critical thinking in new graduate nurses

Improving Critical Thinking in New Graduate Nurses: Are Practical Methods the Answer?

• PMID: 36445276
• DOI: 10.3928/00220124-20221107-04

Critical thinking is an essential skill of health care professionals. Not sufficiently matured during undergraduate studies, critical thinking skills need continued development. One solution could be a practical guide of teaching methods for clinical educators and professional development specialists to use with new graduate nurses. This column describes a few practical methods that can improve critical thinking. [ J Contin Educ Nurs . 2022;53(12):530-532.] .

• Education, Nursing, Graduate*
• Health Personnel

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• v.10(3); 2023 Mar

Critical thinking abilities among newly graduated nurses: A cross‐sectional survey study in China

Yongfang sun.

1 Nursing Department, Lanzhou University Second Hospital, Lanzhou China

2 School of Nursing, Gansu University of Chinese Medicine, Lanzhou China

Jiancheng Wang

3 Geriatrics Department, Gansu Provincial Hospital, Lanzhou China

Zhaohong Ding

4 Nursing Department, Gansu Provincial Hospital, Lanzhou China

Dongping Wang

5 Clinical Educational Department, Gansu Provincial Hospital, Lanzhou China

Yiyin Zhang

Juxia zhang.

6 Physical Examination Center, The First People’s Hospital of Lanzhou City, Lanzhou China

Associated Data

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

The aim of this study is to describe critical thinking dispositions among newly graduated nurses with different educational background in China and to explore related factors.

A cross‐sectional questionnaire survey.

The data were collected using the Chinese Version of Critical Thinking Dispositions Inventory (CTDI‐CV). Overall, 588 newly graduated nurses finally completed the survey. Spearman and Pearson's correlation coefficients were used to examine the correlation between the CDTI‐CV and nurses' general characteristics.

In terms of open‐mindedness, analysis and inquisitiveness subscales, significant differences were found among nurses based on three educational level. When dichotomizing total CTDI scores into high and low, nearly 80% of the respondents fell into low score group. Pressure from workplace was high for 68.4% of them. Significant correlation was found among the new graduated nurses' critical thinking ability and their age, education level, reading habit and attitude towards nursing profession.

1. INTRODUCTION

Critical thinking (CT) is a high‐level thinking method and form, individuals can flexibly use their existing knowledge and experience to identify and analyse problems (Paul,  2014 ), so as to make reasonable judgements and correct choices in complex situations (Hsieh & Hsu,  2013 ). Related to nursing knowledge, CT is defined as an essential skill to find problems, analyse problems (Andreou et al.,  2014 ) and provide flexible and evidence‐based nursing interventions in clinical practices (Lake & McInnes,  2012 ).

2. BACKGROUND

The medical delivery system is changing rapidly because of an aging population, and increases in the number of patients with advanced diseases result in diverse and high‐level health needs. To satisfy these needs in the context of such changes (Andreou et al.,  2014 ; Atakro et al.,  2019 ; Kakemam et al.,  2019 ), the Institute of Medicine specified Evidence‐Based Practice (EBP) as a core competence for all professional healthcare providers (Bigbee & Mixon,  2013 ), which by 2020 aims to apply evidence that is accurate, timely and supported by the latest clinical research to 90% of all clinical decisions. In the EBP process, healthcare providers are not just simple agents, but thinkers with expertise who search for and evaluate evidence to solve problems that emerge in clinical practice, subsequently making decisions to provide optimum treatment and intervention. In this process, critical thinking is vital.

Due to the population aging, complicated changes in diseases, developments in health technology, and the burden of long‐term non‐communicable diseases (Lee et al.,  2016 ), healthcare providers must possess skills such as critical thinking, independence and creativity, so that they can identify solutions to problems based on quick and accurate analyses in complex patient situations (Abas et al.,  2018 ). Also, in order to maintain sufficient human resources of care, a greater proportion of new graduate nurses are routinely employed in many hospitals (Cheng et al.,  2014 ). Furthermore, these new graduates are expected to have adequate competence at time of graduating to profession to be able to guarantee patient safety and quality of care (Kajander‐Unkuri et al.,  2021 ; Orujlu & Hemmati Maslakpak,  2017 ). Thus, critical thinking skills becomes vital for new nurses to be able to search for and evaluate evidence to solve clinical problems that emerge in practice, subsequently making correct decisions to provide optimum intervention (Lake & McInnes,  2012 ). In addition, critical thinking can also improve patient outcomes by using evidence‐based practice in nursing work (Kim et al.,  2018 ). More importantly, critical thinking is considered to be a core program outcome in nursing education (Ludin,  2018 ).

In general, new graduate nurses enter clinical practice experience through a transition period of approximately 2 years (Ludin,  2018 ). However, because of shortness of nurse workforce in healthcare settings, new hired graduate nurses are required to take responsibilities to observe and provide direct care for patients (Nguyen & Liu,  2021 ) with limited supervision or guidance that allows them fitting into the new environment (Lea & Cruickshank,  2015 ). Due to limited clinical technological skills and professional competence (Duchscher,  2009 ), newly graduate nurses may be less developed in the critical thinking skills (Nursing Executive Center,  2008 ), which is crucial to quality of care and patient's safety (Chen et al.,  2021 ). Study indicated that new graduated nurses have difficulty recognizing changes and deterioration in patients' conditions due to lacking a holistic approach (Willman et al.,  2021 ). New nurses have also expressed that patients with multiple diagnoses were outside their scope of expertise and patients who experience a sudden deterioration in their condition are challenging (Greenway et al.,  2019 ). Studies indicated that new graduate nurses have less judgement ability on doctors' orders (Bigbee & Mixon,  2013 ), and those took part in the health care for 1 year were the main responsible group for 43.8% of nursing errors (Dyab et al.,  2018 ). This may mainly due to lacking of critical thinking ability among them. Nursing interventions and decision‐making processes in complex patient situations need to include professional judgement based on experience in addition to the use of nursing care plans and guidelines (Zhang et al.,  2013 ), therefore, new graduated nurses' competence assessment is a key issue for all stakeholders in health care—nursing professionals, managers, educators and policymakers. Currently, most studies about CT were conducted among new graduate nurses with bachelor's degree (Pu et al.,  2019 ), however, when nurses with different education background first enter the clinical workplace, it creates a barrier for their critical thinking ability development in the theory‐practice transition process.

In China, the nursing workforce includes Diploma, Associate, Bachelor and Masters level prepared registered nurses (RN). It has been identified that new graduated nurses performed worst on critical thinking aptitude (Xie et al.,  2021 ; Zhang et al.,  2013 ). In 2016, National Health Commission of the P.R.C formulated “the Training Program for New Nurses (Trial Implementation)”, and medical institutions were required to establish training system, formulate the training program for new nurses (Liu et al.,  2016 ). Since studies indicated that nurses with higher educational background have stronger positive critical thinking ability and can better meet the needs of nursing care (Liu et al.,  2016 ). Meanwhile, organizational orientation for new nurses were identified as factors influencing their competency deployment (Xie et al.,  2021 ), it is urgent to evaluate CT ability of new nurses with different educational level, so as to formulate training program accordingly. Currently, less published studies examined critical thinking dispositions of new graduated nurses with different education level in China. Thus, our aim is to conduct a comparative study of the critical thinking dispositions and skills of new graduated nurses with diploma, 3‐year associate degree and 4‐year baccalaureate, and to find out what's the effect factors. The answer of this question would not only be important globally but also at the national level, because this answer might help us to develop orientation program for newly licensed registered nurses.

3.1. Study design

A cross‐sectional questionnaire survey was used in the study, the STROBE checklist was used in reporting this study (see File  S1 ).

3.2. Setting and participants

The study population were newly graduated nurses. These participants should follow: (1) having graduated from an accredited nursing programme in the last 18 months; (2) had been hired in a medical institution as a registered nurse; (3) successful completion of the National Council Licence Examination and (4) agreement to attend the survey. The one on holiday or resigned during data collection were excluded. The personal information (i.e., name, telephone number, email, etc) of new graduates majoring nursing were obtained from a facility which organized the recruitment interview. To keep the return‐to sender mail rate, all email addresses were tested prior by sending mail to each participant. Once they replied back, one of the researcher will send consent form and consequently send the questionnaire to each participant. If no replying received in 10 days, another researcher will make a call to participants. This process continued until the recommended number of potential respondents was obtained. All nurses ( n  = 650) who had responded after reminders received an online questionnaire.

3.3. Instrument

One questionnaire contain two parts was used. The first part of the questionnaire consisted of questions on demographic data (i.e., age, gender, the educational level, habit of reading professional literature, pressure from workplace and attitude towards the nursing profession). The second part of the questionnaire was the Chinese Version of Critical Thinking Dispositions Inventory (CTDI‐CV) that translated by Peng et al. ( 2004 ) from California Critical Thinking Dispositions Inventory(Searing & Kooken,  2016 ). The CTDI‐CV was used to measure the key theoretical aspects of the overall dispositional dimension of critical thinking. This scale consists of 70 questions in seven sub‐scales, each with 10 items, The seven sub‐scales are open‐mindedness, analyticity, cognition, maturity, truth‐seeking, systematicity, inquisitiveness and self‐confidence.

The instrument uses a 6‐point Likert scale in which 1 = strongly agree and 6 = strongly disagree. Total scores range between 70 and 420, with marks above 350 indicating a strong disposition and 280–350 positive inclination, whereas 210–279 indicating an ambivalent and below 210 strong opposition. The subscale scores range from 10 to 60, with strong disposition above 50 and positive inclination 40–50, and ambivalent 30–39 and strong opposition below 30. In Peng et al.'s study, the Cronbach's 0.90. The questionnaire of the content validity index (CVI) and content validity ratio (CVR) of experts were calculated (Huang et al.,  2021 ).

3.4. Procedure

A pilot study among a small group of students who did not participate in the main study was conducted to ensure the questionnaire was clear. In the main study, the researcher sent the new nurses self‐report questionnaires after they were agreed to participate the survey, and they were told to be free to withdraw from the study without any penalty, and their responses would be kept confidential. The length of time spent with each participant was about 1 week.

The general information which including choosing nursing as the first major, reading professional literature, published articles, attitude towards nursing profession for new graduated nurse in the different educational level were computed. Pressure from workplace were reported based on their clinical practices experiences.

3.5. Data analysis

SPSS19.0 and Amos 21.0 were used to analyse the reliability and validity of the questionnaire. Factor analysis was used to test the structure validity. Content validity index (CVI) and content validity ratio (CVR) were used to analyse the content validity. The internal correlation was tested by Pearson correlation coefficient. Cronbach's coefficient and mean item correlation coefficient (MIIC) were used to test the reliability of the questionnaire.

The SPSS Version 19.0 was used for the data analyses, and descriptive statistics were used to analyse participants' general characteristics. A one‐way ANOVA was used to compare the sub‐scales and total scores of CDTI‐CV among new graduated students. Moreover, the Spearman and Pearson's correlation coefficients were used to examine the correlation between the students' scores in CDTI‐CV and their age, gender, the educational level, habit of reading professional literature, pressure from workplace and attitude towards the nursing profession. The level of significance was considered <0.05.

4.1. Reliability and validity of the questionnaire

The results showed that CVI = 0.912, the range of CVI of each item was 0.866–1.00, CVR = 0.858. The Pearson correlation coefficient between each factor was 0.412–0.483, and the correlation coefficient between each factor and the total score of the scale was 0.621–0.787.

The total Cronbach's coefficient of the questionnaire was 0.938, the MIIC value of the questionnaire was 0.291.

4.2. Participants' general characteristics

The 650 questionnaires were delivered and 588 were returned with response rate of 90.4%. Among them, 39.8% were graduated with BSN, 41.8% with AND and 18.4% DIP. The mean age was 20.85 ± 1.80 years with 65.3% of them were between 21 and 25 years old. About reading professional literature, nearly all (91.2%) read it sometimes, and only 7.1% published articles. The pressure from workplace was high for 68.4% of them, which were 74.4%, 63.4% and 66.7% for new nurses with BSN, AND and DIP, respectively. For attitude towards the nursing profession, 55.5% reported that they are interested while 40.8% moderately and 3.7% uninterested, respectively. In terms of new graduates with BSN, 43.6% were interested in nursing profession, while 48.7% moderately interested (Table  1 ).

General characteristics( N  = 588)

Abbreviations: AND, Associate degree in Nursing; BSN, Bachelor of Science in Nursing; DIP, Diploma in Nursing.

4.3. New graduated nurses' CTDI

A one‐way ANOVA was used to compare the sub‐scales and total scores of CTDI among BSN, ADN and DIP nurses. There were significant differences among the three groups on the total score ( F  = 5.132, p  = 0.006). Follow‐up univariate analyses of variance with LSD revealed the following. There were no statistically significant differences between ADN and DIP students in all mean scores of CTDI. However, BSN students scored significantly higher than the other two groups on the total score and three of the seven sub‐scales on CTDI. Significant differences were found among educational level in terms of their mean scores for the open‐mindedness (BSN vs. DIP, p  = 0.028), analyticity (BSN vs. ADN, p  < 0.001; BSN vs. DIP, p  = 0.003) and inquisitiveness (BSN vs. ADN, p  = 0.047). Among the seven sub‐scales, analyticity (41.12 ± 5.65), inquisitiveness(40.07 ± 7.64) and maturity (40.63 ± 7.24) had the highest scores, followed by open‐mindedness (39.79 ± 6.46), systematicity (37.51 ± 5.73), truth‐seeking (36.48 ± 6.16) and self‐confidence (35.87 ± 6.52). These data are described in Table  2 .

Critical thinking dispositions among student of different educational level ( n  = 588)

When dichotomizing total CTDI scores into high (i.e., strong disposition and positive inclination) and low (i.e., ambivalent and strong opposition towards critical thinking), nearly 80% of the respondents fell into low score group (i.e., 279 or lower), while approximately one‐fifth (27%) fell into the high score group (i.e., 280 or higher). No respondents reported strong opposition (Figure  1 ).

Critical thinking dispositions among newly graduated nurses in China ( n  = 588). Percent of respondents ( y ‐axis) with high and low scores for subscales and total score ( x ‐axis) are shown graphically.

4.4. Correlations between general characteristics and CTDI

To examine the linkage between abilities to think critically and general characteristics, the Pearson correlation test was performed between sub‐scales, total score of CTDI and the general characteristics in terms of age, gender, educational level, reading professional literature, published articles, pressure from workplace, attitude towards nursing profession. Significant correlation was found between nurses' total critical thinking ability and their age ( r  = 0.18, p  = 0.001), especially in sub‐scales including truth‐seeking ( r  = 0.15, p  = 0.009), open‐mindedness ( r  = 0.15, p  = 0.009), analyticity ( r  = 0.13, p  = 0.01), systematicity ( r  = 0.14, p  = 0.01) and maturity ( r  = 0.16, p  = 0.006), educational level ( r  = 0.15, p  = 0.006) especially in sub‐scales of open‐mindedness ( r  = 0.13, p  = 0.02), analyticity ( r  = 0.23, p  < 0.001) and maturity ( r  = 0.14, p  = 0.01). Whether reading professional literature ( r  = 0.19, p  = 0.001), especially in analyticity ( r  = 0.22, p  < 0.001) and inquisitiveness ( r  = 0.16, p  = 0.004). New nurses who were interested in nursing exhibited stronger critical thinking disposition than those who were not ( r  = 0.20, p  < 0.001), especially in truth‐seeking ( r  = 0.20, p  < 0.001) and open‐mindedness ( r  = 0.16, p  = 0.004) (Table  3 ).

Critical thinking dispositions by general characteristics

5. DISCUSSION

Critical thinking skills are essential for nurses to provide safe and efficient nursing care (Chen et al.,  2019 ), which also increase the initiative of nursing work (Zuriguel‐Pérez et al.,  2018 ). Because of the ongoing nursing shortage and the increasing acuity of patients, new graduate nurses must master both psychomotor and critical thinking skills rapidly at the time of commencing employment (Theisen & Sandau,  2013 ). However, in cord with other studies (Ip et al.,  2000 ; Wangensteen et al.,  2010 ), the majority of areas of CTDI in current study showed negative disposition, which may not keep up well with the purpose of the joint competence requirements and therefore insufficient supporting workforce mobility in the common labour market. These may be presumably ascribed to the dissimilarities in the organization of nursing education (e.g., universities, universities of applied sciences, nursing schools, polytechnic institutes). Kajander‐Unkuri et al. ( 2021 ) also found that nursing students taking different degree programmes hold varying views about their competence (Kajander‐Unkuri et al.,  2021 ). It is suggested that schools of nursing should add communication strategies to their curriculum that focusing on critical thinking, clinical reasoning and simulation scenarios and including situation‐specific skills such as end‐of‐life scenarios (Theisen & Sandau,  2013 ). Further research should focus on clinical reasoning and evaluation of measurement tools for new graduates.

The main finding of this study is that among the seven sub‐scales of CTDI, new graduated nurses showed higher results on the sub‐scales of analyticity, inquisitiveness and maturity. However, they showed weaker performance on the sub‐scales of truth‐seeking. This was consisted with Pu et al. ( 2019 ) which assessed critical thinking disposition of undergraduate students from top medical universities in Beijing (297.72) (Pu et al.,  2019 ). These may due to the traditional large‐classroom teaching methods and the bashfulness of the Chinese culture. In Chinese traditional teaching, high scores corresponding to standardized answers are taken as the main indicators to test students' learning effects, making students more dependent on standard answers, thus showing initiative, enthusiasm with thinking and objectivity are declining.

Professional confidence is an essential trait for new graduate nurses to possess so as to provide quality patient care in complex hospital setting. However, many new graduates are entering the workforce without it not only in our study, but also in others (Ortiz,  2016 ). These may because the frequent negative reports of medical accidents or negative influence of failure experience, and the potential lack of proficiency among nurses in both their clinical skills and critical thinking abilities (Greenway et al.,  2019 ). Nevertheless, the increased occurrence of nursing errors, and the episodes of adverse events witnessed/experienced by new nurses (Stevanin et al.,  2015 ). New nursing graduates have revealed that they perceive a gap between theory and practice with reference to their education and the real workplace setting (Jung et al.,  2017 ). Monaghan ( 2015 ) found the theory‐practice gap begins during pre‐registration education (Monaghan,  2015 ). As such, There is an urgent need to reform nursing curricula, collaboration between universities and practice setting is essential to improve the environment in which nursing students learn the clinical skills. Pre‐clinical orientation, distributing and clarifying clinical learning objectives should be offered to students, and frequent visits and supervision of students in clinical area may improve student learning experience in clinical placement (Gemuhay et al.,  2019 ). A well‐designed supportive orientation program including workshops, reflective activities (Raymond et al.,  2018 ), support from colleague and environment are needed for new nurse as it not only provides direction for clinical practice (Menard & Maas,  2019 ) but also flexible enough to meet the individual nurse's needs when problems arise (Jung et al.,  2017 ), meanwhile it also enable the graduate to understand the required level of clinical practice and feel confident in asking for support and thus promoting the retention of graduates for the future nursing workforce (Wardrop et al.,  2019 ).

We also found factors being positively related to new graduated nurses' critical thinking competence level. It is apparent that new nurses with bachelor's degree scored higher on open‐mindedness, analyticity and inquisitiveness. However, Fero et al. ( 2009 ) study showed that new graduate nurses with different education background showed the same difficulties in meeting job expectations and struggled to make and implement independent nursing interventions (Fero et al.,  2009 ). Although the increasing in institutions offering first degree program in nursing, university education remains problematic with many disparities in the nursing program currently being offered in different university. Identified problems that run simultaneously with the present tertiary school curriculum unqualified and poorly trained teachers, inadequate facilities and dilapidated instructional materials. This study suggests that majority of newly graduated nurses with different education background had requirements of training regard improving their critical thinking ability during their clinical practices. Case studies with videotaped vignettes may use to help facilitate the development of critical thinking skills in new graduate nurses (Hooper,  2014 ).

Reading professional literature was related to critical thinking competence level. This link has not been investigated often but a connection between the two has been shown (Xie et al.,  2014 ). The process of reading scientific research papers is actually a good thinking training process and could be used as a teaching strategies for fostering critical thinking ability (Chen & Lin,  2003 ). Undergraduate students can be guided to read original scientific papers so as to cultivate their critical thinking ability (Xie et al.,  2014 ). The students indicated that group discussions and the narrative comments of facilitators contributed the most to develop critical thinking. The correlation between utility judgement and one's pre‐class reading behaviour was statistically significant (Chen & Lin,  2003 ). In this aspect, it would be worthwhile to give more attention to demonstration, guided practice and interaction with others through discussion and feedback will induce more desired learning behaviour to develop critical thinking.

Being interested in nursing profession has also been recognized previously as a factor related to competence in terms of critical thinking ability (Willman et al.,  2021 ). Those with positive perception of the nursing profession may have a nursing career plan for the future, which can benefit nursing students by its influence on in‐depth approach to learning and professional development (Kim & Shin,  2020 ). Therefore, it would be useful to explore in detail the competence outcomes for students by including or not including intensive career planning in the curriculum.(Kajander‐Unkuri et al.,  2021 ). When new graduate nurses move from the school environment to the work setting, they experience conflicts due to the inconsistent roles, values and nursing abilities they learned from the school and various clinical sites. Many nurses experience a reality shock when they participate in clinical practice (Jung et al.,  2017 ). This was revealed in our study as pressure from workplace was high for 68.4% of them. Stresses that new graduates face are related to a lack of competence including skill performance, communication with physicians, developing relationships with colleagues, patients and families, managing workload demands, organizing and prioritizing duties, doing shift reports and adjusting to different shifts (Atakro et al.,  2019 ). New graduates may leave their job in sixth to twelfth months if these stresses are not resolved (Cheng et al.,  2014 ). Since the orientation and the preceptor have a great impact on how newly graduated nurses experience the start of their career. Often, newly graduated nurses wish to continue their relationship with their preceptor after the orientation period (Pasila et al.,  2017 ). New graduate nurse programs enhanced critical thinking, competency and retention and there were advantages with use of bundled preceptor strategies to support new graduates (Rush et al.,  2019 ). The preceptor is a source of knowledge and support for the graduate nurse during their transition through the first year of practice and effective preceptorship has a direct influence on graduate performance and the quality of patient care. Healthcare students learn from mistakes, such as real‐life examples, observing their peers or staff members, but also from their own mistakes (Tracey & McGowan,  2015 ). Therefore, transition interventions are needed which lead to improvements in confidence and competence, job satisfaction, critical thinking and reductions in stress and anxiety for the newly qualified nurse (Edwards et al.,  2015 ). Organizations should ensure that nurse leaders have the resources they need to support the positive transition of new graduate nurses including adequate staffing and realistic workloads for both experienced and new nurses. Nurse leaders should work to create unit cultures that foster learning by encouraging new graduate nurses to ask questions and seek feedback without fear of criticism or incivility (Regan et al.,  2017 ).

A few limitations should be noted in the present study. The first is that it is possible that new graduates may have been reducing anxiety as a result of multiple factors, including preceptor and clinical practice, rather than as a result of the lower critical thinking ability. The second limitation is the non‐random selection of the convenience sample; it may be difficult to generalize the results beyond this population, and it may not be representative of other new graduated nurses. Despite these limitations, however, the present study provided initial insights into the correlation between critical thinking ability and educational background among new nurses who are beginning their clinical experience in a hospital setting, so as to provide basis for transitional orientation program.

6. CONCLUSIONS

This study explored the critical thinking ability of newly graduated nurses and its influencing factors, so can provide evidence for training programs to new nurses. In the current study, most newly graduated nurses fell into the lower critical thinking ability group. Those with bachelor's degrees obtained the highest critical thinking ability scores especially in open‐mindedness, analyticity and inquisitiveness. For fresh graduates, there is a lot of pressure from the workplace. The results suggest that nursing managers and nurse teachers should establish different pre‐job training modes for new nurses by considering the personality traits of new nurses to meet the needs of nurses with different abilities, so as to improve their enthusiasm and participation in learning. At the same time, they should be provided with an environment support where they can read literature and attending discussion activities freely to help them improve their critical thinking ability.

Future research should examine the changing trend of the critical thinking ability of newly graduated nurses during clinical practice and explore whether different types of training program have different effects on critical thinking competency.

7. RELEVANCE TO CLINICAL PRACTICE

Understanding critical thinking abilities among newly hired graduate nurses and its effectiveness factors can assist nurse managers to understand what types of on‐the‐job continuing education workshops should be provided to new nurses to help enhance their critical thinking abilities.

AUTHOR CONTRIBUTIONS

ZJX, WJC and WY designed the study; YYH, WJC, ZYY and DZH performed data collection; WJC and YYH conducted the data analysis; ZJX and WDP wrote the first draft; ZJX and WJC commented on all the drafts; SYF, YYH and WY revised the paper; SYF and WY provided the funding support for this study; All authors read and approved the final manuscript.

All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE ( http://www.icmje.org/recommendations/ )]:

• substantial contributions to conception and design, acquisition of data or analysis and interpretation of data;
• drafting the article or revising it critically for important intellectual content.

FUNDING INFORMATION

This research was funded by the Horizontal project of School of Public Health of Lanzhou University “Research on the Thinking, difficulties and Countermeasures of High‐quality Development of Lanzhou Hand and Foot Surgery Hospital” (071100278), Study on the mode of intelligent medical care integration in Lanzhou (2019RCCX0011) and Natural Science Foundation of Gansu Province (21JR7RA607 and 21JR7RA613) and Lanzhou Science and Technology Bureau Project (2018‐3‐68).

CONFLICT OF INTEREST

The author(s) declare(s) that there is no conflict of interest.

ETHICAL APPROVAL

This study was approved by Gansu Provincial Hospital's Ethic Commission (2018–106). All participants were informed about the purpose and design of this research, and that their participation was voluntary.

Supporting information

Acknowledgements.

We are grateful to the medical colleges and universities for recruiting participants in this study.

Sun, Y. , Yin, Y. , Wang, J. , Ding, Z. , Wang, D. , Zhang, Y. , Zhang, J. , & Wang, Y. (2023). Critical thinking abilities among newly graduated nurses: A cross‐sectional survey study in China . Nursing Open , 10 , 1383–1392. 10.1002/nop2.1388 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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Emerging Nurse Leader

A leadership development blog

Helping New Nurses With Critical Thinking Skills

August 4, 2022 by rose

By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

Onboarding new graduates this year will take a village. A nurse manager recently shared her concerns, “I am shocked at how underprepared our new nurses are this year. While doing leader rounding, I asked a new graduate about her patient, and her assessment of the priorities for care was genuinely concerning. Preceptors are coming to me to say – “even the basics need to be taught because their critical thinking skills are so limited.”

Preceptors need guidance on assessing new graduates’ skills and promoting critical thinking. Many of the preceptors themselves have limited experience. But neither preceptors nor managers can do this alone. Everyone who interacts with new graduates should help them think through situations they are confronted with. This will not happen through osmosis. We become better critical thinkers when good open-ended questions (which can’t be answered with a yes or no) are asked, forcing us to stop and think before we answer them. Critical thinking is crucial in a fast-paced turbulent environment, so understanding what it is and how it can be developed is essential.

What is Critical Thinking?

Critical thinking is reasonable; reflective thinking which is focused on deciding what to believe or do. In nursing, critical thinking for clinical decision-making is the ability to think systematically and logically. Evidence shows that new nurses can be effectively coached to become better critical thinkers. A strong critical thinker can do the following:

• Remain open-minded and mindful of different alternative actions.
• Prioritize what matters most in clinical situations.
• View themselves as a continuous learner and seek out new knowledge.
• Effectively judge the credibility of the evidence.
• Ask appropriate clarifying questions.
• Explain reasons for actions that were taken.
• Seek second opinions when unsure about clinical judgment.

Coaching Questions to Promote Critical Thinking

• To Organize Care – How you will organize care for these six patients? What should your first actions be? What is the WIN here – most important now? If you begin here with the end in mind, what should that goal for the patient be? If you fall behind in your care, what will you do? What team members can be your backup buddy on this shift?
• To Clarify Thinking – Can you explain more about this situation? What do you think the issue is here? What action will you be taking? What do you think will happen if you take that action? Are there other alternatives that you have considered? If you are unsure about something today, who will you ask?
• To Inspire Reflection – Why do you think you were successful or unsuccessful in that situation? Could you have used another approach? What will you do differently the next time?
• To Challenge Assumptions –  How do you know that your assumptions are correct in this situation? Is there another way to view this problem? What are two other possible explanations for what happened here?
• To Build Accountability – Based on your nursing experience, what do you suggest we do here? What changes would be in the best interest of your patients right now? How could you have managed this situation differently? What would great look like with this patient/family (if a service recovery issue with a patient)?
• To Develop a Growth Mindset – What would you do here if you knew you could not fail? How could this situation help you to grow? What have you learned about yourself as a professional? When you have encountered challenging situations in the past – what strengths have you used to get through them.

If there was ever a need for nurse leader coaching, it is now. Every nurse interacting with new graduates is part of this village that will help new graduates assimilate into practice settings and the professional. Helping them with critical thinking is a good beginning point.

©  emergingrnleader.com 2022

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Promoting critical thinking through an evidence-based skills fair intervention

Journal of Research in Innovative Teaching & Learning

ISSN : 2397-7604

Article publication date: 23 November 2020

Issue publication date: 1 April 2022

The lack of critical thinking in new graduates has been a concern to the nursing profession. The purpose of this study was to investigate the effects of an innovative, evidence-based skills fair intervention on nursing students' achievements and perceptions of critical thinking skills development.

Design/methodology/approach

The explanatory sequential mixed-methods design was employed for this study.

The findings indicated participants perceived the intervention as a strategy for developing critical thinking.

Originality/value

The study provides educators helpful information in planning their own teaching practice in educating students.

Critical thinking

Evidence-based practice, skills fair intervention.

Gonzalez, H.C. , Hsiao, E.-L. , Dees, D.C. , Noviello, S.R. and Gerber, B.L. (2022), "Promoting critical thinking through an evidence-based skills fair intervention", Journal of Research in Innovative Teaching & Learning , Vol. 15 No. 1, pp. 41-54. https://doi.org/10.1108/JRIT-08-2020-0041

Emerald Publishing Limited

Copyright © 2020, Heidi C. Gonzalez, E-Ling Hsiao, Dianne C. Dees, Sherri R. Noviello and Brian L. Gerber

Published in Journal of Research in Innovative Teaching & Learning . Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

Introduction

Critical thinking (CT) was defined as “cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge” ( Scheffer and Rubenfeld, 2000 , p. 357). Critical thinking is the basis for all professional decision-making ( Moore, 2007 ). The lack of critical thinking in student nurses and new graduates has been a concern to the nursing profession. It would negatively affect the quality of service and directly relate to the high error rates in novice nurses that influence patient safety ( Arli et al. , 2017 ; Saintsing et al. , 2011 ). It was reported that as many as 88% of novice nurses commit medication errors with 30% of these errors due to a lack of critical thinking ( Ebright et al. , 2004 ). Failure to rescue is another type of error common for novice nurses, reported as high as 37% ( Saintsing et al. , 2011 ). The failure to recognize trends or complications promptly or take action to stabilize the patient occurs when health-care providers do not recognize signs and symptoms of the early warnings of distress ( Garvey and CNE series, 2015 ). Internationally, this lack of preparedness and critical thinking attributes to the reported 35–60% attrition rate of new graduate nurses in their first two years of practice ( Goodare, 2015 ). The high attrition rate of new nurses has expensive professional and economic costs of $82,000 or more per nurse and negatively affects patient care ( Twibell et al. , 2012 ). Facione and Facione (2013) reported the failure to utilize critical thinking skills not only interferes with learning but also results in poor decision-making and unclear communication between health-care professionals, which ultimately leads to patient deaths.

Due to the importance of critical thinking, many nursing programs strive to infuse critical thinking into their curriculum to better prepare graduates for the realities of clinical practice that involves ever-changing, complex clinical situations and bridge the gap between education and practice in nursing ( Benner et al. , 2010 ; Kim et al. , 2019 ; Park et al. , 2016 ; Newton and Moore, 2013 ; Nibert, 2011 ). To help develop students' critical thinking skills, nurse educators must change the way they teach nursing, so they can prepare future nurses to be effective communicators, critical thinkers and creative problem solvers ( Rieger et al. , 2015 ). Nursing leaders also need to redefine teaching practice and educational guidelines that drive innovation in undergraduate nursing programs.

Evidence-based practice has been advocated to promote critical thinking and help reduce the research-practice gap ( Profetto-McGrath, 2005 ; Stanley and Dougherty, 2010 ). Evidence-based practice was defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient” ( Sackett et al. , 1996 , p. 71). Skills fair intervention, one type of evidence-based practice, can be used to engage students, promote active learning and develop critical thinking ( McCausland and Meyers, 2013 ; Roberts et al. , 2009 ). Skills fair intervention helps promote a consistent teaching practice of the psychomotor skills to the novice nurse that decreased anxiety, gave clarity of expectations to the students in the clinical setting and increased students' critical thinking skills ( Roberts et al. , 2009 ). The researchers of this study had an opportunity to create an active, innovative skills fair intervention for a baccalaureate nursing program in one southeastern state. This intervention incorporated evidence-based practice rationale with critical thinking prompts using Socratic questioning, evidence-based practice videos to the psychomotor skill rubrics, group work, guided discussions, expert demonstration followed by guided practice and blended learning in an attempt to promote and develop critical thinking in nursing students ( Hsu and Hsieh, 2013 ; Oermann et al. , 2011 ; Roberts et al. , 2009 ). The effects of an innovative skills fair intervention on senior baccalaureate nursing students' achievements and their perceptions of critical thinking development were examined in the study.

Literature review

The ability to use reasoned opinion focusing equally on processes and outcomes over emotions is called critical thinking ( Paul and Elder, 2008 ). Critical thinking skills are desired in almost every discipline and play a major role in decision-making and daily judgments. The roots of critical thinking date back to Socrates 2,500 years ago and can be traced to the ancient philosopher Aristotle ( Paul and Elder, 2012 ). Socrates challenged others by asking inquisitive questions in an attempt to challenge their knowledge. In the 1980s, critical thinking gained nationwide recognition as a behavioral science concept in the educational system ( Robert and Petersen, 2013 ). Many researchers in both education and nursing have attempted to define, measure and teach critical thinking for decades. However, a theoretical definition has yet to be accepted and established by the nursing profession ( Romeo, 2010 ). The terms critical literacy, CT, reflective thinking, systems thinking, clinical judgment and clinical reasoning are used synonymously in the reviewed literature ( Clarke and Whitney, 2009 ; Dykstra, 2008 ; Jones, 2010 ; Swing, 2014 ; Turner, 2005 ).

Watson and Glaser (1980) viewed critical thinking not only as cognitive skills but also as a combination of skills, knowledge and attitudes. Paul (1993) , the founder of the Foundation for Critical Thinking, offered several definitions of critical thinking and identified three essential components of critical thinking: elements of thought, intellectual standards and affective traits. Brunt (2005) stated critical thinking is a process of being practical and considered it to be “the process of purposeful thinking and reflective reasoning where practitioners examine ideas, assumptions, principles, conclusions, beliefs, and actions in the contexts of nursing practice” (p. 61). In an updated definition, Ennis (2011) described critical thinking as, “reasonable reflective thinking focused on deciding what to believe or do” (para. 1).

The most comprehensive attempt to define critical thinking was under the direction of Facione and sponsored by the American Philosophical Association ( Scheffer and Rubenfeld, 2000 ). Facione (1990) surveyed 53 experts from the arts and sciences using the Delphi method to define critical thinking as a “purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation, and inference, as well as an explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which judgment, is based” (p. 2).

To come to a consensus definition for critical thinking, Scheffer and Rubenfeld (2000) also conducted a Delphi study. Their study consisted of an international panel of nurses who completed five rounds of sequenced questions to arrive at a consensus definition. Critical thinking was defined as “habits of mind” and “cognitive skills.” The elements of habits of mind included “confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection” ( Scheffer and Rubenfeld, 2000 , p. 352). The elements of cognitive skills were recognized as “analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge” ( Scheffer and Rubenfeld, 2000 , p. 352). In addition, Ignatavicius (2001) defined the development of critical thinking as a long-term process that must be practiced, nurtured and reinforced over time. Ignatavicius believed that a critical thinker required six cognitive skills: interpretation, analysis, evaluation, inference, explanation and self-regulation ( Chun-Chih et al. , 2015 ). According to Ignatavicius (2001) , the development of critical thinking is difficult to measure or describe because it is a formative rather than summative process.

Fero et al. (2009) noted that patient safety might be compromised if a nurse cannot provide clinically competent care due to a lack of critical thinking. The Institute of Medicine (2001) recommended five health care competencies: patient-centered care, interdisciplinary team care, evidence-based practice, informatics and quality improvement. Understanding the development and attainment of critical thinking is the key for gaining these future competencies ( Scheffer and Rubenfeld, 2000 ). The development of a strong scientific foundation for nursing practice depends on habits such as contextual perspective, inquisitiveness, creativity, analysis and reasoning skills. Therefore, the need to better understand how these critical thinking habits are developed in nursing students needs to be explored through additional research ( Fero et al. , 2009 ). Despite critical thinking being listed since the 1980s as an accreditation outcome criteria for baccalaureate programs by the National League for Nursing, very little improvement has been observed in practice ( McMullen and McMullen, 2009 ). James (2013) reported the number of patient harm incidents associated with hospital care is much higher than previously thought. James' study indicated that between 210,000 and 440,000 patients each year go to the hospital for care and end up suffering some preventable harm that contributes to their death. James' study of preventable errors is attributed to other sources besides nursing care, but having a nurse in place who can advocate and critically think for patients will make a positive impact on improving patient safety ( James, 2013 ; Robert and Peterson, 2013 ).

Adopting teaching practice to promote CT is a crucial component of nursing education. Research by Nadelson and Nadelson (2014) suggested evidence-based practice is best learned when integrated into multiple areas of the curriculum. Evidence-based practice developed its roots through evidence-based medicine, and the philosophical origins extend back to the mid-19th century ( Longton, 2014 ). Florence Nightingale, the pioneer of modern nursing, used evidence-based practice during the Crimean War when she recognized a connection between poor sanitary conditions and rising mortality rates of wounded soldiers ( Rahman and Applebaum, 2011 ). In professional nursing practice today, a commonly used definition of evidence-based practice is derived from Dr. David Sackett: the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient ( Sackett et al. , 1996 , p. 71). As professional nurses, it is imperative for patient safety to remain inquisitive and ask if the care provided is based on available evidence. One of the core beliefs of the American Nephrology Nurses' Association's (2019) 2019–2020 Strategic Plan is “Anna must support research to develop evidence-based practice, as well as to advance nursing science, and that as individual members, we must support, participate in, and apply evidence-based research that advances our own skills, as well as nursing science” (p. 1). Longton (2014) reported the lack of evidence-based practice in nursing resulted in negative outcomes for patients. In fact, when evidence-based practice was implemented, changes in policies and procedures occurred that resulted in decreased reports of patient harm and associated health-care costs. The Institute of Medicine (2011) recommendations included nurses being leaders in the transformation of the health-care system and achieving higher levels of education that will provide the ability to critically analyze data to improve the quality of care for patients. Student nurses must be taught to connect and integrate CT and evidence-based practice throughout their program of study and continue that practice throughout their careers.

One type of evidence-based practice that can be used to engage students, promote active learning and develop critical thinking is skills fair intervention ( McCausland and Meyers, 2013 ; Roberts et al. , 2009 ). Skills fair intervention promoted a consistent teaching approach of the psychomotor skills to the novice nurse that decreased anxiety, gave clarity of expectations to the students in the clinical setting and increased students' critical thinking skills ( Roberts et al. , 2009 ). The skills fair intervention used in this study is a teaching strategy that incorporated CT prompts, Socratic questioning, group work, guided discussions, return demonstrations and blended learning in an attempt to develop CT in nursing students ( Hsu and Hsieh, 2013 ; Roberts et al. , 2009 ). It melded evidence-based practice with simulated CT opportunities while students practiced essential psychomotor skills.

Research methodology

Context – skills fair intervention.

According to Roberts et al. (2009) , psychomotor skills decline over time even among licensed experienced professionals within as little as two weeks and may need to be relearned within two months without performing a skill. When applying this concept to student nurses for whom each skill is new, it is no wonder their competency result is diminished after having a summer break from nursing school. This skills fair intervention is a one-day event to assist baccalaureate students who had taken the summer off from their studies in nursing and all faculty participated in operating the stations. It incorporated evidence-based practice rationale with critical thinking prompts using Socratic questioning, evidence-based practice videos to the psychomotor skill rubrics, group work, guided discussions, expert demonstration followed by guided practice and blended learning in an attempt to promote and develop critical thinking in baccalaureate students.

Students were scheduled and placed randomly into eight teams based on attributes of critical thinking as described by Wittmann-Price (2013) : Team A – Perseverance, Team B – Flexibility, Team C – Confidence, Team D – Creativity, Team E – Inquisitiveness, Team F – Reflection, Team G – Analyzing and Team H – Intuition. The students rotated every 20 minutes through eight stations: Medication Administration: Intramuscular and Subcutaneous Injections, Initiating Intravenous Therapy, ten-minute Focused Physical Assessment, Foley Catheter Insertion, Nasogastric Intubation, Skin Assessment/Braden Score and Restraints, Vital Signs and a Safety Station. When the students completed all eight stations, they went to the “Check-Out” booth to complete a simple evaluation to determine their perceptions of the effectiveness of the innovative intervention. When the evaluations were complete, each of the eight critical thinking attribute teams placed their index cards into a hat, and a student won a small prize. All Junior 2, Senior 1 and Senior 2 students were required to attend the Skills Fair. The Skills Fair Team strove to make the event as festive as possible, engaging nursing students with balloons, candy, tri-boards, signs and fun pre and postactivities. The Skills Fair rubrics, scheduling and instructions were shared electronically with students and faculty before the skills fair intervention to ensure adequate preparation and continuous resource availability as students move forward into their future clinical settings.

Research design

Institutional review board (IRB) approval was obtained from XXX University to conduct this study and protect human subject rights. The explanatory sequential mixed-methods design was employed for this study. The design was chosen to identify what effects a skills fair intervention that had on senior baccalaureate nursing students' achievements on the Kaplan Critical Thinking Integrated Test (KCTIT) and then follow up with individual interviews to explore those test results in more depth. In total, 52 senior nursing students completed the KCTIT; 30 of them participated in the skills fair intervention and 22 of them did not participate. The KCTIT is a computerized 85-item exam in which 85 equates to 100%, making each question worth one point. It has high reliability and validity ( Kaplan Nursing, 2012 ; Swing, 2014 ). The reliability value of the KCTIT ranged from 0.72 to 0.89. A t -test was used to analyze the test results.

A total of 11 participants were purposefully selected based on a range of six high achievers and five low achievers on the KCTIT for open-ended one-on-one interviews. Each interview was conducted individually and lasted for about 60 minutes. An open-ended interview protocol was used to guide the flow of data collection. The interviewees' ages ranged from 21 to 30 years, with an average of 24 years. One of 11 interviewees was male. Among them, seven were White, three were Black and one was Indian American. The data collected were used to answer the following research questions: (1) What was the difference in achievements on the KCTIT among senior baccalaureate nursing students who participated in the skills fair intervention and students who did not participate? (2) What were the senior baccalaureate nursing students' perceptions of internal and external factors impacting the development of critical thinking skills during the skills fair intervention? and (3) What were the senior baccalaureate nursing students' perceptions of the skills fair intervention as a critical thinking developmental strategy?

Inductive content analysis was used to analyze interview data by starting with the close reading of the transcripts and writing memos for initial coding, followed by an analysis of patterns and relationships among the data for focused coding. The intercoder reliability was established for qualitative data analysis with a nursing expert. The lead researcher and the expert read the transcript several times and assigned a code to significant units of text that corresponded with answering the research questions. The codes were compared based on differences and similarities and sorted into subcategories and categories. Then, headings and subheadings were used based on similar comments to develop central themes and patterns. The process of establishing intercoder reliability helped to increase dependability, conformability and credibility of the findings ( Graneheim and Lundman, 2004 ). In addition, methods of credibility, confirmability, dependability and transferability were applied to increase the trustworthiness of this study ( Graneheim and Lundman, 2004 ). First, reflexivity was observed by keeping journals and memos. This practice allowed the lead researcher to reflect on personal views to minimize bias. Data saturation was reached through following the recommended number of participants as well as repeated immersion in the data during analysis until no new data surfaced. Member checking was accomplished through returning the transcript and the interpretation to the participants to check the accuracy and truthfulness of the findings. Finally, proper documentation was conducted to allow accurate crossreferencing throughout the study.

Quantitative results

Results for the quantitative portion showed there was no difference in scores on the KCTIT between senior nursing students who participated in the skills fair intervention and senior nursing students who did not participate, t (50) = −0.174, p  = 0.86 > 0.05. The test scores between the nonparticipant group ( M  = 67.59, SD = 5.81) and the participant group ( M  = 67.88, SD = 5.99) were almost equal.

Qualitative results

Initial coding.

The results from the initial coding and generated themes are listed in Table 1 . First, the participants perceived the skills fair intervention as “promoting experience” and “confidence” by practicing previously learned knowledge and reinforcing it with active learning strategies. Second, the participants perceived the skills fair intervention as a relaxed, nonthreatening learning environment due to the festive atmosphere, especially in comparison to other learning experiences in the nursing program. The nonthreatening environment of the skills fair intervention allowed students to learn without fear. Third, the majority of participants believed their critical thinking was strengthened after participating. Several participants believed their perception of critical thinking was “enhanced” or “reinforced” rather than significantly changed.

Focused coding results

The final themes were derived from the analysis of patterns and relationships among the content of the data using inductive content analysis ( Saldana, 2009 ). The following was examined across the focused coding process: (1) factors impacting critical thinking skills development during skills fair intervention and (2) skills fair intervention a critical thinking skills developmental strategy.

Factors impacting critical thinking skills development . The factors impacting the development of critical thinking during the skills fair intervention were divided into two themes: internal factors and external factors. The internal factors were characteristics innate to the students. The identified internal factors were (1) confidence and anxiety levels, (2) attitude and (3) age. The external factors were the outside influences that affected the students. The external factors were (1) experience and practice, (2) faculty involvement, (3) positive learning environment and (4) faculty prompts.

I think that confidence and anxiety definitely both have a huge impact on your ability to be able to really critically think. If you start getting anxious and panicking you cannot think through the process like you need too. I do not really think gender or age necessarily would have anything to do with critical thinking.

Definitely the confidence level, I think, the more advanced you get in the program, your confidence just keeps on growing. Level of anxiety, definitely… I think the people who were in the Skills Fair for the first time, had more anxiety because they did not really know to think, they did not know how strict it was going to be, or if they really had to know everything by the book. I think the Skills Fair helped everyone's confidence levels, but especially the Jr. 2's.

Attitude was an important factor in the development of critical thinking skills during the skills fair intervention as participants believed possessing a pleasant and positive attitude meant a student was eager to learn, participate, accept responsibility for completing duties and think seriously. Participant 6 believed attitude contributed to performance in the Skills Fair.

I feel like, certain things bring critical thinking out in you. And since I'm a little bit older than some of the other students, I have had more life experiences and am able to figure stuff out better. Older students have had more time to learn by trial and error, and this and that.

Like when I had clinical with you, you'd always tell us to know our patients' medications. To always know and be prepared to answer questions – because at first as a Junior 1 we did not do that in the clinical setting… and as a Junior 2, I did not really have to know my medications, but with you as a Senior 1, I started to realize that the patients do ask about their meds, so I was making sure that I knew everything before they asked it. And just having more practice with IVs – at first, I was really nervous, but when I got to my preceptorship – I had done so many IVs and with all of the practice, it just built up my confidence with that skill so when I performed that skill during the Fair, I was confident due to my clinical experiences and able to think and perform better.

I think teachers will always affect the ability to critically think just because you want [to] get the right answer because they are there and you want to seem smart to them [Laugh]. Also, if you are leading in the wrong direction of your thinking – they help steer you back to [in] the right direction so I think that was very helpful.

You could tell the faculty really tried to make it more laid back and fun, so everybody would have a good experience. The faculty had a good attitude. I think making it fun and active helped keep people positive. You know if people are negative and not motivated, nothing gets accomplished. The faculty did an amazing job at making the Skills Fair a positive atmosphere.

However, for some of the participants, a positive learning environment depended on their fellow students. The students were randomly assigned alphabetically to groups, and the groups were assigned to starting stations at the Skills Fair. The participants claimed some students did not want to participate and displayed cynicism toward the intervention. The participants believed their cynicism affected the positive learning environment making critical thinking more difficult during the Skills Fair.

Okay, when [instructor name] was demonstrating the Chevron technique right after we inserted the IV catheter and we were trying to secure the catheter, put on the extension set, and flush the line at what seemed to be all at the same time. I forgot about how you do not want to put the tape right over the hub of the catheter because when you go back in and try to assess the IV site – you're trying to assess whether or not it is patent or infiltrated – you have to visualize the insertion site. That was one of the things that I had been doing wrong because I was just so excited that I got the IV in the vein in the first place – that I did not think much about the tape or the tegaderm for sterility. So I think an important part of critical thinking is to be able to recognize when you've made a mistake and stop, stop yourself from doing it in the future (see Table 2 ).

Skills fair intervention as a developmental strategy for critical thinking . The participants identified the skills fair intervention was effective as a developmental strategy for critical thinking, as revealed in two themes: (1) develops alternative thinking and (2) thinking before doing (See Table 3 ).

Develops alternative thinking . The participants perceived the skills fair intervention helped enhance critical thinking and confidence by developing alternative thinking. Alternative thinking was described as quickly thinking of alternative solutions to problems based on the latest evidence and using that information to determine what actions were warranted to prevent complications and prevent injury. It helped make better connections through the learning of rationale between knowledge and skills and then applying that knowledge to prevent complications and errors to ensure the safety of patients. The participants stated the learning of rationale for certain procedures provided during the skills fair intervention such as the evidence and critical thinking prompts included in the rubrics helped reinforce this connection. The participants also shared they developed alternative thinking after participating in the skills fair intervention by noticing trends in data to prevent potential complications from the faculty prompts. Participant 1 stated her instructor prompted her alternative thinking through questioning about noticing trends to prevent potential complications. She said the following:

Another way critical thinking occurred during the skills fair was when [instructor name] was teaching and prompted us about what it would be like to care for a patient with a fractured hip – I think this was at the 10-minute focused assessment station, but I could be wrong. I remember her asking, “What do you need to be on the look-out for? What can go wrong?” I automatically did not think critically very well and was only thinking circulation in the leg, dah, dah, dah. But she was prompting us to think about mobility alterations and its effect on perfusion and oxygenation. She was trying to help us build those connections. And I think that's a lot of the aspects of critical thinking that gets overlooked with the nursing student – trouble making connections between our knowledge and applying it in practice.

Thinking before doing . The participants perceived thinking before doing, included thinking of how and why certain procedures, was necessary through self-examination prior to taking action. The hands-on situational learning allowed the participants in the skills fair intervention to better notice assessment data and think at a higher level as their previous learning of the skills was perceived as memorization of steps. This higher level of learning allowed participants to consider different future outcomes and analyze pertinent data before taking action.

I think what helped me the most is considering outcomes of my actions before I do anything. For instance, if you're thinking, “Okay. Well, I need to check their blood pressure before I administer this blood pressure medication – or the blood pressure could potentially bottom out.” I really do not want my patient to bottom out and get hypotensive because I administered a medication that was ordered, but not safe to give. I could prevent problems from happening if I know what to be on alert for and act accordingly. So ultimately knowing that in the clinical setting, I can prevent complications from happening and I save myself, my license, and promote patient safety. I think knowing that I've seen the importance of critical thinking already in practice has helped me value and understand why I should be critically thinking. Yes, we use the 5-rights of medication safety – but we also have to think. For instance, if I am going to administer insulin – what do I need to know or do to give this safely? What is the current blood sugar? Has the patient been eating? When is the next meal scheduled? Is the patient NPO for a procedure? Those are examples of questions to consider and the level of thinking that needs to take place prior to taking actions in the clinical setting.

Although the results of quantitative data showed no significant difference in scores on the KCTIT between the participant and nonparticipant groups, during the interviews some participants attributed this result to the test not being part of a course grade and believed students “did not try very hard to score well.” However, the participants who attended interviews did identify the skills fair intervention as a developmental strategy for critical thinking by helping them develop alternative thinking and thinking before doing. The findings are supported in the literature as (1) nurses must recognize signs of clinical deterioration and take action promptly to prevent potential complications ( Garvey and CNE series 2015 ) and (2) nurses must analyze pertinent data and consider all possible solutions before deciding on the most appropriate action for each patient ( Papathanasiou et al. , 2014 ).

The skills fair intervention also enhanced the development of self-confidence by participants practicing previously learned skills in a controlled, safe environment. The nonthreatening environment of the skills fair intervention allowed students to learn without fear and the majority of participants believed their critical thinking was strengthened after participating. The interview data also revealed a combination of internal and external factors that influenced the development of critical thinking during the skills fair intervention including confidence and anxiety levels, attitude, age, experience and practice, faculty involvement, positive learning environment and faculty prompts. These factors should be considered when addressing the promotion and development of critical thinking.

Conclusions, limitations and recommendations

A major concern in the nursing profession is the lack of critical thinking in student nurses and new graduates, which influences the decision-making of novice nurses and directly affects patient care and safety ( Saintsing et al. , 2011 ). Nurse educators must use evidence-based practice to prepare students to critically think with the complicated and constantly evolving environment of health care today ( Goodare, 2015 ; Newton and Moore, 2013 ). Evidence-based practice has been advocated to promote critical thinking ( Profetto-McGrath, 2005 ; Stanley and Dougherty, 2010 ). The skills fair intervention can be one type of evidence-based practice used to promote critical thinking ( McCausland and Meyers, 2013 ; Roberts et al. , 2009 ). The Intervention used in this study incorporated evidence-based practice rationale with critical thinking prompts using Socratic questioning, evidence-based practice videos to the psychomotor skill rubrics, group work, guided discussions, expert demonstration followed by guided practice and blended learning in an attempt to promote and develop critical thinking in nursing students.

The explanatory sequential mixed-methods design was employed to investigate the effects of the innovative skills fair intervention on senior baccalaureate nursing students' achievements and their perceptions of critical thinking skills development. Although the quantitative results showed no significant difference in scores on the KCTIT between students who participated in the skills fair intervention and those who did not, those who attended the interviews perceived their critical thinking was reinforced after the skills fair intervention and believed it was an effective developmental strategy for critical thinking, as it developed alternative thinking and thinking before doing. This information is useful for nurse educators who plan their own teaching practice to promote critical thinking and improve patient outcomes. The findings also provide schools and educators information that helps review their current approach in educating nursing students. As evidenced in the findings, the importance of developing critical thinking skills is crucial for becoming a safe, professional nurse. Internal and external factors impacting the development of critical thinking during the skills fair intervention were identified including confidence and anxiety levels, attitude, age, experience and practice, faculty involvement, positive learning environment and faculty prompts. These factors should be considered when addressing the promotion and development of critical thinking.

There were several limitations to this study. One of the major limitations of the study was the limited exposure of students' time of access to the skills fair intervention, as it was a one-day learning intervention. Another limitation was the sample selection and size. The skills fair intervention was limited to only one baccalaureate nursing program in one southeastern state. As such, the findings of the study cannot be generalized as it may not be representative of baccalaureate nursing programs in general. In addition, this study did not consider students' critical thinking achievements prior to the skills fair intervention. Therefore, no baseline measurement of critical thinking was available for a before and after comparison. Other factors in the nursing program could have affected the students' scores on the KCTIT, such as anxiety or motivation that was not taken into account in this study.

The recommendations for future research are to expand the topic by including other regions, larger samples and other baccalaureate nursing programs. In addition, future research should consider other participant perceptions, such as nurse educators, to better understand the development and growth of critical thinking skills among nursing students. Finally, based on participant perceptions, future research should include a more rigorous skills fair intervention to develop critical thinking and explore the link between confidence and critical thinking in nursing students.

Initial coding results

Factors impacting critical thinking skill development during skills fair intervention

Skills fair intervention as a developmental strategy for critical thinking

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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?