learning objectives for critical thinking in nursing

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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1 comment . leave new.

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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Miller J. Effective clinical learning for nursing students. American Nurse Journal. 2024;19(4):32-37. doi:10.51256/anj042432 https://www.myamericannurse.com/effective-clinical-learning-for-nursing-students/

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

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• Volume 10, Issue 1
• Teaching strategies and outcome assessments targeting critical thinking in bachelor nursing students: a scoping review protocol
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• http://orcid.org/0000-0002-4086-0086 Frida Westerdahl 1 ,
• Elisabeth Carlson 1 ,
• Anne Wennick 1 ,
• Gunilla Borglin 1 , 2
• 1 Department of Care Science , Malmö University , Malmö , Sweden
• 2 Nursing Education , Lovisenberg Diaconal University College , Oslo , Norway
• Correspondence to Frida Westerdahl; frida.nygren{at}mau.se

Introduction Applying critical thinking is essential for nursing students both in an academic and clinical context. Particularly, as critical thinking is a vital part of nurses’ everyday problem-solving and decision-making processes. Therefore, regardless of the topic taught or the setting in which it is taught, it requires teaching strategies especially targeting students’ critical thinking skills and abilities. One challenge with the latter is the difficulties to assess and evaluate the impact of such teaching strategies on the students’ critical thinking disposition. Hence, our objective will be to review published literature on; existing teaching strategies and outcomes assessments targeting nursing students’ critical thinking skills and abilities.

Methods and analysis Our scoping review will be conducted in accordance with Arksey and O’Malley’s framework for scoping studies. Search strategies will be developed in cooperation with an experienced librarian, and adjusted to each individual database for example, CINAHL, PubMed, PsycINFO, ERIC and ERC. A preliminary search in CINAHL was conducted on the 17 th of July 2019. Peer-reviewed published studies conducted with a qualitative, quantitative or mixed method design and focussing our objectives, will be eligible for inclusion. Included studies will be quality assessed in accordance with their study design. Data will be charted using a standardised extraction form. The qualitative data will be presented through a thematic analyses, and the quantitative data by descriptive numerical analysis. Lastly, nurse educators and nursing students will be consulted for validation of the findings from the scoping review.

Ethics and dissemination Under the Swedish Ethical Review Act (2003:460) this study does not need ethical clearance by a Regional Ethical Review Authority as it not includes any primary empirical data on biological material or sensitive information. The findings will be used to inform the design of a future study aiming to develop an, and subsequently evaluate it, educational intervention targeting teaching strategies focussing on nursing students’ critical thinking skills and abilities.

• critical thinking abilities
• critical thinking skills
• descriptive numerical analysis
• nurse educators
• thematic analysis

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2019-033214

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Strengths and limitations of this study

To ensure rigour and transparency the upcoming scoping review will be based on (1) a solid methodological framework for scoping studies and (2) the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist.

A minimum of two members of the review team will independently assess study eligibility.

Eligible studies will be quality assessed in accordance with their study design.

To achieve a comprehensive picture of the existing research qualitative, quantitative and mixed methods designs will be included in this scoping review.

One limitation might be the potential risk for publication bias since grey literature will not be included, as this will facilitate charting of teaching strategies and outcome assessments targeting critical thinking skills and abilities as described solely in published research.

Introduction

Applying critical thinking is essential for bachelor nursing students (hereafter nursing students); particularly, considering the complex care situations they regularly will find themselves in after graduation. 1 Care situations that among others require them to work in accordance with established standards 2 to be able to contribute to a safe, evidence based and optimal clinical practice. Given that nursing is based on scientific knowledge, critical thinking is the reasonable reflection to justify nursing actions based on evidence. Skills and abilities in critical thinking have consequently been found to predict nursing competence together with working years, position, title and educational level, that is, Bachelor or Master in Nursing. 3 Critical thinking is, therefore, a crucial component of every registered nurse’s daily activities, aiding problem-solving and decision-making processes. 4

According to Scheffer and Rubenfeld the ability to execute critical thinking in nursing could be seen from two perspectives; habits of the mind (cognition), and skills employed by the critical thinker. 5 Critical thinking can also be seen as a consecutive process including (i) gathering information, (ii) questioning, (iii) analysis and evaluation and (iv) problem-solving and application of theory, that is, the nursing process. 6 This consecutive process of critical thinking needs to be applied both in the clinical area and in the classroom. 7 However, to develop this ability among nursing students is a complex process. To apply critical thinking, the necessary skills and abilities need to be taught and developed during both the students’ clinical placements as well as during their theory courses throughout the nursing education. 4

One challenge with the concept of critical thinking, often highlighted in the literature, and despite its priority within the nursing education, is the interchangeable use of the concepts of critical thinking, clinical reasoning and clinical judgement. 7–9 Concepts that Victor-Chmil describe as; ‘they are not one and the same’ (p 34). It needs to be acknowledged, as the authors of this current protocol do, that critical thinking often is used as a broader term which includes the concepts of clinical reasoning and clinical judgement. 8 According to Alfaro-LeFevre clinical reasoning refers to the process used to solve clinical issues and clinical judgement refers to the outcome or conclusion of this process. 7 Therefore, regardless of the topic taught or the setting in which it is taught, requires teaching strategies especially targeting nursing students’ critical thinking skills and abilities. For these strategies to be favourable, it requires implementation throughout the nursing education, and thereby reflected in all parts of the nursing programmes’ learning objectives and curricula. 10 It has been outlined that teaching strategies such as, problem-based learning, concept-mapping, case-based learning interventions and reflective writing are often used in nursing programmes to support critical thinking. 6 10 11 However, another challenge with critical thinking, besides the interchangeable use of concepts, is the difficulty to assess and evaluate the impact of different teaching strategies on the students’ critical thinking disposition (ie, skills and abilities) as well as the assessment of the different components in the critical thinking process. 8 Previous reviews in the current research area have only included either experimental studies 12 or randomised clinical trials 13 measuring the effectiveness of teaching strategies. Further, other reviews have involved mixed populations including not only nursing students, but also working nurses and nursing managers 14 and midwifery students. 15 Since critical thinking is a vital part of registered nurses’ problem-solving and decision-making, this ability needs to be taught already during the nursing education. It is therefore necessary to focus the educational context of undergraduate nursing taking an extended approach on how teaching strategies targeting critical thinking are described, experienced and assessed. Hence, our overarching objective will be to review published literature on; existing teaching strategies and outcomes assessments targeting nursing students’ critical thinking skills and abilities.

Methods and analysis

The upcoming scoping review will address a broad topic (ie, teaching strategies targeting nursing students’ critical thinking skills and abilities, as well as outcome assessments of such skills and abilities), where a diverse range of study designs can be considered relevant in answering our additionally wide review questions. Our scoping review will therefore be designed in accordance with Arksey and O’Malley’s methodological framework for scoping studies. 16 However, our design will also be informed by other more recent methodological accounts. 17 18 The framework will enable us to identify existing gaps in the literature as well as to summarise, evaluate and disseminate the overall state of research activities within the field. 16 The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist (PRISMA-ScR) was used to prepare this protocol. 19 PRISMA-ScR will also form the base for the upcoming scoping review as standardised reporting guidelines can according to Colquhoun et al support the critical appraisals of published reviews by expanding on their transparency and reproducibility. 20

Stage 1: identifying the research question

The research questions for the upcoming scoping review aims for comprehensiveness, that is, they will be broad to cover the breadth of research evidence in our field of focus. As scoping is an iterative methodological process, 16 it is possible for us to decide to add supplementary questions based on the findings emerging during the review process. A modified 21 PICOS (Population, Intervention, Comparison, Outcome and Study Setting) framework will aid us in determining the appropriateness of the research questions, as well as guide us in our database searches ( table 1 ).

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Framework (PICOS) for determination of eligibility of review questions

Since the subsequent goal of the upcoming scoping review is to further the knowledge and understanding about how nurse educators via teaching strategies can target the development of nursing students’ critical thinking skills and abilities we will additionally engage in findings of relevance to this. The following tentative research questions were developed to capture the objectives of the upcoming study:

Which are the teaching strategies described in the literature as targeting critical thinking skills and abilities among nursing students?

How are these teaching strategies conceptualised, described and experienced by students and/or nurse educators for example, pros and cons?

Which outcomes are described in the literature as used to assess critical thinking skills and abilities?

Stage 2: identifying relevant studies

The upcoming scoping review will include primary studies utilising qualitative, quantitative and mixed methods, published in peer-reviewed journals. This strategy will support us to achieve a comprehensive picture of the existing research focussing peer-reviewed studies on teaching strategies targeting critical thinking skills and abilities among nursing students, as well as on existing research focussing on outcome assessments of such skills and abilities. No limits will be applied concerning publication year, since we aim at conducting a comprehensive overview of published studies. Studies will be excluded if the population is not identifiable, qualitative and quantitative data is not possible to extract in case of mixed method design or published in other languages than English. All reasons for exclusion will be documented.

In our upcoming scoping review the term ‘teaching strategies’ will be used. Thus, our focus is not the overall educational organisation of teaching (ie, educational strategies) or the students’ individual general learning process (ie, learning strategies). However, as we are aware of the commonly interchangeable use in the literature of the terms; teaching strategies, educational strategies and learning strategies, they will all be included in our searches. Here the term teaching strategies are operationalised in accordance with Banning, and as encompassing three different perspectives; (i) the didactic perspective, which is teacher centred and mainly involves lectures; (ii) the facilitative perspective, focussing on self-directed learning making the students articulate their knowledge and lastly (iii) the Socratic perspective which is emphasising student-centredness and use objective questioning from the teacher. 22

The following databases; CINAHL, PubMed, PsycInfo, ERIC and ERC will be used to search for eligible studies. These databases are chosen to cover a comprehensive sample of literature from healthcare science and education. A search strategy for each database will be developed by the review team with assistance from an experienced librarian. Our strategies will include both database specific heading that is, Medical Subject Headings, keywords and synonyms. All specific headings and key words will be combined using the Boolean operators OR as well as AND. To ensure comprehensiveness, included studies reference lists will be manually searched. As outlined by Arksey and O’Malley the search strategy should be an iterative process and the search terms could be adjusted while an increased familiarity with the literature is achieved. For this reason, a preliminary pilot search strategy will be applied to the databases and the first 100 search results will be reviewed by the review team to assess validity. 16 During the review team meetings, adjustments will be applied to the search strategy and search terms until full agreement is reached. Grey literature (ie, literature that is not formally published in sources such as journal articles or books) will not, as described elsewhere, be included in our upcoming scoping study. 23 This will support us to focus on and to chart how teaching strategies targeting skills and abilities such as critical thinking is described in published peer-reviewed research. A draft of a preliminary search in CINAHL conducted on the 17 th of July 2019 is attached in online supplementary file 1 .

Supplemental material

Stage 3: study selection.

The study selection will first consist of a title and abstract scan. If the title and abstract are in line with the scoping review’s objectives and questions to the literature or if the relevance of the study is unclear a full-text review will follow. Retrieved studies from each database are going to be divided equally among a minimum of two reviewers, who independently will conduct the selection process. 17 To facilitate the process, we are going to use the data programme Rayyan. The programme is a mobile and web application developed to facilitate the screening of title and/or abstract as well as the collaboration between the reviewers. 24 During the study selection process, the first reviewer (FW) will be responsible for regularly convoking the review team for discussions concerning uncertainties and to refine the study selection process. 17 Criteria for inclusion can also be applied ad hoc during the process when acquaintance with the field of research is increased. 16 If any disagreements on study inclusion occur, an additional reviewer will be consulted to determine the final inclusion. 17 The study selection process ( figure 1 ) will be accounted for by the PRISMA flow diagram. 25

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Overview study selection process.

Contrary to Arksey and O’Malley’s methodological framework, 16 studies eligible for inclusion in our scoping review are going to be quality assessed. The assessment of the included studies’ quality will allow us to identify where the research itself is of poor quality, that is, identifying gaps in the existing literature review. According to Grant and Booth the lack of quality assessments in scoping reviews are likely to limit the uptake of the findings. 26 Their sentiment is supported by both Levac, Colquhoun and O’Brien 17 and Daudt, van Mossel and Scott 18 who state that a quality assessment of included studies will likely result in findings more useful for practice. The quality assessment will be conducted by a minimum of two reviewers, who will use the relevant study design checklists from the Critical Appraisal Skills Programme (CASP). 27 As, CASP lack a checklist for mixed methods studies, the mixed method appraisal tool will be applied. 28 In the case of any ambiguity concerning a study’s quality assessment, an additional reviewer is going to be consulted. No exclusion of eligible studies will be made on behalf of the quality assessment as studies with limited quality nevertheless can provide a valid rationale as guidance as to where more research is required.

Stage 4: charting data

A data charting form would be developed, and piloted on the first 5 to 10 included studies in this review. The piloting will support the team to reach an agreement on extraction consistency. The latter is especially important, as the extraction will be conducted individually and independently by a minimum of two reviewers. 17 A systematic and analytical approach will be utilised to extract the relevant information of each included study. The variables and themes to be included in order to answer the review’s objective and questions to the literature will be established iteratively ( box 1 ). Thus, the data charting form will be updated throughout the review by one of the reviewers (FW) who will also hold regular discussion with the others in the review team. 17

Tentative data charting form

Author and date.

Study title.

Journal full reference.

Aim, objective and/or research questions.

Study and recruitment context (eg, in what country and where people were recruited).

Participant characteristics (eg, age, gender, education year/semester of study, course (ie, theoretical or clinical placement)).

Sampling method.

Number of study participants.

Study design.

Data collection (eg, what data collection methods were used?).

Data analysis (eg, how was the data analysed?).

Described ethical approval and/or considerations. 29

Described teaching strategies and/or interventions targeting review focus.

Described outcomes and assessments.

Most relevant findings.

Study quality appraisal. 27 28

Tentative ethical requirements influenced by Weingarten, Paul and Leibovici.

Was the study approved by a research ethical committee? (Yes/No)

Was informed consent obtained? (Yes/No)

Were adequate measurements taken to protect personal data? (Yes/No)

Is there a declaration on financial support? (Yes/No)

Is there a declaration on potential conflict of interest? (Yes/No)

Influenced by Weingarten, Paul and Leibovici’s substantial contribution to raise the ethical awareness in reviews, an ethical assess form ( box 2 ) was developed for the upcoming scoping review including five requirements. 29 Included studies valued by the review team as not adhering to the ethical requirements will be excluded at this stage of the scoping review process.

Stage 5: collating, summarising and reporting the results

In the fifth stage, an overview and narrative account of variables and information extracted in stage 4 will be presented, and as highlighted by Arksey and O’Malley no evidence grading will be executed. 16 Levac, Colquhoun and O’Brien 17 and Daudt, Van Mossel and Scott 18 suggest that the extracted qualitative data should be presented through thematic analysis, since no synthesis of data is required. 16 For this purpose, the thematic analysis by Braun and Clarke will be applied which is a flexible method suitable when the data is broad and allowing for a wide range of analytical options. 30 This cohere with the upcoming scoping review, which will include studies with a wide range of research questions and methods. Quantitative data will be reviewed through basic descriptive numerical analysis and presented in tables and charts to highlight the range of data. 16 If studies with a mixed method design are included in stage 3, the qualitative and quantitative data will be extracted and analysed separately. A minimum of two reviewers will be responsible for this stage of the scoping review process. During the process, meetings with the entire review team will be scheduled by the first reviewer (FW) to discuss and come to agreement concerning analysis and presentation of extracted data.

Stage 6: consultation stage

To validate the findings of this scoping study and make it more useful for practice the optional stage consultation will be applied. For this purpose, the findings from the scoping review will be presented to a group of educators and students connected to a nursing programme as a means to contribute with valuable insights on issues connected to the application and implementation of the findings.

Patient and public involvement

No patients have been involved in the design of this study. However, to conduct a study targeting teaching strategies for critical thinking in nursing education will eventually benefit patients since education is the foundation for raising future nurses and improve patient care.

Ethics and dissemination

Under the Swedish Ethical Review Act (2003:460) 31 this study does not need ethical clearance by a Regional Ethical Review Authority as it does not include any primary empirical data on biological material or sensitive information (eg, ethnicity, political or sexual orientation). However, the issue of ethical consideration in the execution of reviews is raised by Vergnes et al 32 as well as by Weingarten, Paul and Leibovici. 29 They state that without an ethical judgement of the included studies it could result in establishing clinical practise and guidelines based on studies with poor ethical quality and even unethical studies. It could further be seen as a way of increasing the awareness and necessity of high ethical standards in research. To meet these requirements one variable in the charting form will be ethical consideration and for that purpose a tentative checklist for ethical requirements was developed ( box 2 ). The checklist will be tested on a minimum of 10 publications, and revised accordingly if necessary.

The upcoming scoping review will contribute to the advancement of research concerning teaching strategies targeting nursing students’ skills and abilities in critical thinking and the outcome assessment of it. It will also provide an indication of the maturity of the literature by identifying research gaps. Gaining more knowledge of the targeted research area can act as a benchmark to implement new teaching strategies facilitating students’ critical thinking disposition within the nursing education. This will better prepare future nurses for the complex care situations they will approach. Our findings will be used to inform the design of a future study aiming to develop and evaluate an educational intervention targeting teaching strategies focussing on nursing students’ critical thinking skills and abilities. The upcoming scoping review will be published in a peer-reviewed journal. We expect to report in late spring 2020.

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• ↵ Act concerning the ethical review of research involving humans (SFS 2003:460) .
• Vergnes J-N ,
• Marchal-Sixou C ,
• Nabet C , et al

Contributors FW, EC, AW and GB were responsible for the initial design of this study. FW conceptualised the review approach and led the writing of the manuscript. FW, EC, AW and GB contributed to the protocol’s development and approved the final version of this protocol. GB, EC and AW led the supervision of the manuscript preparation.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

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

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

What is Critical Thinking in Nursing?

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

• 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?

43.2 Developing Critical Thinking

Learning objectives.

By the end of this section, you will be able to:

• Analyze the types of thinking used in nursing
• Recognize when to use the different types of thinking in nursing
• Explore the application of knowledge to thinking in nursing
• Appy Critical Thinking Indicators (CTIs) to decision making

Thinking is something we usually do subconsciously, because we are not usually “thinking about thinking.” However, with the ever-increasing autonomy being afforded to nurses, there is also an increased need for nurses to be able to critically think effectively and intentionally. Being able to critically think helps nurses’ problem solve, generate solutions, and make sound clinical judgments that affect the lives of their patients. Keep reading to learn more about how nurses use critical thinking in practice and how you can develop your own critical thinking skills.

Types of Thinking Used in Nursing

Nurses make decisions while providing patient care by using critical thinking and clinical reasoning. In nursing, critical thinking is a broad term that includes reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” On the other hand, clinical reasoning is defined as a complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions. Each of these types of thinking is described in more detail in the following sections.

Cognitive Thinking

The term cognitive thinking refers to the mental processes and abilities a nurse uses to interpret, analyze, and evaluate information in their practice. Basically, it encompasses how nurses think about the practice decisions they are making. Cognitive thinking and critical thinking go hand in hand because nurses must be able to use their knowledge and mental processes to devise solutions and actions when caring for patients. Using critical thinking means that nurses take extra steps to maintain patient safety and do not just follow orders. It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research. Critical thinkers possess certain attitudes that foster rational thinking:

• confidence: believing in yourself to complete a task or activity
• curiosity: asking “why” and wanting to know more
• fair-mindedness: treating every viewpoint in an unbiased, unprejudiced way
• independence of thought: thinking on your own
• insight into egocentricity and sociocentricity: thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
• integrity: being honest and demonstrating strong moral principles
• intellectual humility: recognizing your intellectual limitations and abilities
• interest in exploring thoughts and feelings: wanting to explore different ways of knowing
• nonjudgmental: using professional ethical standards and not basing your judgments on your own personal or moral standards
• perseverance: persisting in doing something despite it being difficult

Cognitive thinking is significant to nursing because it provides a foundation on which nurses can make rapid and accurate decisions in clinical practice. Nurses must be able to think quickly and make informed decisions to promote optimal patient outcomes.

Effective Thinking

To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process. Effective thinking in nursing involves the integration of clinical knowledge and critical thinking to make the best decisions for patients. For example, if a nurse was caring for a patient who presents with hypertension and new-onset left-sided weakness, it is important that the nurse be able to quickly consider potential causes for the weakness and implement immediate stroke protocols. Without the ability to critically think, the nurse may overlook the weakness as being unrelated to the hypertension and not consider the possibility of stroke, leading to a poor patient outcome. Thus, it is imperative that nurses develop effective thinking skills.

Inductive Reasoning

The term inductive reasoning involves noticing cues, making generalizations, and creating hypotheses. Cues are data that fall outside of expected findings and give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A generalization is a judgment formed on the basis of a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes clearer. On the basis of generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. Remember, a hypothesis is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored. No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to act quickly, especially in emergency situations. They can see how certain objects or events form a pattern (or a generalization) that indicates a common problem.

Consider this example: A nurse assesses a patient who has undergone surgery and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.

Deductive Reasoning

Another type of critical thinking is deductive reasoning ; it is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.

Think about this example: On the basis of research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking, because the intervention is applied to all patients regardless of whether they have difficulty sleeping or not.

Identify the Purpose of Thinking

Rationalizing the purpose of thinking is probably not something you do often, but it is the foundational first step in critical thinking. To effectively use critical thinking in practice, the nurse must first identify the purpose of thinking. For example, the nurse is caring for a patient who presents with fever, tachycardia, and shortness of breath. The patient also has an open, infected wound on the left foot that is not healing. The nurse must recognize that the patient is exhibiting signs and symptoms that may be indicative of an underlying problem. At this point, the nurse must be able to identify that the purpose of thinking with regard to the patient is to consider what might be happening with the patient and formulate a plan of care. This begins the process of critical thinking, which involves several steps: thinking ahead, thinking in action, and reflection on thinking.

Thinking Ahead

Thinking ahead in nursing involves considering what may be going on with the patient to anticipate potential outcomes and complications that may arise. Remember competent nurses are proactive versus reactive. Reactive nursing is letting situations arise and then responding to the change, but proactive nursing is recognizing cues behaviors and patterns that are leading up to a complicated event. Additionally, the nurse will formulate goals of care and must try to anticipate specific needs the patient will have. Considering the patient discussed in the preceding paragraph, the nurse should begin the process of thinking ahead about potential outcomes and complications. The nurse may hypothesize that the patient is starting to develop sepsis from the open wound on the foot so severe sepsis and/or septic shock could be a complication to begin preparing for. The nurse thinks ahead about goals of care for the patient and determines that wound care to prevent infection spread and sepsis is the priority goal at this time.

Thinking in Action

Thinking in action encompasses the thought processes occurring while the nurse is performing interventions. So, if the nurse in our example begins performing wound care, they are thinking about the best dressing to use, how to clean the wound, and if antibiotics should be considered. All of these thoughts are likely occurring as the nurse is providing the care; thus, they are examples of how the nurse is using thinking in action.

Reflection on Thinking

After performing interventions or making decisions, the nurse should reflect on the thinking that occurred. The nurse will use this thinking process to determine if the decision was reactive or responsive. Reactive decision-making involves responding to situations after they have occurred, often in a hurried or unplanned manner. These decisions tend to be impulsive and are driven by immediate needs or crises. Responsive decisions, on the other hand, involve careful deliberation about how to address a situation based on careful consideration of information. In our example, the nurse’s decision appears to have been responsive. The patient was exhibiting some altered vital signs, but nothing indicated that the situation had become emergent yet. The nurse was able to think carefully about the patient’s situation and determine that wound care was the highest priority and begin to implement care in a calm, deliberate manner. In an ideal world, all nursing decisions would be responsive, but in a lot of cases, they must be reactive because of situation severity and medical emergencies.

Application of Knowledge

During the outset of the critical thinking process, nurses must judge whether their knowledge is accurate, complete, factual, timely, and relevant. This can be done by applying knowledge to nursing practice in a multitude of ways, including drawing from past education and experience in nursing and using professional resources and standards. Each of these is discussed in more detail in the following sections.

Knowledge Base

Becoming a nurse requires years of schooling, which contributes to the development of a robust knowledge base. Nurses receive formal education and training that provides them foundational knowledge in anatomy, physiology, pharmacology, and patient care techniques, among many others. Additionally, nurses are required to complete continuing education courses specific to their chosen practice setting, further developing their knowledge base. When applying knowledge in practice, nurses can draw from their knowledge base and make informed decisions about patient care.

Experience in Nursing

Nursing is considered a practice. Nursing practice means we learn from our mistakes and our past experiences and apply this knowledge to our next patient or to the next population we serve. As nurses gain more experience, they can use what they have learned in practice and apply it to new patient situations. Each new encounter with a patient presents unique challenge and learning opportunities that contribute to the development of clinical expertise. Reflecting on these experiences allows nurses to recognize patterns, anticipate patient outcomes, and refine their decision-making processes. Whether they are identifying effective nursing interventions for common conditions, adapting care plans to individual patient needs, or navigating complex situations with compassion, nurses draw upon their accumulated knowledge base from clinical experience to provide high-quality, patient-centered care. Through reflection and continuous learning from past experiences, nurses enhance their clinical skills, ultimately improving patient outcomes.

Professional Resources and Standards

In addition to foundational knowledge bases and experience, nurses can also use professional resources and standards to gain and apply knowledge in practice. Nurses can refer to clinical practice guidelines that have been established by professional organizations and healthcare institutions to help provide a framework for implementing nursing interventions based on the best evidence. By following the guidelines, nurses are ensuring that their care aligns with established standards and promotes optimal patient outcomes. Additionally, nurses should remain up to date about new and emerging research in their practice area, which can be obtained by reading professional journals and publications and attending conferences, workshops, and other trainings. Nurses can use the information learned from these resources to influence practice and ensure the highest standards of care are being performed in their practice setting. By staying informed about the latest developments in nursing and health care, nurses enhance their knowledge base and can adapt their practice to incorporate new evidence and innovations. Along with professional development and staying current with professional practices, nursing students should actively seek and join professional organizations such as critical care nursing or oncology nursing societies because this will lead the student to become expert in that subject and stay relevant with current evidence and practice guidelines.

Clinical Safety and Procedures (QSEN)

Qsen competency: evidence-based practice.

Definition: Providing quality patient care based on up-to-date, theory-derived research and knowledge, rather than personal beliefs, advice, or traditional methods.

Knowledge: The nurse will describe how the strength and relevance of available evidence influences the choice of intervention in provision of patient-centered care.

Skill: The nurse will:

• subscribe to professional journals that produce original research and evidence-based reports related to their specific area of practice
• become familiar with current evidence-based clinical practice topics and guidelines
• assist in creating a work environment that welcomes new evidence into standards of practice
• question the rational for traditional methods of care that result in sub-par outcomes or adverse events

Attitude: The nurse will appreciate the importance of regularly reading relevant professional journals.

Critique of Decision

After determining the best course of action based on the application of knowledge, the nurse can critique the decisions that were made. Specifically, the nurse will use self-reflection to review their actions and thoughts that led them to the decision. The nurse will consider the outcomes of their chosen interventions, reflect on the effectiveness of their approach, and identify areas of improvement. Additionally, the nurse may seek feedback from colleagues to obtain different perspectives about decisions made. Soliciting input from others helps the nurse gain insight and learn from their peers to further inform their future practice. Reflection questions that the nurse may ask themselves to critique their decision include the following:

• Was the patient goal or outcome met?
• Could the intervention have been done differently? Could it have been done better?
• What are alternative decisions that could have been made? What are the merits of each?

Critical Thinking Indicators

Certain behaviors that demonstrate the knowledge, skills, and attitudes that promote critical thinking are called critical thinking indicators (CTIs) . Critical thinking indicators are tangible actions that are performed to assess and improve your thinking skills.

4-Circle CT Model

There are many models and frameworks within nursing and other disciplines that attempt to explain the process of critical thinking. One of the most popular is Alfaro-LeFevre’s 4-Circle CT Model (Alfaro-LeFevre, 2016). This model breaks critical thinking into four components: personal characteristics, intellectual and cognitive abilities, interpersonal abilities and self-management, and technical skills. These four components overlap, forming interconnections in critical thinking.

Link to Learning

Learn more here about the 4-Circle CT Model and see an illustration of it.

Personal Critical Thinking Indicators

Personal CTIs are behaviors that are indicative of critical thinkers. Some of these behaviors that are most relevant to nursing include:

• confidence and resilience: showing ability to reason and learn and overcoming problems
• curiosity and inquisitiveness: asking questions and looking for the “why” behind things
• effective communication: listening well, showing understanding for others thoughts and feelings, and speaking and writing with clarity
• flexibility: changing approaches as needed to obtain the best results
• honesty: looking for the truth and demonstrating integrity while adhering to moral and ethical standards
• self-awareness: being able to identify one’s own knowledge gaps and acknowledge when thinking may be negatively influenced by emotions or self-interests.

Personal Knowledge and Intellectual Skills

Personal knowledge and intellectual skills encompass the knowledge gained from nursing school and clinical experiences. Examples of each of these kinds of skills are listed in Table 43.3 .

Interpersonal and Self-Management Skills

Interpersonal and self-management skills encompass the knowledge and skills needed for effective collaboration. These include:

• addressing conflicts fairly
• advocating for patients, self, and others
• dealing with complaints constructively
• establishing empowered partnerships
• facilitating and navigating change
• fostering positive interpersonal relationships and promoting teamwork
• giving and taking constructive criticism
• leading, motivating, and managing others
• managing stress, time, and energy
• promoting a learning and safety culture
• upholding healthy workplace standards
• using skilled communication in high-stake situations

Technical Skills

Technical skills in nursing refer to the practical abilities and competencies that nurses use in the delivery of patient care. These skills are typically learned through education, training, and hands-on experience. Some common technical skills in nursing include:

• administering medications
• assisting with personal hygiene and activities of daily living
• documentation and charting
• inserting intravenous catheters
• inserting urinary catheters and nasogastric tubes
• performing tracheostomy care
• performing wound care
• taking vital signs

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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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Introduction, section snippets, references (40), cited by (1).

Nurse Education in Practice

Factors associated with the critical thinking ability among nursing students: an exploratory study in iran, background and objective, study method, setting and sample, reliability and validity, limitations, author statement, credit authorship contribution statement, declaration of competing interest, acknowledgement, ethical approval, critical thinking skills in intensive care and medical-surgical nurses and their explaining factors, nurse educ. pract., a systematic review of critical thinking in nursing education, nurse educ. today, development and evaluation of a physical examination and health assessment course, building consensus on critical thinking assessment tool for undergraduate nursing students in a socialist low-middle income country: a delphi study, critical thinking skills of undergraduate nursing students: description and demographic predictors, the relationship between critical thinking and emotional intelligence in nursing students: a longitudinal study, practice and effectiveness of “nursing case-based learning” course on nursing student's critical thinking ability: a comparative study, the effect of gender role orientation on student nurses’ caring behaviour and critical thinking, int. j. nurs. stud., does good critical thinking equal effective decision-making among critical care nurses a cross-sectional survey, intensive crit. care nurs., critical thinking disposition among nurses working in puplic hospitals at port-said governorate, int. j. nurs. sci., nurse educators' critical thinking: a mixed methods exploration, the strengthening the reporting of observational studies in epidemiology (strobe) statement: guidelines for reporting observational studies, int. j. surg., the efficacy of team-based learning in developing the generic capability of problem-solving ability and critical thinking skills in nursing education: a systematic review, the effect of cooperative learning on critical thinking of nursing students in clinical practicum: a quasi-experimental study, j. prof. nurs., clinical nurses's critical thinking level according to sociodemographic and professional variables (phase ii): a correlational study, the nursing critical thinking in clinical practice questionnaire for nursing students: a psychometric evaluation study.

• Alfaro-Lefevre, R. (2016). Critical thinking, clinical reasoning and clinical judgment: A practical approach, pageburst...

Assessing perceptions about critical thinking, motivation learning strategies in online psychiatric and mental health nursing education among Egyptian and Saudi undergraduate nursing students

• Babazhanova, U. (2020). The critical thinking skills of nursing students in...

Critical thinking in nursing students and its relationship with professional self-concept and relevant factors

Res dev. med educ., the effectiveness of case-based concept map to improve pathophysiology knowledge and critical thinking among first-year nursing students: a quasi-experimental study.

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Clinical supervision strategies, learning, and critical thinking of nursing students

Estrategias de supervisión clínica, aprendizaje y pensamiento crítico de los estudiantes de enfermería, estratégias de supervisão clínica, aprendizagem e pensamento crítico dos estudantes de enfermagem, angélica oliveira veríssimo da silva.

I Universidade de Aveiro, Departamento de Educação e Psicologia. Aveiro, Portugal

António Luís Rodrigues Faria de Carvalho

II Escola Superior de Enfermagem do Porto. Porto, Portugal

Rui Marques Vieira

Cristina maria correia barroso pinto, associated data.

https://doi.org/10.48331/scielodata.PC3XOX

To identify the supervisory strategies that Nursing students consider facilitators of the development of critical thinking skills in clinical teaching.

This is a qualitative study, within the interpretative paradigm, using the focus group methodology. Eight undergraduate nursing students participated in the study.

Participants recognized the indispensability of critical thinking for professional responsibility and quality of care and highlighted the importance of using supervisory strategies adapted to their needs, learning objectives, and the context of clinical practice.

Final considerations:

This study highlights the urgent need to establish, within the Nursing curricula, clinical supervision strategies that promote critical thinking and favor the development of skills for good clinical judgment, problem solving, and safe, effective, and ethical decision-making.

Identificar as estratégias supervisivas que os estudantes de Enfermagem consideram facilitadoras do desenvolvimento das capacidades de pensamento crítico no contexto de ensino clínico.

Métodos:

Estudo de natureza qualitativa, inserido no paradigma interpretativo, com recurso à metodologia focus group . Participaram do estudo oito estudantes do curso de licenciatura em Enfermagem.

Resultados:

Os participantes reconheceram a imprescindibilidade do pensamento crítico para a responsabilidade profissional e qualidade na assistência; e destacaram a importância da utilização de estratégias supervisivas adequadas às suas necessidades, aos objetivos de aprendizagem e ao contexto da prática clínica.

Considerações finais:

Este estudo sobreleva a premência em se estabelecer, dentro dos currículos do curso de Enfermagem, estratégias de supervisão clínica promotoras do pensamento crítico, que favoreçam o desenvolvimento de capacidades para o bom julgamento clínico, resolução de problemas e tomada de decisão segura, eficaz e ética.

Identificar las estrategias de supervisión que los estudiantes de Enfermería consideran facilitadoras del desarrollo de las capacidades de pensamiento crítico en el contexto de enseñanza clínica.

Estudio de naturaleza cualitativa, inserido en el paradigma interpretativo, con recurso a la metodología focus group . Participaron del estudio ocho estudiantes del curso de licenciatura en Enfermería.

Los participantes reconocieron la imprescindibilidad del pensamiento crítico para la responsabilidad profesional y calidad en la asistencia; y destacaron la importancia de la utilización de estrategias de supervisión adecuadas a sus necesidades, a los objetivos de aprendizaje y al contexto de la práctica clínica.

Consideraciones finales:

Este estudio sobrepasa la urgencia en establecerse, dentro de los currículos del curso de Enfermería, estrategias de supervisión clínica promotoras del pensamiento crítico, que favorezcan el desarrollo de capacidades para el bueno juicio clínico, resolución de problemas y toma de decisión segura, eficaz y ética.

INTRODUCTION

The complex challenges that globalization imposes incorporate the need to establish critical thinking (CT) as a pillar today. It is the duty of educational institutions to prepare their students adequately so that they can provide timely and appropriate answers to the diverse and emerging problems that society and patients impose on them ( 1 ) . Critical thinking, as a set of skills and dispositions, has sparked the interest of the scientific community and of national and international organizations ( 2 - 3 ) . In recent years, efforts have been made to incorporate it into the curricula in different educational institutions.

Widely studied in the last decades, CT can be defined as intentional, rational, and reflective thinking, focused on what one should believe and do ( 4 ) , which results in interpretation, analysis, evaluation, inference, explanation, and self-regulation ( 5 ) . It is considered essential for the development of the ability to process information and evaluate its plausibility, to clearly argue and defend one’s position, to foresee consequences, to examine the pros and cons in the decision-making process ( 6 - 7 ) . Being able to think critically is evidenced as an important predictor of good academic performance ( 8 ) . Students with high CT skills are capable of organizing their learning, monitor and evaluate their performance ( 9 ) , and such skills favor successful decision making ( 8 ) .

Like globalization, health care has also become complex and demanding; nursing has evolved as a profession, a fact that has generated the need for professionals to demonstrate critical-reflexive characteristics in their daily practice ( 10 ) . Nursing as a profession is configured as the largest workforce in health care, both by the number of professionals and by its proximity to patients and their families, because it is the nursing professionals who ensure 24 hours of patient care. This proximity and all the complexity involved in nursing care, along with technological advances, require skills that allow nurses to provide safe and quality care ( 11 - 15 ) .

In the context of health care, CT can be defined as the rigorous, intentional, and result-focused reasoning based on the patient’s needs ( 16 ) . For the promotion of safe and quality care, nursing students should be trained in a reflective manner to be able to act and respond assertively to the complex tangle of issues that emerge from the clinical context in the face of dynamic, uncertain, unpredictable, and inconstant situations ( 15 , 17 ) . Thus, CT skills are considered essential components for professional responsibility and quality in nursing care ( 11 - 12 , 14 , 16 , 18 - 19 ) .

Thinking critically is not innate, so it requires effort and integration of contexts and teaching and learning proposals that favor its evolution ( 20 ) . For the development of CT skills, it is important to ensure learning environments that enable the active involvement of students ( 21 ) , since active learning methodologies can stimulate the development of higher order cognitive processes ( 12 , 15 , 22 - 23 ) . Active learning methodologies are considered the key to success that guarantees students the ability to analyze evidence and proposals, make fair judgments, propose solutions ( 22 , 24 - 25 ) , evaluate their decisions and, if necessary, go back to the start and reconstruct the whole process ( 26 ) .

Thus, the clinical teaching context constitutes the space of choice for the development of CT skills due to its dynamic, interactive, unpredictable, mediating, facilitating, and enhancing nature of practical learning ( 27 - 28 ) . Clinical teaching, performed in health institutions, is characterized by learning in real context, where the student applies theoretical knowledge in practice, that is, it integrates knowing with doing, resulting in a reflective and critical process and in the improvement of clinical skills and competencies that, when properly conducted, culminates in a conscious, critical, and creative student action ( 11 , 29 - 30 ) . Clinical teaching, through the supervisory process, aims to guarantee the student the acquisition of knowledge and the development of skills and attitudes for the performance of autonomous, conscious, and grounded interventions ( 29 - 31 ) .

It is possible to state that CT, as a set of skills, can be taught, and the more these skills are trained, the greater the probability of favorable results, which contributes to the training of students capable of providing assertive answers to the complex problems presented ( 5 , 22 , 32 ) . Critical teaching, due to its real-world nature, favors the development of these abilities (professional competencies), since it enables the articulation between theory and practice, enhanced by the adoption of a proactive learning attitude ( 29 ) . Clinical supervision strategies (CSS) can influence the development of nursing students’ CT skills, which are essential for their performance in care practice.

Currently, there are several studies that address CT issues ( 1 - 6 , 8 , 19 , 32 ) in a general manner and others more directed to nursing ( 18 , 21 - 22 , 26 ) ; however, there are still no studies relating supervision strategies to the development of CT in nursing students. Based on the premise that CT is a fundamental aspect during the critical teaching of these students, the adoption of constructivist teaching strategies that allow them to improve CT learning should be encouraged. In this sense, it is essential to identify the students’ CT skills and the CSSs that most promote their development.

To identify the supervisory strategies that Nursing students consider facilitators of the development of CT skills in clinical teaching.

Ethical aspects

This study was submitted to the opinion of the Ethics Committee of a Nursing School in Northern Portugal, and its ethical and methodological aspects were approved. All study participants signed the Informed Consent Form, which guarantees the right to data privacy, anonymity, and confidentiality.

Theoretical and methodological framework

The theoretical and methodological framework is based on the qualitative approach. This seeks to interpret and understand a reality from the perspective of the actors involved in the process ( 33 ) .

The qualitative nature, as a theoretical and methodological foundation, enables the unveiling of the undergraduate nursing students’ thought referential about their experience in the critical teaching context, namely to identify the clinical supervision strategies considered by them as facilitators of the development of their CT skills.

This is a qualitative study, inserted in the interpretative paradigm, since it seeks to interpret and understand the meanings of human action from the perspective of those who live it ( 33 ) , namely undergraduate nursing students in the context of critical teaching. It is an exploratory and cross-sectional study, using the focus group methodology. For the preparation of the manuscript, to ensure rigor and transparency in the writing of the summary of results, this work was conducted and structured based on the Standards for Reporting Qualitative Research (SRQR), whose objective is to establish standards for reporting qualitative research.

The qualitative nature of focus group data collection provides a rich environment for discussion among several participants, as it allows the researcher to gain an in-depth view of different opinions, knowledge, perceptions, feelings, and experiences on a given topic, which may be analyzed later ( 34 ) . Its objective is to understand the human being and his/her relations with the theme under investigation, by observing the participants’ discourses, behaviors, and reactions ( 33 ) . Among the benefits of this methodology, we can highlight its quick execution, the ease of being performed nowadays by videoconference, its dynamic character due to flexibility in its conduction, and contact between the participants and moderator ( 34 ) .

Study setting

Study carried out in a Nursing School in Northern Portugal, during the months of May to July 2021. The research was carried out with students enrolled in the 2020/2021 academic year of the Bachelor of Science in Nursing (BSN) course.

Data source

Bachelor of science in nursing students were part of the sample for this study. The eligibility criteria were: active enrollment in the year 2020/2021 and having at least one critical teaching experience, due to familiarity with the critical teaching context and the CSSs. Eight fourth-year BSN students participated in the focus group session.

During the planning phase of data collection, there was concern about how to recruit the students. Thus, the main researcher was allowed to contact the coordinators of the Clinical Practice curricular units (CU), and they, in turn, contacted the students and explained the nature and objectives of the research. To those who expressed interest in participating, the coordinator requested authorization to give their electronic address, and, by this means, a formal invitation was sent to each student. After accepting the invitation, the students received, also by e-mail, the Free and Informed Consent Form to sign and return to the main researcher. A date and time was then scheduled for the focus group session, and the respective link to access the session was sent to all participants.

Data collection and organization

Due to the pandemic context caused by covid-19 and the restrictions it imposed on educational establishments and health services, data collection was conducted via videoconference, through the Zoom platform, adopting a focus group session format.

To conduct the focus group, a script consisting of a set of open questions was constructed. In its elaboration, fidelity and validity - essential characteristics that determine the quality of any measurement instrument - were considered. Fidelity is a condition that shows if the measurement instrument provides constant values from one use to the next; in this sense, a pre-test of the script was carried out with a focus group composed of four students who met the eligibility criteria for the research and who were not part of the group of participants. After analysis, there was no need for reformulation. Validity was checked through the evaluation of the script by an expert external to the study: a professor and researcher in nursing with 20 years of experience in clinical supervision, who gave a favorable opinion about the instrument.

The execution or moderation of the focus group was carried out by the main researcher, assisted by another researcher of the team, experienced in using the methodology. The session lasted about two hours. The session was recorded in image and audio and was destroyed after being transcribed.

Analysis of results

Content analysis was used globally, according to the methodology proposed by Bardin. Such analysis allows us to verify the order, intensity, and frequency of a discourse ( 33 ) , with the aim of improving the results, expanding its validity and, consequently, enabling a reliable final interpretation ( 35 ) .

Data analysis was performed by two independent researchers, with a backup researcher who was involved in case of disagreement, and followed three phases: organization, coding, and categorization. The first phase comprised the full transcription of the focus group participants’ speeches according to their sequence. To guarantee focus group anonymity, each participant was classified with the letter P (Participant) plus a number corresponding to the order of his or her speech (P1, P2, ...P8). Next, a skimming of the entire document that composed the corpus of analysis was performed, followed by an exhaustive reading. In the second phase, we performed the codification based on the theme and listed according to the frequency and intensity in the speeches. Finally, the semantic and lexical categorization was performed considering the meanings and reasoning of the speeches, based on which the categories and respective subcategories emerged ( 35 ) .

Eight BSN students participated in the focus group session, six female and two male. All of them were attending the 4th year of the Clinical Practices CUs course; and their ages ranged from 21 to 24 years, with an average age of 22.

The content analysis of the participants’ discourse allowed us to organize the information into categories and subcategories as shown in Chart 1 . The categories found were “Critical thinking skills”, “Factors that facilitate the development of critical thinking”, “Factors that hinder the development of critical thinking”, and “Clinical supervision strategies”.

Critical thinking skills

The participants recognized the importance of CT in the initial training of nurses, listing it as a factor that favors professional responsibility and quality in nursing care, since it promotes reflective thinking, meaningful and autonomous involvement in the complex context of health care, clinical judgment, and the development of decision-making skills.

I think it’s quite important that we develop our critical thinking because I think that’s one of the foundations of nursing practice; and I think that we as students, the earlier we develop it, the easier it will be for us when we are nurses. (P1) [...] I think it’s a fundamental part of being a good nurse [...]. (P5)

However, despite the extensive dissemination of the need for CT in nursing education, it is perceived that students are often not stimulated or are even prevented from putting their competencies into practice. Such difficulty is evidenced in their speech:

[...] it is true, sometimes we enact our critical thinking and we even manage to sustain it, but it is not always used, because many times we are even told “This is the protocol here”, and we actually end up performing the intervention according to the protocol, and not according to what we think, which is even more based on the most current evidence [...]. (P7)

In addition to recognizing its importance, participants also highlighted that the CT skills (evaluation, interpretation, analysis, inference, explanation, and self-regulation) are essential for their good performance in critical teaching, namely for clinical judgment, decision-making, and problem solving.

It is basically having the tendency not to say, oh, this is like this, it’s like that, because that person is telling me it’s like that; it’s having the ability to make the decision ourselves, taking into account the data that we have and the information that we can collect from that problem. (P7) Even if there are protocols at the service level, whatever they are, we shouldn’t look at them as a norm or a rule. We should respect them, but take into consideration what principles or what kind of bibliography they are based on... we should always look for evidence that justifies and supports the practices [...]. (P8)

Factors that facilitate the development of critical thinking

In the critical teaching context, the relationship between supervisors, students, and multiprofessional team is key to facilitate student learning. The spirit of cooperation favors autonomy, good clinical judgment, and the decision-making process. Regarding facilitating factors for the development of CT, participants highlight the importance of having a supervisor, having multiple supervisors, the supervisory relationship, experience in clinical supervision, student characteristics, the role of the supervisor, and integration into the team.

The establishment of a good supervisory relationship I think is the key, because from a good supervisory relationship comes all the rest, comes questioning, autonomy, trust, and also availability, which then will encourage us to seek more information, to question more, and learn more about the service we are in. (P4) [...] much more important than the strategies used, is also knowing the role that the supervisor has [...] knowing for a fact where he can really contribute to our critical thinking. (P6)

Factors that hinder the development of critical thinking

As supervisors move away from the characteristics previously described, they establish an authoritarian, oppressive, hostile, apathetic environment with little communication and make it impossible to create a good supervisory relationship, besides causing negative experiences in students. The absence of a good relationship between supervisor and supervised shows itself as a hindrance to the development of CT.

The analysis of the participants’ discourse allowed us to identify the following aspects as hindering the development of CT: nurse’s attitude, lack of feedback, communication problems, not wanting to be a supervisor, not having a supervisor, lack of support, and negative experience.

[...] I did many shifts with this supervisor, and she had a very authoritarian and very hostile attitude [...] I think I could have learned a lot more, and I didn’t learn exactly because of this attitude of hostility and neglect. (P3) [...] there was a little bit of a mocking attitude towards me for not knowing, and “how is it possible that you don’t know this? ” (P3) [...] my family was worked up, everything was going wrong, and the supervisor [...] never showed any concern, not even on a knowledge level, not on a personal level, nothing. It was the same thing being with her, I did things with her, and if I wasn’t with her it was the same, that was it. (P4) Having been placed with a supervisor who didn’t want to have students, I know it’s a little contradictory, but she told me, in this case directly, that she didn’t want to have students; and I think that makes clinical teaching a little difficult, because the person in particular didn’t ask me questions, when I asked questions she answered me in a less than friendly way, or sometimes she didn’t answer me at all. And then, throughout the clinical teaching, it felt a little bit as if the person was doing me a favor, and I didn’t feel secure and confident to be able to develop what I wanted, and I think it hindered my learning a little bit. (P1)

Clinical supervision strategies

The strategy adopted by the supervisor is established as the structuring axis of the teaching and learning process within critical teaching, since it allows students to develop essential clinical skills aiming at success in their performance. Regarding the CSSs, the participants highlight the pedagogical questions, reflection, individualized study, guidance, support, encouragement, feedback, discussion of clinical cases, definition of individual goals, observation and stimulation, and communication with the team.

[...] the fact that the supervisors ask us questions helps us to reflect on certain issues that are important and that, perhaps, we would not pay much attention to. (P2) [...] the fact that those questions, which are questions of another level, that ultimately take us further, are those questions that are not basic, but that we have to study in depth and understand different relationships to answer those questions [...]. (P8) [...] the questions, I think are important, but I think the moment, that is, when they ask us the questions is fundamental; I just don’t think it should be a stressful moment [...]. (P5) It really made me reflect and think [...]. (P1) [...] that is, with one question, I think I could encompass great knowledge, which would then have repercussions on my critical thinking in the short or long term. (P7) [...] but also, at the same time, it would guide my study at the initial moment; it would help, for example, “Look, right now, I think it makes sense for you to study this.” (P3) [...] she was a supervisor who cared about me as a person. For example, if there was any change, she was the first to say: “If you can’t make it, you can come and do it on another day; there’s no problem. (P3) [...] in more stressful situations, she was the first one to say: “Calm down, I’ll help you, I’m here and you can do it”. (P3) I consider feedback as something central, that is, to understand how well we are doing in clinical teaching, because we often have a wrong perception [...]. I think we should always understand how we are doing and what we can improve on. (P8) [...] and I think that, in the third year, in some of the initial clinical teaching, it was essential to establish objectives [...], also because when we start clinical teaching, we somehow feel lost, because there are a lot of things that we must know, so the definition of objectives ends up guiding us in some way. (P8)

The participants recognized the indispensability of CT for clinical practice, describing it as essential for professional responsibility and quality in nursing care, by virtue of being an enabling factor for reflective thinking, autonomy, good clinical judgment, acquisition of problem-solving skills, and safe, effective, and ethical decision-making. In addition, they highlighted the importance of establishing a good supervisory relationship, i.e., the need for the supervisor to get to know the student within his or her personal and academic journey. This close relationship was considered essential in determining the supervisory strategy best suited to the students’ needs, learning objectives, and clinical teaching context.

Peter Facione, through the memorable The Delphi Report, emphasizes the indispensability of the development of CT capabilities for the execution of sensible judgments and correct decisions. The abilities, also recognized as cognitive competencies or skills, are classified into six spheres: interpretation, analysis, evaluation, inference, explanation, and self-regulation ( 5 - 6 , 36 ) . These competencies are considered primordial for the student’s good academic, personal, and professional performance ( 36 ) since they allow them to improve problem-solving skills and, in turn, make assertive decisions ( 9 ) .

The participants’ discourse makes it possible to identify the critical thinker as one updated in knowledge, diligent in the search for a valid reason, thoughtful, flexible in his judgments, able to judge the credibility of information. However, it can be inferred that the absence of a cordial relationship between supervisor and supervised as well as the impossibility of putting current scientific knowledge into practice constitute major hindrances to the development of the students’ CT. Similarly, the critical thinker is described as curious, well-informed, creative, open to different possibilities, possessing reflective thinking, and therefore capable of judging the credibility of information ( 17 ) . Because the context of health care demands prudence from the nursing student in the search for and selection of information ( 10 ) , it becomes urgent to develop the habit of questioning and searching for scientific evidence to support safe and quality care.

Critical teaching allows the student to experience valuable moments of observation and interaction, as it favors the development of essential knowledge, skills, and attitudes for professional practice, provides self-regulation resources, besides facilitating the appropriation, mobilization, and materialization of knowledge ( 29 ) . In this environment, the supervisory process is configured as dynamic, interactive, facilitator, and which empowers learning, since it is based on a relationship of trust and mutual help, in which the supervisor adopts strategies for the personal and professional development of those supervised ( 37 ) .

The clinical supervisor, as the mediator of the students’ learning and professional development, ensures the transition from being a student to being a professional ( 29 ) . In this framework, the supervisory strategy constitutes an important phase in the training process since it provides the planning of actions and the organization of activities that favors students’ personal and professional development ( 37 ) .

Anchored in the principle of equity, supervisors should not treat students in an exactly equal manner regarding learning, a fact that is justified by the individual needs inherent to each supervisee ( 38 ) . There is no single, incontestable strategy that fits all contexts and all students; rather, there are different strategies that can be used in different combinations. For the strategy selection to be successful, it is important to consider the clinical context, the students, the learning objectives, and the available resources, which is why individualization of teaching is indispensable ( 37 ) .

Reflection allows students to construct and appropriate knowledge through their professional practice. In this process, the supervisor has a fundamental role in leading the student in the reflective process, either by creating real learning opportunities, or by provoking him/her in the search for more knowledge. Upon a doubt or difficulty, reflective thinking is initiated, followed by a mental process of questioning, which motivates the student to research so that he can then resolve that doubt or difficulty ( 39 ) . Reflection improves the capacity to solve problems and makes it possible to revisit and reformulate the experience lived, with the objective of establishing alternatives and constructing new learning ( 37 ) . The reflective process is enunciated as an effective strategy for the promotion of CT ( 17 ) , since reflecting on priorities in care promotes the development of confidence, autonomy, and communication skills ( 28 ) .

To formulate questions that instigate students’ restlessness and motivate them in the search for answers is pointed out as a propulsive strategy for reflective and creative thinking ( 37 ) . As the questions increase the students’ interest and curiosity, they contribute to experiential learning, enabling the connection between knowledge and practice ( 17 ) . At the same time, the supervisor, at opportune moments, in a friendly manner and withholding his/her evaluative character, asks questions. Besides facilitating the construction of a competent professional, it also instills in the student the habit of asking questions, allowing progress toward the potential development of CT skills.

Providing feedback allows students to become active subjects in the teaching and learning process, since it facilitates the self-evaluation process, and reflective, creative, and critical thinking ( 40 ) , and autonomy ( 17 ) , characteristics that are indispensable to nurses. Thus, the supervisor should find the most opportune moment to provide effective, clear, and constructive feedback ( 40 ) .

Study limitations

There are two limitations. First, the participants are only 4th year BSN students, i.e., graduates; this made it impossible to determine the strategies that promote CT for all BSN students in a critical teaching context. The second limitation relates to the fact that the study was conducted in a pandemic context, so online data collection did not allow establishing a physical meeting place with the participants, a fact that may have conditioned the responses due to the lack of familiarity with this format. In this sense, it is suggested to carry out studies in post-pandemic contexts, with students at different stages of critical teaching, in the early and final academic years, which will make it possible to demonstrate the causal relationship between the CSSs and the CT skills in students throughout the Nursing course.

Contributions to the field

The study highlights the need for the use of CSSs that favor the reflective process. It also reiterates the urgency to establish within the curricula of undergraduate nursing courses constructivist teaching strategies that allow students to develop CT, essential skills for good clinical judgment, problem solving, and safe, effective, and ethical clinical decision-making.

FINAL CONSIDERATIONS

Students recognized the importance of CT skills in the critical teaching context, considering them fundamental for clinical judgment, decision making, and problem solving. Since critical thinking demands effort and association of contexts and strategies that enable its development, this study highlights the importance of using different CSSs. Thus, the perspective of strategies acting in interchangeable and complementary ways is emphasized. Pedagogical questions, reflection, individualized study, orientation, support, encouragement, feedback, discussion of clinical cases, definition of individual goals, observation, and stimulation of communication with the team are the strategies identified as the most favorable for CT. At certain times, it is appropriate to use several strategies at the same time; at other times, only one is sufficient to achieve the learning objectives. To establish the most appropriate supervisory strategy for the student and the learning context, it is essential that the supervisor, in addition to knowing the academic path of his supervisee, recognize his individuality and needs.

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Exploring the impact of collaborative learning on the development of critical thinking and clinical decision-making skills in nursing students: A quantitative descriptive design

Affiliation.

• 1 Ankara Yıldırım Beyazıt University, Faculty of Health Sciences, Department of Nursing, Ankara, Turkey.
• PMID: 39295990
• PMCID: PMC11408133
• DOI: 10.1016/j.heliyon.2024.e37198

This study aims to introduce collaborative learning as a method in the Mental Health and Diseases Nursing course for actively enrolled fourth-year nursing students. The objective is to assess the impact of collaborative learning on critical thinking and clinical decision-making among nursing students. Collaborative learning involves the use of small groups to help students identify effective ways of working together to enhance their learning outcomes. A quantitative research methodology was employed in this study. To evaluate the effectiveness of the collaborative learning program, a within-subject repeated-measures design was implemented. This study was conducted in the nursing department of a university in Turkey. The study included 96 female students (92.3 %) and 8 male students (7.7 %). Data collection involved the sociodemographic data form, the California Critical Thinking Disposition Inventory (CCTDI), and the Clinical Decision-Making in Nursing Scale (CDMNS). The students' pre-program CDMNS median score was 146.00 (117.00-177.00), and the post-program CDMNS median score was 147.50 (115.00-175.00). While there was an increase in the students' clinical decision-making scores after the program, this increase was not statistically significant (p > 0.05). The pre-program median score for CCTDI was 223.26 (176.87-296.02), and the post-program median score was 227.88 (188.87-359.00). The students' critical thinking disposition scores showed a statistically significant increase after the program (p < 0.05). The study results revealed notable enhancements among students who participated in courses utilizing the collaborative learning method. These enhancements included heightened academic performance, elevated levels of critical thinking, increased self-confidence, and improved clinical decision-making abilities.

Keywords: Clinical decision-making; Collaborative learning; Critical thinking; Learning methods; Nursing education.

© 2024 The Authors.

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Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Flow diagram of the study.

Within-group change of CDMNS and…

Within-group change of CDMNS and CCTDI (n = 104).

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