CDIO teaching model to carry out special nursing training on the new coronary pneumonia disease is conducive to the nursing staff to better master specialized nursing training skills and related knowledge, comprehensively improving their comprehensive nursing ability. Liu Mei [ 15 ] and other scholars discussed the application of a team-based teaching method combined with a flipped classroom in the training of orthopedic nurses, and the results depict that the teaching mode can effectively improve the core competencies of orthopedic nurses such as understanding and application of theoretical knowledge, teamwork, critical thinking and scientific research. Li Ruyue [ 16 ] researched the application effect of the improved Nursing Mini-CEX in the standardized training of new surgical nurses and found that teachers can find their weaknesses in clinical teaching or work by using Nursing Mini-CEX to evaluate the whole process of assessing nurses and giving real-time feedback. In the link between self-supervision, self-reflection, absorbing the bright spots in the assessment of nurses’ work, adjusting the teaching plan, and further improving the quality of clinical teaching, students can improve the comprehensive ability of surgical clinical nursing, test the actual clinical processing ability in different situations, deeply understand and improve nursing work, and cultivate strong professional ethics and communication skills.However, no study has reported the application of a CDIO concept-based flipped classroom combined with mini-CEX evaluation model in the teaching of orthopedic nursing students. The author employed the CDIO model in the design of the orthopedic nursing student training course, constructed a flipped classroom based on the CDIO concept and combined the mini-CEX evaluation model, realized the“three-in-one”training mode of knowledge, ability, and quality, promoted continuous improvement in teaching quality, to provide a reference for practical teaching in teaching hospitals.

Materials and methods

Study design.

A prospective controlled experimental design was used in this study.

Participants

To facilitate the implementation of the course, convenience sampling was used to select the 2017 and 2018 undergraduate nursing students who practiced in the Orthopedics Department of a tertiary hospital as the research objects. Since there were 52 interns at each level, the sample size was 104. Four students did not participate in full clinical practice.Fifty undergraduate nursing students who practiced in the Orthopedics Department of a tertiary hospital in June 2017 were enrolled in the control group, including 6 males and 44 females; aged 20 to 22 (21.30 ± 0.60) years old; fifty undergraduate nursing students who practiced in the same department in June 2018 were enrolled in the intervention group, including 8 males and 42 females, aged 21 to 22 (21.45 ± 0.37) years old. All subjects gave informed consent. Inclusion criteria: (1)Orthopedic intern nursing students with a bachelor’s degree. (2)Informed consent and voluntary participation in this study. Exclusion criteria: Those who cannot fully participate in the clinical practice. There was no significant difference in the general data of the two groups of trainee nursing students (p > 0.05), which was comparable.

Training methods

Both groups had a four-week-long clinical practice, and all courses were completed in the orthopedic department.During the observation period, there were ten batches of nursing students, with five students in each batch. The teaching was completed in accordance with the nursing student practice syllabus, which included two parts: theory and skill operation. The two groups of teachers had the same qualifications, and the teaching nurse was responsible for the quality control of teaching.

Control group

The control group adopted the traditional teaching method. In the first week of admission, the teaching commenced on Monday. The teacher taught the theory on Tuesday and Wednesday, and the operation training was concentrated on Thursday and Friday. From the second to the fourth week, each teacher was responsible for one nursing student to conduct random teaching in the department. In the fourth week, the assessment and evaluation were completed three days before leaving the department.

Intervention group

As stated earlier, the author adopted the flipped classroom teaching method based on the CDIO concept, described as follows.

The first week of teaching was the same as that of the control group; the second to fourth weeks of orthopedic perioperative teaching adopted a flipped classroom teaching plan based on the CDIO concept, with a total of 36 class hours. The conception and design part was completed in the second week, and the implementation part was completed in the third week. The operation was completed in the fourth week, and the assessment and evaluation were completed three days before leaving the department. Specific allocations of class hours are presented in Table  1 .

Step one: form a teaching team

A teaching team consisting of one head nurse in charge of teaching, eight orthopedic teachers, and one non-orthopedic CDIO nursing expert was established. The head nurse organized teaching group members to study and master the CDIO outline and standards, the CDIO workshop manual, and other related theories and specific implementation methods (for no less than 20 hours) and consulted experts at any time on challenging problems in theoretical learning. In accordance with the requirements of Adult Nursing and the syllabus of practice, the teaching team formulated teaching objectives, led teaching plans, and prepared lessons uniformly.

Step two: setting teaching objectives

According to the internship training syllabus, referring to the CDIO talent training syllabus and standards [ 17 ], and combining with the characteristics of orthopaedic nursing teaching, the teaching objectives of the internship nursing students were set in three dimensions, namely knowledge objectives (mastering basic professional knowledge and related system processes, etc.), ability objectives (enhance professional basic skills, critical thinking ability and autonomous learning ability, etc.) and quality objectives(establish correct professional values and humanistic care spirit, etc.).Among them, the knowledge objectives correspond to the technical knowledge and reasoning of the CDIO syllabus, which corresponds to the personal ability, professional ability, and attitude of the CDIO syllabus, and the quality objectives correspond to the interpersonal skills of the CDIO syllabus: teamwork and communication.

Step three: develop a teaching plan

After two rounds of meetings, the teaching team discussed the flipped classroom nursing practice teaching plan based on the CDIO concept, divided the teaching into four stages, and determined the goals and outlines, as summarized in Table  1 .

Step four: implement the CDIO teaching model

Project conceive.

After analyzing the nursing work on orthopedic ailments, the teacher conceived the cases of common diseases and frequently occurring orthopedic diseases. Take the nursing program for patients with lumbar disc herniation as an example: Patient Zhang Moumou (male, 73 years old, 177 cm tall, and 80 kg in weight) complained of “low back pain with left lower limb numbness and pain for 2 months” and was admitted to the outpatient clinic As a responsible nurse: (1) Please systematically take the medical history based on the knowledge you have learned and judge what happened to the patient; (2) Select the systemic and specialist evaluation approach according to the condition and propose the inspection items that require further evaluation; (3) When making a nursing diagnosis, find the basis in the case; write out the targeted nursing measures related to the patient; and (4) Discuss the problems existing in the patient’s self-management and the current method and content of the patient’s discharge follow-up. Post the student case and task list two days before the class. The task list for this case is as follows: (1) Review and consolidate theoretical knowledge on the etiology and clinical manifestations of lumbar disc herniation; (2) Make a targeted nursing plan; (3) Design this case according to clinical work to execute two main scenario simulation learning projects of pre- and post-operative nursing. Nursing students independently previewed the course content with case questions, consulted relevant literature and databases, and completed the self-learning tasks in the form of WeChat group solitaire check-in.

Project design

Students freely formed unit teams,the team chose a team leader, and the team leader was responsible for the division of labor and coordination of the project. The pre-class team leader was responsible for allocating the four contents of case introduction, nursing procedure implementation, health education, and disease-related knowledge to each team member. Students sought theoretical basis or materials for solving case problems in their spare time during the internship, discussing in teams and perfecting specific project plans. While designing the project, the teacher assisted the team leader in assigning team members to be responsible for sorting out relevant knowledge points, designing and producing projects, demonstrating and revising projects, and instructing nursing students to integrate professional-related knowledge points into the design and experience the knowledge of each module. The difficulties and key points of this group were sorted out and designed to implement the scenario simulation implementation plan for this group. Teachers also organized a bedside nursing ward round demonstration at this stage.

Project implementation

Students made project reports in teams. After the report was over, other group members and teachers discussed and commented on the report group to further improve the nursing plan. The team leader led the team members to simulate the overall nursing process, and the teacher guided the students to deepen their understanding and construction of theoretical knowledge and develop critical thinking ability through learning the dynamic changes of the disease during the simulation practice.The practical operations that need to be completed in the development of specialist diseases were completed under the guidance of teachers, who commented on and led nursing students to complete bedside practices to achieve the integration of knowledge points and clinical practices.

Project operation

After the assessment of each group, the teacher made comments, noted the strengths and weaknesses of the members of each group in the process of content arrangement and skill operation, and continuously improved the nursing students’ understanding of the teaching content.After the project, teachers completed the analysis of teaching quality and optimized the curriculum according to the assessment results of nursing students and their evaluation of teaching.

Observation indicators

Theory and operational assessment.

Nursing students completed the theory and operation examinations after practical teaching. Theoretical intervention questions were set by the instructor.The intervention papers were divided into two sets (A and B), and one set was randomly selected for the intervention. The intervention questions were divided into two parts, specialist theoretical knowledge and case analysis, each with 50 points, for a total of 100 points. Nursing skills assessment students randomly selected one of them, including axial turning technique, good limb placement technique for patients with spinal cord injury, the technique of using air pressure therapy apparatus, the technique of using CPM Joint rehabilitation machine, etc. The full score is 100 points.

Self-directed learning ability evaluation scale

In the fourth week, the assessment of Self-directed learning ability evaluation scale was conducted three days before leaving the department.The self-directed learning ability evaluation scale developed by Zhang Xiyan [ 18 ] was used, including learning motivation (8 items), self-management ability (11 items), learning cooperation ability (5 items), and information literacy (6 items).Each item was scored on a 5-point Likert scale, that is, from “completely inconsistent” to “completely consistent”, with 1 to 5 points. The total score is 150 points, and the higher the score, the stronger the autonomous learning ability. The scale Cronbach’s alpha coefficient was 0.822.

Critical thinking ability assessment scale

In the fourth week, the assessment of Critical Thinking Ability Assessment Scale was conducted three days before leaving the department.The Chinese version of the Critical Thinking Ability Assessment Scale translated by Meici [ 19 ] was used. It has seven dimensions, including finding the truth, open mind, analytical ability, and systematization ability, with 10 items for each dimension. A 6-level scoring was used, that is, from “strongly disagree” to “strongly agree,” with 1 to 6 points, respectively, and negative statements were scored in reverse, with a total score of 70 to 420 points. A total score of ≤ 210 indicates negative performance, 211–279 indicates neutral performance, 280–349 indicates positive performance, and ≥ 350 indicates strong critical thinking ability. The scale Cronbach’s alpha coefficient was 0.90.

Assessment of clinical practice ability

In the fourth week, the assessment of clinical practice ability was conducted three days before leaving the department.The mini-CEX scale used in this study was adapted from YiJing [ 20 ] in accordance with mini-CEX, with 1–3 points for not meeting the requirements, 4–6 points for meeting the requirements, and 7–-9 points for good. Nursing students completed their training after the completion of the specialist practice. The Cronbach’s alpha coefficient of the scale was 0.780, and the split-half reliability coefficient was 0.842, indicating good reliability.

Evaluation of teaching quality

In the fourth week,a teacher-student symposium and the evaluation of teaching quality were conducted the day before leaving the department.The teaching quality evaluation table was designed by Zhou Tong [ 21 ], including five aspects: teaching attitude, teaching content, teaching method, teaching effect, and teaching characteristics. A 5-point Likert scale was used. The higher the score, the better the teaching quality. Completed after completion of the specialist internship. The questionnaire has good reliability, the Cronbach’s alpha coefficient of the scale was 0.85.

Data analysis

SPSS 21.0 statistical software was used to analyze the data. Measurement data were expressed as mean ± standard deviation ( \(\overline X \pm S\) ), and group t intervention was used for comparison between groups. Enumeration data were expressed as cases (%), and comparison was made using chi-squared intervention or Fisher’s exact intervention. p-value < 0.05 corresponded to a statistically significant difference.

The comparison of the theoretical and operational intervention scores of the two groups of nursing interns is shown in Table  2 .

Comparison of scores of independent learning ability and critical thinking ability of nursing interns in the two groups are shown in Table  3 .

Comparison of the clinical practice ability assessment of nursing interns in the two groups.The clinical nursing practice ability of the students in the intervention group was significantly better than that in the control group, and the difference was statistically significant (p < 0.05), as shown in Table  4 .

The teaching quality evaluation results of the two groups showed that the total score of teaching quality in the control group was 90.08 ± 2.34 points, and the total score of teaching quality in the intervention group was 96.34 ± 2.16 points, and the difference was statistically significant (t = − 13.900, p < 0.001).

The development and progress of medicine require medical talents to conduct sufficient practice accumulation. Although there are many simulation and simulation training methods, they cannot replace clinical practice, which is directly related to the level of future medical talents to treat diseases and save lives. After the new crown epidemic, the state paid more attention to the clinical teaching function of the affiliated hospitals of colleges and universities [ 22 ]. Strengthening the integration of medicine and education and improving the quality and effect of clinical practice teaching are critical challenges facing medical education. The difficulty of orthopedic teaching lies in the characteristics of a wide variety of diseases, strong professionalism, and relatively abstract characteristics, which affect the initiative, enthusiasm, and learning effect of nursing students [ 23 ].

The flipped classroom teaching method of CDIO teaching concept integrates teaching content with the process of teaching, learning, and doing. It changes the structure of the teaching classroom and makes nursing students the backbone of the teaching scene. In the teaching process, teachers guide nursing students to independently consult relevant materials for difficult nursing problems in typical cases [ 24 ]. Research has shown that CDIO involves the task designing and activity of clinical practice teaching. The design provides detailed guidance, which closely integrates the consolidation of specialized knowledge points and the cultivation of hands-on operation ability and finds problems during simulation, which is beneficial for nursing students to improve their independent learning ability and critical thinking ability in self-study and guidance. The results of this study showed that the scores of autonomous learning ability and critical thinking ability of nursing students in the intervention group were significantly higher than those in the control group after four weeks of training (both p < 0.001). This is consistent with Fan Xiaoying’s research results [ 25 ], who studied the application effect of CDIO combined with the CBL teaching method in internal medicine nursing teaching. This teaching method can significantly improve the critical thinking and autonomous learning abilities of interns.In the conception stage, the teacher first handed out the difficult points in the classroom case to the nursing students. The nursing students then learned relevant information independently through the micro-lecture videos and actively searched for relevant materials to further enrich their understanding of orthopedic nursing work. In the design process, nursing students, under the guidance of their teachers, relied on cases and exercised teamwork and critical thinking skills in group discussions. In the realization stage, the teachers took the actual disease perioperative nursing as an opportunity and used the scenario simulation teaching method to guide the nursing students to execute scenario drills under group cooperation to familiarize themselves with and find out the problems in the nursing work. At the same time, in teaching real cases, nursing students could learn the key points of pre- and post-operative nursing so that they could clearly understand that each link of perioperative nursing is an important factor in patients’ post-operative rehabilitation. In the operation link, teachers guided nursing students to master theories and skills in practice. At the same time, they learned to observe changes in the condition and think about possible complications in actual cases so that they no longer memorized various nursing procedures by rote and helped nursing students. In the process of construction and implementation, the teaching-related content was organically integrated. In this participatory, interactive, and experiential learning process, nursing students’ autonomous learning ability and learning enthusiasm were well mobilized, and their critical thinking ability was improved.Scholars used a Design Thinking (DT)-Conceive-Design-Implement-Operate (CDIO) engineering design framework in a fipped web programming course to develop students’ learning achievement and computational thinking (CT) abilities, and the results displayed that the students significantly improved their learning achievement and computational thinking ability [ 26 ].

In this study, nursing students were guided to participate in the whole process according to the process of“asking questions- conception- design- implementation -operation-summary.”First, teachers published cases, designed problems, guided nursing students to conceive, and designed clinical situations. Then, based on group collaboration and independent thinking, supplemented by the teacher answering questions, students put forward solutions to problems to complete data collection, situational exercises, and finally complete bedside practice. The results of the study showed that the scores of the theoretical knowledge assessment and operation skills assessment of nursing students in the intervention group were better than those in the control group, and the differences were statistically significant (p < 0.001),and this was consistent with the findings of related research [ 27 , 28 ]. The reason for the analysis is that in the CDIO model, the disease knowledge points with higher morbidity are first selected, and second, the difficulty of item setting is in line with the fundamental level. In this model, after learning the practical content, students complete the project task book as needed, check the relevant content again, and discuss the tasks with the group members to realize the digestion and absorption of the learning content and summarize the new knowledge and the old knowledge in a new way. The mastery of knowledge is improved.

This study shows that through the application of the CDIO clinical teaching model, the nursing students in the intervention group were better than the nursing students in the control group in terms of nursing consultation, physical examination, determination of nursing diagnosis, implementation of nursing measures, and humanistic care. Furthermore, statistically significant differences were found in each dimension between the two groups (p < 0.05), which was similar to the results of Hongyun [ 29 ]. Zhou Tong [ 21 ] studied the application effect of the teaching mode under the guidance of the conception-design-implementation-operation concept (CDIO) in the clinical practice teaching of cardiovascular specialist nursing and found that the students in the experimental group who adopted the CDIO clinical practice teaching method were significantly better than those who adopted the traditional teaching method in the eight dimensions of nursing procedures, humanistic care ability, and overall.It may be because in the learning process, nursing students no longer passively accept knowledge but use their various abilities to acquire knowledge. Team members give full play to team spirit to integrate learning resources and repeatedly report, practice, analyze, and discuss clinical practical nursing problems, cognition from the shallower to the deeper, and pay more attention to the specific content of the cause analysis of health problems, the formulation of nursing goals, and the feasibility analysis of nursing measures. Teachers guide and demonstrate in the discussion to form a cyclic stimulus of perception–practice–response to guide nursing students to complete a meaningful learning process and improve the clinical practice abilities of nursing students, improve the interest and efficiency of learning, and continuously improve the ability to learn from theory to practice while completing the internalization of knowledge.

The application of the CDIO-based clinical teaching scheme improved the quality of clinical teaching. The research results of Ding Jinxia [ 30 ] and others suggest a correlation between various dimensions of learning motivation, autonomous learning ability, and the effective teaching behavior of clinical teachers.In this study, with the development of CDIO clinical teaching, clinical teachers received several specialized trainings, updated teaching concepts, and improved their teaching abilities. Second, it enriches the clinical teaching cases and teaching content of cardiovascular nursing and grasps the orderliness and operability of the teaching mode from a macro perspective, which is conducive to students’ understanding and memory of the course content. The feedback after each lecture can promote clinical teachers’ self-awareness and urge clinical teachers to reflect on their own skills, professional level and humanistic accomplishment to truly achieve mutual teaching and improve the quality of clinical teaching. The results showed that the teaching quality of clinical teachers in the intervention group was better than that in the control group,which was similar to Xiong Haiyan’s research results [ 31 ].

Limitations and suggestions

Although the findings of this study are valuable for clinical teaching, there are still many limitations in our research. First, the use of convenience sampling may limit the generalization of these findings, and we also had a limited sample for one tertiary hospital. Second, the training is conducted only four weeks, and the critical thinking skills of nursing interns need more time to develop. Third, in this study, the patients used in Mini-CEX are real patients who have not been trained, the quality completed by the nursing interns may vary from patient to patient. These are the main issues that limit the findings of this study. Future research is needed to expand the sample size, and increase the training of clinical teachers, unify the design standards of teaching cases. Longitudinal studies should also be conducted to examine whether the flipped classroom based on the concept of CDIO can foster the comprehensive ability of nursing students over a long period.

Conclusions and implications

This study developed the CDIO model in designing an orthopedic nursing student training course, constructed a flipped classroom based on the CDIO concept, and combined the mini-CEX evaluation model. The results indicated that the flipped classroom based on the concept of CDIO improved students’ independent learning ability, critical thinking ability, and clinical practice abilities while improving the quality of clinical teaching. This teaching method was more credible and effective than the traditional lectures. It can be concluded that study results may have implications for medical education. The flipped classroom, based on the concept of CDIO, has significant potential to prepare students for performing clinical work by focusing on teaching, learning, and doing, which closely integrates the consolidation of specialized knowledge points and the cultivation of hands-on operation ability. Because of the importance of involving students in learning and practicing for positive, it is proposed that the CDIO-based clinical teaching mode can be used in medical education considering all aspects. This method can also be recommended as an innovative and student-centered method for clinical teaching. In addition, the results can be extremely helpful to policymakers and academics in developing strategies for improving medical education.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgments

The authors would like to convey their gratitude to the Nursing Department of the Binzhou Medical University Hospital and all the nursing staff of the Orthopedics Department for their thoughtful support of this project.

The present study was funded by Shandong Province Medical and Health Science and Technology Development Plan Research Project(No.2017WS550).

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Xinyang Su, Huaxiu Ning & Xiaoling Zhang

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Study design: Xinyang Su, Hongmei Xu,Huaxiu Ning. Data collection:Fang Zhang and Xiaoling Zhang. Statistical analysis: Li Liu. Manuscript writing and editing: Xinyang Su, Huaxiu Ning, Hongmei Xu. All authors gave approval for the fInal manuscript.

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Su, X., Ning, H., Zhang, F. et al. Application of flipped classroom based on CDIO concept combined with mini-CEX evaluation model in the clinical teaching of orthopedic nursing. BMC Med Educ 23 , 219 (2023). https://doi.org/10.1186/s12909-023-04200-9

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DOI : https://doi.org/10.1186/s12909-023-04200-9

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The effects of simulation-based education on undergraduate nursing students' competences: a multicenter randomized controlled trial

• Lai Kun Tong 1 ,
• Yue Yi Li 1 ,
• Mio Leng Au 1 ,
• Wai I. Ng 1 ,
• Si Chen Wang 1 ,
• Yongbing Liu 2 ,
• Yi Shen 3 ,
• Liqiang Zhong 4 &
• Xichenhui Qiu 5  

BMC Nursing volume  23 , Article number:  400 ( 2024 ) Cite this article

Metrics details

Education in nursing has noticed a positive effect of simulation-based education. There are many studies available on the effects of simulation-based education, but most of those involve a single institution, nonrandomized controlled trials, small sample sizes and subjective evaluations of the effects. The purpose of this multicenter randomized controlled trial was to evaluate the effects of high-fidelity simulation, computer-based simulation, high-fidelity simulation combined with computer-based simulation, and case study on undergraduate nursing students.

A total of 270 nursing students were recruited from five universities in China. Participants were randomly divided into four groups at each institution: the high-fidelity simulation group, the computer-based simulation group, the high-fidelity simulation combined with computer-based simulation group, and the case study group. Finally, 239 participants completed the intervention and evaluation, with 58, 67, 57, and 57 participants in each group. The data were collected at three stages: before the intervention, immediately after the intervention, and three months after the intervention.

The demographic data and baseline evaluation indices did not significantly differ among the four groups. A statistically significant difference was not observed between the four methods for improving knowledge, interprofessional collaboration, critical thinking, caring, or interest in learning. While skill improvement differed significantly among the different groups after the intervention ( p  = 0.020), after three months, no difference was observed ( p  = 0.139). The improvement in skill in the computer-based simulation group was significantly lower at the end of the intervention than that in the high-fidelity simulation group ( p  = 0.048) or the high-fidelity simulation combined with computer-based simulation group ( p  = 0.020).

Conclusions

Nursing students benefit equally from four methods in cultivating their knowledge, interprofessional collaboration, critical thinking, caring, and interest in learning both immediately and over time. High-fidelity simulation and high-fidelity simulation combined with computer-based simulation improve skill more effectively than computer-based simulation in the short term. Nursing educators can select the most suitable teaching method to achieve the intended learning outcomes depending on the specific circumstances.

Trial registration

This clinical trial was registered at the Chinese Clinical Trial Registry (clinical trial number: ChiCTR2400084880, date of the registration: 27/05/2024).

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Introduction

There are many challenges nursing students face in the clinical setting because of the gap between theory and practice, the lack of resources, and unfamiliarity with the medical environment [ 1 ]. Nursing education needs an innovative teaching method that is more closely related to the clinical environment. Simulation-based education is an effective teaching method for nursing students [ 2 ]. It provides students with an immersive clinical environment for practicing skills and gaining experience in a safe, controlled setting [ 3 ]. This educational approach not only supports the development of various competencies [ 2 , 4 ], including knowledge, skill, interprofessional collaboration, critical thinking, caring, and interest in learning, but also enables students to apply learned concepts to complex and challenging situations [ 5 ].

Manikin-based and computer-based simulations are commonly employed simulators in nursing education. Manikin-based simulation involves the use of a manikin to mimic a patient’s characteristics, such as heart and lung sounds [ 6 ]. Computer-based simulation involves the modeling of real-life processes solely using computers, usually with a keyboard and monitor as inputs and outputs [ 6 ]. According to a recent meta-analysis, manikin-based simulation improves nursing students' knowledge acquisition more than computer-based simulation does, but there are no significant differences in confidence or satisfaction with learning [ 4 ].

Based on the level of fidelity, manikin-based simulation can be categorized as low, medium, or high fidelity [ 7 ]. High-fidelity simulation has become increasingly popular since it replaces part of clinical placement without compromising nursing student quality [ 8 ]. Compared to other teaching methods, high-fidelity simulation is associated with elevated equipment and labor costs [ 9 ]. To enhance cost-effectiveness, it is imperative to maximize the impact of high-fidelity simulation. To improve learning outcomes, mixed learning has gained popularity across higher education in recent years [ 10 ]. The most widely used mixed learning method for simulation education in the nursing field is high-fidelity simulation combined with computer-based simulation. There have been only a few studies on the effect of high-fidelity simulation combined with computer-based simulation on nursing students, and these are either pre-post comparison studies without control groups [ 11 ] or quasi-experimental studies without randomization [ 12 ]. To obtain a better grasp of the effects of combining high-fidelity simulation and computer-based simulation, a randomized controlled trial is needed.

In addition to enhancing effectiveness, optimizing cost-effectiveness can be achieved by implementing cost reduction measures. Case study, which eliminates the need for additional equipment, offers a relatively low-cost alternative. A traditional case study provides all pertinent information, whereas an unfolding case study purposefully leaves out information [ 13 ]. It has been shown that unfolding case study fosters critical thinking in students more effectively than traditional case studies [ 14 ]. Despite being regarded as an innovative and inexpensive teaching method, there is little research comparing unfolding case study with other simulation-based teaching methods. To address this knowledge gap, further study is necessary.

An umbrella review highlights that the existing literature on the learning outcomes of simulation-based education predominantly emphasizes knowledge and skills, while conferring limited focus on other core competencies, such as interprofessional collaboration and caring [ 15 ]. Therefore, future research should evaluate various learning outcome indicators.

This multicenter randomized controlled trial aimed to assess the effectiveness of high-fidelity simulation, computer-based simulation, high-fidelity simulation combined with computer-based simulation, and case study on nursing students’ knowledge, skill, interprofessional collaboration, critical thinking, caring, and interest in learning.

Study design

A multicenter randomized controlled trial was conducted between March 2022 and May 2023 in China. The study conforms to the CONSORT guidelines. This clinical trial was registered at the Chinese Clinical Trial Registry (clinical trial number: ChiCTR2400084880, date of the registration: 27/05/2024).

Participants and setting

Participants were recruited from five universities in China, two of which were private and three of which were public. Among the five universities, four were equipped with two high-fidelity simulation laboratories. Specifically, three universities had laboratories simulating intensive care unit wards and delivery rooms, while the remaining university had two laboratories simulating general wards. Additionally, one university possessed a high-fidelity simulation laboratory specifically designed to simulate a general ward setting. Three universities utilized Laerdal patient simulators in their laboratories, while the other two universities employed Gaumard patient simulators.

A recruitment poster with the time and location of the project promotion was posted on the school bulletin board. The research team provided a briefing to students at the designated time and location indicated on the poster, affording them the opportunity to inquire about and enhance their understanding of the project.

The study mandated that participants fulfill the following criteria: 1) enroll in a nursing undergraduate program; 2) have full-time student status; 3) complete courses in Anatomy and Physiology, Pathophysiology, Pharmacology, Health Assessment, Basic Nursing, and Medical and Surgical Nursing (Respiratory System); 4) have proficiency in reading and writing Chinese; and 5) participate voluntarily. Those who met the following criteria were excluded: 1) had a degree or diploma and 2) took the course again.

The sample size was calculated through the use of G*Power 3.1, which was based on F tests (ANOVA: Repeated measures, between factors). Several assumptions were taken into consideration, including a 5% level of significance, 80% power, four groups, three measurements, and a 0.50 correlation between pre- and postintervention time points. Compared to other teaching methods, high-fidelity simulation exhibited a medium effect size (d = 0.49 for knowledge, d = 0.50 for performance) [ 16 ]. The calculation employed a conservative approach, accommodating a small yet clinically significant effect size (0.25), thereby bolstering the reliability and validity of the findings. Based on these assumptions, the total sample size required was determined to be 124, with each group requiring 31 participants.

Randomization and blinding

Due to inconsistent teaching schedules at the five universities involved in the study, the participants were divided into four groups at each institution: the high-fidelity simulation group, the computer-based simulation group, the high-fidelity simulation combined with computer-based simulation group, and the case study group. Participant grouping was carried out by study team members who were not involved in the intervention or evaluation. The participants were each assigned a random nonduplicate number between zero and 100 using Microsoft Excel. The random numbers/participants were divided into four groups based on quartiles: the lower quarter, the lower quarter to a half, the half to three-fourths, and the upper quarter were assigned to the high-fidelity simulation group, the computer-based simulation group, the high-fidelity simulation combined with computer-based simulation group, and the case study group, respectively. It was not possible to implement participant blinding because the four teaching methods differed significantly, while effect evaluation and data analysis were conducted in a blinded manner. Each participant was assigned a unique identifier to maintain anonymity throughout the study.

Baseline test

Baseline testing started after participant recruitment had ended, so the timing of the study varied between universities. The baseline test items were the same for all participants and included general characteristics, knowledge, skills, interprofessional collaboration, critical thinking, caring, and interest in learning. The evaluation of skills was conducted by trained assessors, whereas a non-face-to-face online survey was utilized for the assessment of others.

Intervention

The four groups were taught with three scenarios covering the three different cases, in the following order: asthma worsening, drug allergy, and ventricular fibrillation. These three cases represent commonly encountered scenarios necessitating emergency treatment. It is anticipated that by means of training, students can enhance their aptitude to effectively handle emergency situations within clinical settings. It is vital that the case used in simulation-based education is valid so that its effectiveness can be enhanced [ 17 ]. The cases used in this study were from vSim® for Nursing | Lippincott Nursing Education, which was developed by Wolters Kluwer Health (Lippincott), Laerdal Medical, and the National League for Nursing. Hence, the validity of the cases can be assured. Participants received all the materials, including learning outcomes, theoretical learning materials, and case materials (medical history and nursing document), at least one day before teaching. All the teachers in charge of teaching participated in the meeting to discuss the lesson plans to reach a consensus on the lesson plans. The lesson plans were written by three members of the research team and revised according to the feedback. Table 1 shows the teaching experience of each case in the different intervention groups. The instructors involved had at least five years of teaching experience and a master's degree or higher.

Posttest and follow-up test

The posttest was conducted within one week of the intervention using the same items as those used in the baseline test. The follow-up test was administered after three months of the intervention.

General characteristics

The general characteristics of the participants included gender, age, and previous semester grade.

This was measured by five multiple-choice items developed for this study. The items were derived from the National Nurse Licensing Examination [ 18 ]. The maximum score was five, with one awarded for each correct answer. The questionnaire exhibited high content validity (CVI = 1.00) and good reliability (Kuder-Richardson 20 = 0.746).

The Creighton Competency Evaluation Instrument (CCEI) is designed to assess clinical skills in a simulated environment by measuring 23 general nursing behaviors. This tool was originally developed by Todd et al. [ 19 ] and subsequently modified by Hayden et al. [ 20 ]. The Chinese version of the CCEI has good reliability (Cronbach’s α = 0.94) and validity (CVI = 0.98) [ 21 ]. The CCEI was scored by nurses with master’s degrees who were trained by the research team and blinded to the intervention information. A dedicated person was assigned to handle the rating for each university, and the raters did not rotate among the participants. The Kendall's W coefficient for the raters' measures was calculated to be 0.832, indicating a high level of interrater agreement and reliability. All participants were tested using a high-fidelity simulator, with each test lasting ten minutes. The skills test without debriefing employed a single-person format, and the nursing procedures did not rely on laboratory results, so the items "Delegates Appropriately," "Reflects on Clinical Experience," "Interprets Lab Results," and "Reflects on Potential Hazards and Errors" were excluded from the assessment. The total score ranged from 0–19 and a higher score indicated a higher level of skill.

• Interprofessional collaboration

The Assessment of the Interprofessional Team Collaboration Scale for Students (AITCS-II Student) was used to assess interprofessional collaboration. It consists of 17 items rated on a 5-point Likert scale (1 = never, 5 = always), for a total score ranging from 17 to 85 [ 22 ]. The Chinese version of the AITCS-II has good reliability (Cronbach’s α = 0.961) and validity [ 23 ].

• Critical thinking

Critical thinking was measured by Yoon's Critical Thinking Disposition Scale (YCTD). It is a five-point Likert scale with values ranging from 1 to 5, resulting in a total score ranging from 27 to 135 [ 24 ]. Higher scores on this scale indicate greater critical thinking ability. The YCTD has good reliability (Cronbach’s α = 0.948) and validity when applied to Chinese nursing students [ 25 ].

Caring was assessed using the Caring Dimensions Inventory (CDI), which employs a five-point Likert scale ranging from 25 to 125 [ 26 ]. Higher scores on the CDI indicate a greater level of caring. The Chinese version of the CDI exhibited good reliability (Cronbach’s α = 0.97) and validity [ 27 ].

• Interest in learning

The Study Interest Questionnaire (SIQ) was used to assess interest in learning. The SIQ is a four-point Likert scale ranging from 18 to 72, where a higher total score indicates a greater degree of interest in the field of study [ 28 ]. The SIQ has good reliability (Cronbach’s α = 0.90) and validity when applied to Chinese nursing students [ 29 ].

Ethical considerations

The institution of the first author granted ethical approval (ethical approval number: REC-2021.801). Written informed consent was obtained from all participants. Participants were permitted to withdraw for any reason at any time without penalty. Guidelines emphasizing safety measures and precautions during the intervention were provided to participants, and study coordinators closely monitored laboratory and simulation sessions to address concerns or potential harm promptly.

Data analysis

Descriptive statistics were used to describe the participant characteristics and baseline characteristics. Continuous variables are presented as the mean and standard deviation, while categorical variables are presented as frequencies and percentages. According to the Quantile–Quantile Plot, the data exhibited an approximately normal distribution. Furthermore, Levene's test indicated equal variances for the variables of knowledge, skill, interprofessional collaboration, critical thinking, caring, and interest in learning, with p-values of 0.171, 0.249, 0.986, 0.634, 0.992, and 0.407, respectively. The baseline characteristics of the four groups were compared using one-way analysis of variance. The indicators of knowledge, skill, interprofessional collaboration, critical thinking, caring, and interest in learning were assessed at baseline, immediately after the intervention, and three months postintervention. Changes in these indicators from baseline were calculated for both the postintervention and three-month follow-up periods. The changes among the four groups were compared using one-way analysis of variance. Cohen's d effect sizes were computed for the between-group comparisons (small effect size = 0.2; medium effect size = 0.5; large effect size = 0.8). Missing data were treated as missing without imputation. The data analysis was conducted using jamovi 2.3.28 ( https://www.jamovi.org/ ). Jamovi was developed on the foundation of the R programming language, and is recognized for its user-friendly interface. The threshold for statistical significance was established at a two-sided p  < 0.05.

Participants

A total of 270 participants were initially recruited from five universities for this study. However, an attrition rate of 11.5% was observed, resulting in 31 participants discontinuing their involvement. Consequently, the final analysis included data from 239 participants who successfully completed the intervention and remained in the study. Specifically, there were 58 participants in the high-fidelity simulation group, 67 in the computer-based simulation group, 57 in the high-fidelity simulation combined with computer-based simulation group, and 57 in the case study group (Fig.  1 ). The participant demographics and baseline characteristics are displayed in Table  2 , and no significant differences were observed in these variables.

Study subject disposition flow chart

Efficacy outcomes

All the intervention groups showed improvements in knowledge after the intervention, with the high-fidelity simulation group showing the greatest improvement (Fig.  2 ). However, there were no significant differences in knowledge improvement among the groups (p = 0.856). The computer-based simulation group and case study group experienced a decrease in knowledge compared to baseline three months after the intervention, while the other groups showed an increase in knowledge. The high-fidelity simulation combined with computer-based simulation group performed best (Fig.  3 ), but no significant differences were observed (p = 0.872). The effect sizes between groups were found to be small, both immediately after the intervention and at the three-month follow-up (Table  3 ).

Changes in all effectiveness outcomes at post intervention. Note: A  High-fidelity simulation group; B  Computer-based simulation group; C  High-fidelity simulation combined with computer-based simulation group; D  Case study group

Changes in all effectiveness outcomes at three months of intervention. Note: A  High-fidelity simulation group;  B  Computer-based simulation group;  C  High-fidelity simulation combined with computer-based simulation group;  D  Case study group

The different intervention groups showed improvements in skills after the intervention and three months after the intervention. The high-fidelity simulation combined with computer-based simulation group showed the greatest improvement after the intervention (Fig.  2 ), while the greatest improvement was observed in the high-fidelity simulation group three months after the intervention (Fig.  3 ). There was a significant difference in the improvement in skills among the different groups after the intervention ( p  = 0.020). Specifically, the improvement observed in the computer-based simulation group was significantly lower than that in both the high-fidelity simulation group ( p  = 0.048) and the high-fidelity simulation combined with computer-based simulation group ( p  = 0.020). However, three months after the intervention, there was no statistically significant difference in skill improvement among the groups ( p  = 0.139). Except for the between-group effect sizes of the high-fidelity simulation group compared to the computer-based simulation group (Cohen d = 0.51) and the computer-based simulation group compared to the high-fidelity simulation combined with computer-based simulation group (Cohen d = 0.56), the effects were found to be medium after the intervention, while the other between-group effect sizes were small both after the intervention and three months after the intervention (Table  3 ).

In all intervention groups except for the high-fidelity simulation group, interprofessional collaboration improved after the intervention and three months after the intervention, with the case study group (Figs. 2 and 3 ) demonstrating the greatest improvement. No significant difference was found between the intervention groups after or three months after the intervention in terms of changes in interprofessional collaboration. Both immediately following the intervention and three months later, the effect sizes between groups were small (Table  3 ).

After the intervention and three months after the intervention, the critical thinking of all the intervention groups improved. Among them, the high-fidelity simulation group improved the most after the intervention (Fig.  2 ), while the computer-based simulation group improved the most three months after the intervention (Fig.  3 ). However, no statistically significant differences were observed in the improvement of critical thinking across the different groups. The between-group effect sizes of each group were small both after the intervention and three months after the intervention (Table  3 ).

Caring improved following the intervention in all intervention groups, with the exception of the high-fidelity simulation group and case study group (Fig.  2 ). However, no significant difference was observed between the intervention groups in terms of changes ( p  = 0.865). A decrease in caring was observed three months after the intervention in all intervention groups, except for the case study group (Fig.  3 ). Nevertheless, no statistically significant difference was detected between the intervention groups in terms of changes (p = 0.607). Both immediately following the intervention and three months later, the effect sizes between groups were small (Table  3 ).

In terms of interest in learning, both the high-fidelity simulation group and the high-fidelity simulation combined with computer-based simulation group improved after the intervention or three months later. Among the groups, the high-fidelity simulation combined with computer-based simulation group improved the most after both the intervention and three months after the intervention (Figs. 2 and 3 ). However, no statistically significant difference was detected between the intervention groups in terms of changes either after the intervention (p = 0.144) or three months after the intervention (p = 0.875). Both immediately following the intervention and three months later, the effect sizes between groups were small (Table  3 ).

To our knowledge, this study is the first multicenter randomized controlled trial to explore the effects of different simulation teaching methods on nursing students' competence and the first study in which multiple different indicators were evaluated simultaneously. The indicators included both objectively assessed indicators of knowledge and skills and subjectively assessed indicators of interprofessional collaboration, critical thinking, caring, and interest in learning. This study assessed the immediate and long-term effects of the intervention by examining its immediate impact as well as its effects three months postintervention.

The results obtained from this study indicate that high-fidelity simulation, computer-based simulation, high-fidelity simulation combined with computer-based simulation, and case study could improve nursing students’ knowledge immediately after intervention. Furthermore, these four teaching methods exhibited comparable effectiveness in improving knowledge. The findings of this study contradict previous meta-analyses that showed that high-fidelity simulation improved nursing students' knowledge over other teaching techniques [ 2 ]. This discrepancy may be attributed to the inclusion of simulation teaching in the previous study alongside theoretical teaching [ 12 ], whereas the current study solely employed simulation teaching without incorporating theoretical instruction. Notably, three months following the intervention, computer-based simulation and case study did not result in knowledge retention. Conversely, high-fidelity simulation, particularly when combined with computer-based simulation, demonstrated knowledge retention, with the latter exhibiting superior performance in this regard. The realistic nature of the simulation provided students with a context in which to apply their knowledge, enhancing their understanding of key concepts [ 30 ]. High-fidelity simulation surpasses computer-based simulation and case study in terms of realism. When combined with computer-based simulation, this approach affords students the opportunity to practice their knowledge in a safe environment while also providing them with access to additional resources and learning opportunities [ 31 ]. Therefore, in this study, high-fidelity simulation combined with computer-based simulation proved to be the most effective at retaining knowledge.

Four simulation-based education strategies were found to be effective at acquiring and retaining skills by the students in this study. High-fidelity simulation combined with computer-based simulation was found to be more effective at acquiring skill than was using either method alone. This method combines the benefits of both teaching methods, providing students with a comprehensive learning experience that combines physical realism and virtual interactivity [ 32 ]. Hybrid simulation creates a seamless learning experience in which individuals can practice their skills in a simulated environment, receive immediate feedback, and then transfer those skills to real-world situations. This integration provides a seamless transition from theoretical knowledge to practical skills, making it easier for individuals to apply what they have learned and enhance their overall performance [ 33 ]. Hybrid simulation may seem to be an attractive option [ 34 ]; however, this study found that hybrid simulation had no advantage in terms of skill retention; rather, high-fidelity simulation performed best. More research is needed in the future to confirm the results of this study and the underlying reasons since previous studies have not compared hybrid simulation with high-fidelity simulation on skill retention.

The findings of this study reveal a noteworthy observation: interprofessional collaboration improved across all interventions, except for high-fidelity simulation. This finding diverges from prior studies that indicated high-fidelity simulation as a more effective method for enhancing students' interprofessional collaboration compared to traditional case study [ 35 ]. This discrepancy may be attributed to the use of an unfolding case study in the current study, wherein patient scenarios evolve unpredictably, thereby prompting students and team members to engage in heightened collaborative efforts to address evolving patient care challenges [ 36 ]. Interprofessional collaboration plays a crucial role in improving healthcare outcomes. Studies have shown that when healthcare professionals collaborate effectively, patients experience better outcomes, fewer errors, and shorter hospital stays [ 37 ]. While high-fidelity simulation has gained popularity as a training tool, according to the results of this study, its impact on interprofessional collaboration remains limited. There may be two reasons for this. First, high-fidelity simulation scenarios are often time constrained [ 38 ], which can hinder effective interprofessional collaboration. Each team member may prioritize their individual goals or tasks, making it difficult to achieve optimal teamwork and coordination. Second, interprofessional team members may not have worked together extensively, which can hinder their ability to collaborate effectively in a high-fidelity simulation setting. It takes time to build trust and rapport, which may not be readily available in a simulated environment [ 39 ]. Despite being assigned the roles of senior nurse or junior nurse, participants in the high-fidelity simulation group were provided with the opportunity to engage with peers at various levels and individuals from different professions, such as instructors assuming the role of doctors. However, the duration of the simulation section for this group was limited to only 10 min. In contrast, participants in the computer-based simulation group and case study group were allocated 30 min and 35 min, respectively. It is crucial for healthcare institutions and educators to critically evaluate their simulation-based training programs and incorporate key components that promote interprofessional collaboration [ 40 ].

This study revealed that four interventions effectively promoted students' critical thinking, and these effects lasted for three months after the interventions. Furthermore, high-fidelity simulation was most effective at improving critical thinking in the short term, whereas computer-based simulation was most effective at fostering long-term improvements. High-fidelity simulation involves creating a realistic and immersive environment that closely resembles a real-world scenario [ 41 ]. This approach affords individuals the opportunity to actively participate and immerse themselves in the simulated scenario, thereby enhancing their experiential understanding [ 3 ]. Computer-based simulation does not provide the same immediate and tangible experience as high-fidelity simulation. High-fidelity simulation commonly incorporates the utilization of medical devices and mannequins that closely resemble clinical scenarios, thereby affording students a more authentic and immersive learning encounter. Only 5% of students perceive computer-based simulation as a viable substitute for mannequin-based simulation within the curriculum [ 42 ]. As a result, high-fidelity simulation is highly effective in the short term, and a previous meta-analysis reported similar results [ 43 ]. However, computer-based simulation provides advantages for data collection and analysis that contribute to the long-term development of critical thinking skills. In the simulation, participants can record their actions, decisions, and results [ 3 ]. These data can be used to compare different strategies and approaches, allowing participants to reflect on their own critical thinking skills and identify areas for improvement. Furthermore, it is noteworthy that the four simulation teaching methods demonstrated the ability to enhance students' critical thinking. However, it is important to consider the substantial disparity in costs among these methods. Therefore, educators should carefully evaluate their available resources and opt for the most cost-effective approach to foster students' critical thinking.

This study found limited evidence that all four simulation teaching methods contribute to improve caring among students. High-fidelity simulation often focuses on technical skills rather than patient interaction or emotional sensitivity [ 44 , 45 ]. Moreover, research has demonstrated that using mannequins in high-fidelity simulation leads some students to perceive them as separate from real-life patients [ 45 ]. This perception reduces students' concern for the consequences of their actions during the simulation [ 45 ], hindering empathy development and limiting the cultivation of their caring abilities [ 46 ]. Unlike high-fidelity simulation, which provides tactile experiences and simulates real-life interactions, computer-based simulation is characterized by the absence of human connections. This lack of physical proximity can hinder the development of caring behaviors such as nonverbal communication, empathy, and sympathy [ 47 , 48 ]. Similarly, the absence of direct patient interaction is a notable drawback of case study. Although case study simulates complex patient care scenarios, they do not allow students to practice hands-on or experience caregiving emotions. Similarly, the absence of direct patient interactions in case study is a notable limitation. This lack of personal connection and guided practice may hinder the development of caring behaviors. By recognizing these limitations and seeking alternative instructional methods, educational institutions can strive to enhance students' caring skills and equip them with the qualities and behaviors necessary for providing compassionate and patient-centered care.

The findings of this study revealed that neither computer-based simulation nor case study improved students' interest in learning, whereas high-fidelity simulation combined with computer-based simulation was most effective. One possible explanation for the ineffectiveness of computer-based simulation and case study in promoting students' interest is that they may lack the authenticity and immersive nature of real-world experiences [ 47 , 48 ]. High-fidelity simulation, on the other hand, provides a more lifelike and interactive learning environment, which may enhance students' engagement, interest, and retention [ 49 ]. High-fidelity simulation combined with computer-based simulation allows students to interact with the simulation in a hands-on manner while also having access to additional resources and information through computer-based simulation [ 50 ]. This combination provides a well-rounded learning experience that can captivate students' attention and keep them engaged. Notably, these findings are exploratory and should be further explored and validated in future studies. Further research should aim to identify the reasons behind the lack of improvement in students' interest in learning when using computer-based simulation and case study alone. Additionally, the impact of different combinations of simulation techniques on students' interest in learning should be investigated to further refine instructional practices.

Limitations

This study provides valuable insights into the effectiveness of simulation-based education in improving nursing students' competences. However, it is essential to acknowledge and address the study's limitations. One of the limitations is the possible selection bias introduced by the recruiting process. It is possible that students who were more motivated or had a greater interest in simulation-based education may have been more likely to participate in the study. This bias may have influenced the outcomes and interpretation of the results. Additionally, the participants were primarily from one cultural background, which may limit the generalizability of the findings. Future studies should include participants from diverse backgrounds to enhance generalizability. Third, participants assigned to different intervention groups may engage in communication and information sharing, potentially leading to contamination effects. To mitigate this issue, future studies could employ cluster randomized controlled trials, which can effectively minimize the risk of contamination among participants. Finally, the follow-up period was relatively short, which limits the understanding of the long-term impact of simulation-based education on competence. Long-term follow-up studies are needed to evaluate the sustained effect of simulation-based education on competence. Future research should aim to address these limitations to further our understanding of the effects of simulation-based education on undergraduate nursing students' competences.

The four methods are effective at improving skills and critical thinking both immediately and over time. In addition to high-fidelity simulation, the other three methods promote interprofessional collaboration both immediately and long term. High-fidelity simulation combined with computer-based simulation is the most effective approach for enhancing interest in learning both immediately and long term. Undergraduate nursing students benefit equally from four methods in cultivating their knowledge, interprofessional collaboration, critical thinking, caring, and interest in learning both immediately and over time. High-fidelity simulation and high-fidelity simulation combined with computer-based simulation improve skill more effectively than computer-based simulation in the short term. Nursing educators can select the most suitable teaching method to achieve the intended learning outcomes depending on the specific circumstances.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

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This work was supported by a research grant from Higher Education Fund of Macao SAR Government (project number: HSS-KWNC-2021–01). This funding source had no role in the design of this study and will not have any role during its execution, analyses, interpretation of the data, or decision to submit results.

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Study conceptualization and planning were organized and performed by LKT, YYL, MLA, WIN, SCW, YBL, YS, LQZ, and XCHQ. Data collection, data analysis and data interpretation were performed by LKT, YYL, MLA, WIN, SCW, YBL, YS, LQZ, and XCHQ. LKT drafted the initial version of the manuscript. YYL, MLA, WIN, SCW, YBL, YS, LQZ, and XCHQ revised the manuscript for important intellectual content. All authors had full access to the data and have reviewed and approved the submitted version of the manuscript. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Tong, L.K., Li, Y.Y., Au, M.L. et al. The effects of simulation-based education on undergraduate nursing students' competences: a multicenter randomized controlled trial. BMC Nurs 23 , 400 (2024). https://doi.org/10.1186/s12912-024-02069-7

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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.