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The Value of Critical Thinking in Nursing

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Gayle Morris

Contributing Writer

Learn about our editorial process .

Updated October 3, 2023

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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.

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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

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

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

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

Portrait of Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads, Ph.D., RN

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

Portrait of Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan, BSN, RN, CCRN

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

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

student nurse critical thinking examples

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

What Is Critical Thinking In Nursing?

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

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

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

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Developing Critical-Thinking Skills in Student Nurses

April 8, 2020

View all blog posts under Articles | View all blog posts under Master of Science in Nursing

Nurse educators should ensure that students can incorporate critical thinking skills into everyday practice.

Critical thinking skills for nurses include problem-solving and the ability to evaluate situations and make recommendations. Done correctly, critical thinking results in positive patient outcomes, Srinidhi Lakhanigam, an RN-BSN, said in a Minority Nurse article.

“Critical thinking is the result of a combination of innate curiosity; a strong foundation of theoretical knowledge of human anatomy and physiology, disease processes, and normal and abnormal lab values; and an orientation for thinking on your feet,” Lakhanigam said in “Critical Thinking: A Vital Trait for Nurses.” “Combining this with a strong passion for patient care will produce positive patient outcomes. The critical thinking nurse has an open mind and draws heavily upon evidence-based research and past clinical experiences to solve patient problems.”

Since the 1980s, critical thinking has become a widely discussed component of nurse education, and a significant factor for National League for Nursing (NLN) nursing school accreditation. Nursing school curriculum is expected to teach students how to analyze situations and develop solutions based on high-order thinking skills. For nurse educators who are responsible for undergraduate and graduate learners , teaching critical thinking skills is crucial to the future of healthcare.

Characteristics of Critical Thinkers

A landmark 1990 study found critical thinkers demonstrate similar characteristics. The Delphi Report by the American Philosophical Association (APA) identified these cognitive skills common to critical thinkers:


Critical thinkers are able to categorize and decode the significance and meaning of experiences, situations, data, events, and rules, among others.

Critical thinkers can examine varying ideas, statements, questions, descriptions and concepts and analyze the reasoning.

Critical thinkers consider relevant information from evidence to draw conclusions.


Critical thinkers state the results of their reasoning through sound arguments.


Critical thinkers monitor their cognitive abilities to reflect on their motivations and correct their mistakes.

In addition, critical thinkers are well-informed and concerned about a wide variety of topics. They are flexible to alternative ideas and opinions and are honest when facing personal biases. They have a willingness to reconsider their views when change is warranted.

In nursing, critical thinking and clinical reasoning are inextricably linked, columnist Margaret McCartney said in the BMJ . While experienced nurses are able to make sound clinical judgements quickly and accurately, novice nurses find the process more difficult, McCartney said in “Nurses must be allowed to exercise professional judgment.”

“Therefore, education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills,” McCartney said. “Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgments and decisions are reached in complex healthcare environments.”

Teaching Critical Thinking to Nurses

In 2015, a study in the Journal of College Teaching & Learning found a positive correlation between critical thinking skills and success in nursing school. The study said, “It is the responsibility of nurse educators to ensure that nursing graduates have developed the critical thinking abilities necessary to practice the profession of nursing.”

To help new nurses develop critical-thinking skills, the professional development resources provider Lippincott Solutions recommended nurse educators focus on the following in the classroom:

Promoting interactions

Collaboration and learning in group settings help nursing students achieve a greater understanding of the content.

Asking open-ended questions

Open-ended questions encourage students to think about possible answers and respond without fear of giving a “wrong” answer.

Providing time for students to reflect on questions

Student nurses should be encouraged to deliberate and ponder questions and possible responses and understand that perhaps the immediate answer is not always the best answer.

Teaching for skills to transfer

Educators should provide opportunities for student nurses to see how their skills can apply to various situations and experiences.

In the Minority Nurse article, Lakhanigam also said students who thirst for knowledge and understanding make the best critical thinkers. The author said novice nurses who are open to constructive criticism can learn valuable lessons that will translate into successful practice.

At the same time, however, critical thinking skills alone will not ensure success in the profession , Lakhanigam said in the article. Other factors count as well.

“A combination of open-mindedness, a solid foundational knowledge of disease processes, and continuous learning, coupled with a compassionate heart and great clinical preceptors, can ensure that every new nurse will be a critical thinker positively affecting outcomes at the bedside,” Lakhanigam said.

Another element that ensures success as both an educator and student is earning a nursing degree from a school that focuses on student accomplishments. At Duquesne University’s School of Nursing, students learn best practices in healthcare. The online master’s in nursing program prepares educators to train the next generation of nurses.

About Duquesne University’s online Master of Science in Nursing (MSN) Program

Duquesne University’s MSN curriculum for the Nursing Education and Faculty Role program focuses on preparing registered nurses (RNs) for careers as nurse educators. Students enrolled in the online master’s in nursing program learn the skills needed in the classroom and for clinical training. RNs learn how to empower student nurses to work to their fullest potential.

The MSN program is presented entirely online, so RNs can pursue their career goals and continue personal responsibilities simultaneously.  Duquesne University has been recognized for excellence in education as a U.S. News & World Report Best Online Graduate Nursing Program and best among Roman Catholic universities in the nation.

For more information, contact Duquesne University today.

Critical Thinking: A Vital Trait for Nurses: Minority Nurse

Consensus Descriptions of Core CT Skills And Sub-Skills: Delphi

Margaret McCartney: Nurses must be allowed to exercise professional judgment: BMJ

Predicting Success in Nursing Programs: Journal of College Teaching & Learning

Turning New Nurses Into Critical Thinkers: Wolters Kluwer

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Two Examples of How I Used Critical Thinking to Care for my Patient (Real Life Nursing Stories) | NURSING.com

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Critical Thinking on the Nursing Floor

Critical thinking can seem like such an abstract term that you don’t practically use. However, this could not be farther from the truth. Critical thinking is frequently used in nursing. Let me give you a few examples from my career in which critical thinking helped me take better care of my patient.

The truth is, that as nurses we can’t escape critical thinking . . . I know you hate the word . . . but let me show you how it actually works!

Critical Thinking in Nursing: Example 1

I had a patient that was scheduled to go to get a pacemaker placed at 0900. The physician wanted the patient to get 2 units of blood before going downstairs for the procedure. I administered it per protocol. About 30 minutes after that second unit got started, I noticed his oxygen went from 95% down to 92% down to 90%. I put 2L of O2 on him and it came up to 91%. But it just sort of hung around the low 90s on oxygen.

I stopped. And thought. What the heck is going on?

I looked at his history. Congestive heart failure.

I looked at his intake and output. He was positive 1.5 liters.

I thought about how he’s got extra fluid in general, and because of his CHF, he can’t really pump out the fluid he already has, let alone this additional fluid. Maybe I should listen to his lungs..

His lungs were clear earlier. I heard crackles throughout both lungs.

OK, so he’s got extra fluid that he can’t get out of his body. What do I know that will get rid of extra fluid and make him pee? Maybe some Lasix?

I ran over my thought process with a coworker before calling the doc. They agreed. I called the doc and before I could suggest anything, he said “Give him 20 mg IV Lasix one time, and I’ll put the order in.” CLICK.

I gave the Lasix. He peed like a racehorse (and was NOT happy with me for making that happen!). And he was off of oxygen before he went down to get his pacemaker.

Badda Bing Bada Boom!

Critical Thinking in Nursing: Example 2

My patient just had her right leg amputated above her knee. She was on a Dilaudid PCA and still complaining of awful pain. She maxed it out every time, still saying she was in horrible pain. She told the doctor when he rounded that morning that the meds weren’t doing anything. He added some oral opioids as well and wrote an order that it was okay for me to give both the oral and PCA dosings, with the goal of weaning off PCA.

“How am I going to do that?” I thought. She kept requiring more and more meds and I’m supposed to someone wean her off?

I asked her to describe her pain. She said it felt like nerve pain. Deep burning and tingling. She said the pain meds would just knock her out and she’d sleep for a little while but wake up in even worse pain. She was at the end of her rope.

I thought about nerve pain. I thought about other patients that report similar pain. Diabetics with neuropathy would talk about similar pain… “What did they do for it? ” I thought. Then I remembered that many of my patients with diabetic neuropathy were taking gabapentin daily for pain.

“So if this works for their nerve pain, could it work for a patient who has had an amputation?” I thought.

I called the PA for the surgeon and asked them what they thought about trying something like gabapentin for her pain after I described my patient’s type of pain and thought process.

“That’s a really good idea, Kati. I’ll write for it and we’ll see if we can get her off the opioids sooner. ”

She wrote for it. I gave it. It takes a few days to really kick in and once it did, the patient’s pain and discomfort were significantly reduced. She said to get rid of those other pain meds because they “didn’t do a damn thing,” and to “just give her that nerve pain pill because it’s the only thing that works”.

And that we did!

She was able to work with therapy more because her pain was tolerable and was finally able to get rest.

What the HELL is Critical Thinking . . . and Why Should I Care?

What your nursing professor won’t tell you about critical thinking .

by Ashely Adkins RN BSN

When I started nursing school, I remember thinking,   “how in the world am I going to remember all of this information, let alone be able to apply it and critically think?”   You are not alone if you feel like your critical thinking skills need a little bit of polishing.

Let’s step back for a moment, and take a walk down memory lane. It was my first semester of nursing school and I was sitting in my Fundamentals of Nursing course. We were learning about vital signs, assessments, labs, etc. Feeling overwhelmed with all of this new information (when are you   not   overwhelmed in nursing school?), I let my mind wonder to a low place…

Am I really cut out for this? Can I really do this? How can I possibly retain all of this information?  Do they really expect me to remember everything AND critically think at the same time?

One of my first-semester nursing professors said something to me that has stuck with me throughout my nursing years. It went a little something like this:

“Critical thinking does not develop overnight . It takes time. You don’t learn to talk overnight or walk overnight. You don’t   learn to critically think overnight .”

My professor was absolutely right.

As my journey throughout nursing school, and eventually on to being a “real nurse” continued, my critical thinking skills began to BLOSSOM. With every class, lecture, clinical shift, lab, and simulation, my critical thinking skills grew.

You may ask…how?

Well, let me tell you…

  • Questioning

These are the key ingredients to growing your critical thinking skills.

Time.   Critical thinking takes time. As I mentioned before, you do not learn how to critically think overnight. It is important to set   realistic   expectations for yourself both in nursing school and in other aspects of your life.

Exposure.   It is next to impossible to critically think if you have never been exposed to something. How would you ever learn to talk if no one ever talked to you? The same thing applies to nursing and critical thinking.

Over time, your exposure to new materials and situations will cause you to think and ask yourself, “why?”

This leads me to my next point.   Questioning.   Do not be afraid to ask yourself…

“Why is this happening?”

“Why do I take a blood pressure and heart rate before I give a beta-blocker?”

“Why is it important to listen to a patient’s lung sounds before and after they receive a blood transfusion?”

It is important to constantly question yourself. Let your mind process your questions, and discover answers.

Confidence.   We always hear the phrase, “confidence is key!” And as cheesy as that phrase may be, it really holds true. So many times, we often times sell ourselves short.


In case you did not catch it the first time…

Be confident in your knowledge, because trust me, it is there. It may be hiding in one single neuron in the back of your brain, but it is there.

It is impossible to know everything. Even experienced nurses do not know everything.

And if they tell you that they do…they are wrong!

The   key   to critical thinking is   not about knowing everything ; It is about   how you respond when you do not know something .

How do you reason through a problem you do not know the answer to? Do you give up? Or do you persevere until you discover the answer?

If you are a nursing student preparing for the NCLEX, you know that the NCLEX   loves   critical thinking questions. NRSNG has some great tips and advice on   critical thinking when it comes to taking the NCLEX .

There are so many pieces to the puzzle when it comes to nursing, and it is normal to feel overwhelmed. The beauty of nursing is when all of those puzzle pieces come together to form a beautiful picture.

That is critical thinking.

Critical thinking is something you’ll do every day as a nurse and honestly, you probably do it in your regular non-nurse life as well. It’s basically stopping, looking at a situation, identifying a solution, and trying it out. Critical thinking in nursing is just that but in a clinical setting.

We’ve written a MASSIVE lesson on Care Plans and Critical Thinking :

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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

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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.


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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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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How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples


Last updated on August 19th, 2023

Nurses play a critical role in making critical decisions that directly impact patient outcomes in the dynamic field of healthcare. Developing strong critical thinking skills is essential for success in this role.

In this article, we present a comprehensive list of 23 nursing-specific strategies aimed at improving critical thinking and improve the quality of patient care.

24 Strategies to improve critical thinking skills in nursing

You may also want to check out: 15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)

1. Reflective Journaling: Delving into Deeper Understanding

Reflective journaling is a potent tool for nurses to explore their experiences, actions, and decisions.

By regularly pondering over situations and analyzing their thought processes, nurses can identify strengths and areas for improvement.

This practice encourages the conscious development of critical thinking by comparing past experiences with current knowledge and exploring alternative solutions.

After a particularly challenging case, a nurse reflects on their decision-making process, exploring what worked well and what could have been done differently.

2. Meeting with Colleagues: Collaborative Learning for Critical Thinking

Regular interactions with colleagues foster a collaborative learning environment. Sharing experiences, discussing diverse viewpoints, and providing constructive feedback enhance critical thinking skills .

Colleagues’ insights can challenge assumptions and broaden perspectives, ultimately leading to more well-rounded clinical judgments.

A nursing team gathers to discuss a recent complex case, sharing their perspectives, insights, and lessons learned to collectively improve patient care strategies.

3. Concept Mapping: Visualizing Complexity

Concept mapping is an excellent technique to synthesize intricate patient information. By creating visual representations of patient problems and interventions, nurses can identify relationships and patterns that might not be apparent otherwise.

This strategy aids in comprehensive care planning and encourages nurses to think holistically about patient care.

Creating a concept map to connect patient symptoms, diagnostics, and interventions reveals patterns that help the nurse formulate a comprehensive care plan.

4. Socratic Questioning: Digging Deeper into Situations

The art of Socratic questioning involves asking probing questions that lead to deeper understanding.

Applying this technique allows nurses to uncover assumptions, examine inconsistencies, and explore multiple viewpoints.

This approach is especially valuable when reviewing patient history, discussing conditions, and planning care strategies.

When assessing a patient’s deteriorating condition, a nurse asks probing questions to uncover potential underlying causes and prioritize appropriate interventions.

5. Inductive and Deductive Reasoning: From Specifics to Generalizations

Developing skills in both inductive and deductive reasoning equips nurses to analyze situations from different angles.

Inductive reasoning involves drawing conclusions from specific observations, while deductive reasoning starts with general premises to arrive at specific conclusions.

Proficient use of these methods enhances nurses’ ability to make accurate clinical judgments.

When encountering a series of patients with similar symptoms, a nurse uses inductive reasoning to identify a common pattern and deduce potential causes.

6. Distinguishing Statements: Fact, Inference, Judgment, and Opinion

Clear thinking demands the ability to differentiate between statements of fact, inference, judgment, and opinion.

Nurses must critically evaluate information sources, ensuring they rely on evidence-based practice.

This skill safeguards against misinformation and supports informed decision-making.

While reviewing a patient’s history, a nurse differentiates factual medical information from inferences and subjective judgments made by different healthcare professionals.

7. Clarifying Assumptions: Promoting Effective Communication

Recognizing assumptions and clarifying their underlying principles is vital for effective communication. Nurses often hold differing assumptions, which can impact patient care.

By acknowledging these assumptions and encouraging open discussions, nursing teams can collaboratively create care plans that align with patients’ best interests.

Before suggesting a treatment plan, a nurse engages in a conversation with a patient to understand their cultural beliefs and preferences, ensuring assumptions are not made.

8. Clinical Simulations: Learning through Virtual Scenarios

Clinical simulations provide nurses with a risk-free environment to practice decision-making and problem-solving skills.

These virtual scenarios mimic real-life patient situations and allow nurses to test different approaches, assess outcomes, and reflect on their choices.

By engaging in simulations, nurses can refine their critical thinking abilities, learn from mistakes, and gain confidence in their clinical judgment.

Engaging in a simulated scenario where a patient’s condition rapidly changes challenges a nurse’s decision-making skills in a controlled environment.

9. Case Studies and Grand Rounds: Analyzing Complex Cases

Engaging in case studies and participating in grand rounds exposes nurses to complex patient cases that require in-depth analysis.

Working through these scenarios encourages nurses to consider various factors, potential interventions, and their rationale.

Discussing these cases with colleagues and experts fosters collaborative critical thinking and widens the spectrum of possible solutions.

Nurses participate in grand rounds, discussing a challenging case involving multiple medical specialties, encouraging a holistic approach to patient care.

10. Continuing Education and Lifelong Learning: Expanding Knowledge

Staying up-to-date with the latest advancements in nursing and healthcare is crucial for effective critical thinking.

Pursuing continuing education opportunities, attending conferences, and engaging in self-directed learning keeps nurses informed about new research, technologies, and best practices.

This continuous learning enriches their knowledge base, enabling them to approach patient care with a well-rounded perspective.

Attending a nursing conference on the latest advancements in wound care equips a nurse with evidence-based techniques to improve patient outcomes.

11. Debates and Discussions: Encouraging Thoughtful Dialogue

Organizing debates or participating in structured discussions on healthcare topics stimulates critical thinking.

Engaging in debates requires researching and presenting evidence-based arguments, promoting the evaluation of different perspectives.

Nurses can exchange insights, challenge assumptions, and refine their ability to defend their viewpoints logically.

Engaging in a debate on the pros and cons of a new treatment method encourages nurses to critically analyze different viewpoints and strengthen their own understanding.

12. Multidisciplinary Collaboration: Gaining Insights from Various Disciplines

Collaborating with professionals from diverse healthcare disciplines enriches nurses’ critical thinking.

Interacting with doctors, pharmacists, therapists, and other experts allows nurses to benefit from different viewpoints and approaches.

This cross-disciplinary collaboration broadens their understanding and encourages innovative problem-solving.

Collaborating with physical therapists, nutritionists, and pharmacists helps a nurse develop a holistic care plan that addresses all aspects of a patient’s recovery.

13. Ethical Dilemma Analysis: Balancing Patient Autonomy and Best Practice

Ethical dilemmas are common in nursing practice. Analyzing these situations requires nurses to weigh the principles of beneficence, non-maleficence, autonomy, and justice.

By critically examining ethical scenarios, nurses develop the capacity to navigate morally complex situations, prioritize patient welfare, and make ethically sound decisions.

When faced with a patient’s refusal of treatment due to religious beliefs, a nurse evaluates the ethical considerations, respects autonomy, and seeks alternatives.

14. Root Cause Analysis: Investigating Adverse Events

When adverse events occur, performing a root cause analysis helps identify the underlying causes and contributing factors.

Nurses engage in a systematic process of analyzing events, exploring the “5 Whys” technique , and developing strategies to prevent similar occurrences in the future.

This approach cultivates a thorough and analytical approach to problem-solving.

After a medication error, a nurse leads a root cause analysis to identify system failures and implement preventive measures to enhance patient safety.

15. Creative Thinking Exercises: Expanding Solution Repertoire

Encouraging creative thinking through brainstorming sessions or scenario-based exercises widens the range of possible solutions nurses consider.

By thinking outside the box and exploring innovative approaches, nurses develop adaptable problem-solving skills that can be applied to complex patient care challenges.

Brainstorming creative approaches to comfort a distressed pediatric patient empowers a nurse to find innovative methods beyond routine interventions.

16. Journal Clubs: Fostering Evidence-Based Discussion

Participating in journal clubs involves healthcare professionals coming together to dissect recent research articles.

This practice ignites critical thinking by allowing nurses to evaluate study methodologies, scrutinize findings, and consider the implications for their practice.

Engaging in evidence-based discussions not only cultivates a culture of critical inquiry but also reinforces continuous learning.

At the monthly journal club meeting, Nurse Mark engages in a discussion on a recent research article focusing on pain management strategies for post-operative patients.

The group analyzes the study design, scrutinizes the findings, and considers the potential implications for their practice.

During the discussion, Mark raises thought-provoking questions about the study’s methodology and suggests potential applications in their hospital’s patient care protocols.

This active participation in journal clubs not only refines Mark’s critical thinking but also instills evidence-based practices into his nursing approach.

17. Critical Reflection Groups: Collaborative Learning and Analysis

Similarly, establishing critical reflection groups, where nurses meet regularly to discuss experiences, cases, and challenges, fosters collective learning.

These sessions encourage the exchange of diverse perspectives, enriching the analysis process and ultimately enhancing patient care strategies.

Through shared insights and discussions, nurses can refine their clinical reasoning and broaden their problem-solving capabilities.

Nurse Emma actively participates in critical reflection groups in order to broaden her clinical knowledge. During a recent meeting, the group tackled a difficult patient case with complicated symptomatology.

Emma suggests alternative diagnostic pathways based on her own experiences. Emma’s critical thinking skills are honed as a result of the group’s dynamic interaction, which also emphasizes the importance of collaborative decision-making in complex scenarios.

18. Mindfulness and Reflection Practices: Enhancing Self-Awareness

Mindfulness techniques, such as meditation and deep breathing, encourage self-awareness and a clear mind.

Engaging in these practices helps nurses become more attuned to their thoughts and emotions, leading to better self-regulation and improved decision-making during high-pressure situations.

Engaging in mindfulness exercises before a demanding shift helps a nurse maintain focus, manage stress, and make clear-headed decisions.

19. Problem-Based Learning: Applying Knowledge in Real Scenarios

Problem-based learning involves presenting nurses with real-world patient cases and encouraging them to collaboratively solve the problems.

This approach bridges the gap between theoretical knowledge and practical application, fostering critical thinking through active problem-solving.

Working through a simulated patient case challenges nurses to apply theoretical knowledge to practical situations, refining their clinical reasoning.

20. Self-Assessment and Feedback: Evaluating Decision-Making Skills

Regularly assessing one’s own decision-making process and seeking feedback from peers and mentors is essential for improvement.

Reflecting on past decisions, considering alternative approaches, and understanding the rationale behind them contribute to the refinement of critical thinking skills.

A nurse evaluates their performance after a patient’s unexpected complication, seeking feedback from peers and mentors to identify areas for improvement.

21. Cultural Competence Training: Navigating Diverse Perspectives

Cultural competence training enhances critical thinking by enabling nurses to understand the diverse cultural beliefs and practices of patients.

This knowledge is vital for providing patient-centered care, as it encourages nurses to think critically about the unique needs of each individual.

A nurse attends cultural competence training to understand the dietary preferences of a diverse patient population, ensuring respectful and patient-centered care.

22. Active Listening and Empathetic Communication: Gathering Insights

Active listening and empathetic communication with patients and their families enable nurses to gather comprehensive information about their conditions, concerns, and preferences.

This data forms the basis for critical analysis and informed decision-making in patient care.

Through attentive listening, a nurse uncovers a patient’s underlying concerns, leading to an informed care plan that addresses both medical needs and emotional well-being.

23. Mentorship and Preceptorship: Learning from Experienced Professionals

Having a mentor or preceptor provides novice nurses with the opportunity to learn from experienced professionals.

Mentors guide critical thinking by sharing their insights, challenging assumptions, and offering guidance in complex situations. This relationship fosters growth and expertise development.

A novice nurse gains valuable insight from a mentor, who guides them through complex cases, offering real-world wisdom and refining critical thinking skills.

24. Self-Assessment and Feedback: Evaluating Decision-Making Skills

Reflecting on past decisions, considering alternative approaches, and understanding the rationale behind them contribute to the refinement of critical thinking skills .

Nurse Sarah regularly takes time to assess her decision-making skills by reviewing past patient cases. After a challenging case involving conflicting symptoms, she reflects on her initial approach, the outcomes, and what she could have done differently.

She seeks feedback from her senior colleague, who provides insights on alternative diagnostic paths. Sarah’s self-assessment and feedback-seeking process enable her to identify areas for improvement and refine her critical thinking in similar situations.

  • Clinical Reasoning In Nursing (Explained W/ Example)
  • 8 Stages Of The Clinical Reasoning Cycle
  • What is Critical Thinking in Nursing? (Explained W/ Examples)

Enhancing critical thinking skills is an ongoing journey that transforms nursing practice.

Reflective journaling, collaborative learning, concept mapping, Socratic questioning , reasoning techniques, distinguishing statements, and clarifying assumptions all play integral roles in nurturing these skills.

By incorporating these strategies into their daily routines, nurses can improve their critical thinking skills.

Additionally, this will help nurses in navigating the complexities of the healthcare field with confidence, expertise, and the ability to make well-informed decisions that improve patient outcomes.

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Strategies to promote critical thinking and active learning

15 Strategies to promote critical thinking and active learning Connie J. Rowles, DSN, RN Nursing faculty spend a considerable amount of their time planning experiences to facilitate student learning. The selection of teaching strategies and learning experiences traditionally has been governed by behavioral objectives. However, nursing education has been undergoing a major revolution, with attention focused on how to teach students to think critically. Therefore nurse educators are continually reexamining the “best” way to teach and to empower students for learning. The purpose of this chapter is to identify strategies that students and faculty can use to promote learning. The chapter begins with a discussion of critical thinking as the basis for any teaching strategy. Developing effective learning experiences comes next. A variety of teaching strategies are then presented with a discussion of their use, advantages, disadvantages, and tips for making the learning experience interactive and meaningful. Critical thinking and active learning Thinking, reflective thinking, and critical thinking have been topics of discussion among educators for many years ( Bandman & Bandman, 1995; Brookfield , 1987, 1995; Dewey , 1933; Facione , 1990; Halpern et al., 1994; Hunkins , 1985; Kurfiss , 1988; McPeck , 1981; Norris & Ennis, 1989; Paul , 1995; Perry , 1970; Siegel , 1980; Watson & Glaser, 1984). A recent search in the Cumulative Index to Nursing and Allied Health (CINAHL) located 58 articles about critical thinking even when the search was limited to full-length articles in English in the time frame of July 2009 through July 2010. One excellent source from the search is Romeo (2010). She reviewed the critical thinking literature and found issues related to the definition of critical thinking as well as issues in the use of instruments to measure critical thinking. She also cited the lack of findings that show a clear-cut correlation with factors that interest nurse educators, such as licensing exam pass rates and changes in critical thinking over time in the program. So, while there is still a lot in the literature about critical thinking, there are some who recommend a change in the dialogue about thinking in nursing. A brief discussion of some of the newer terms found in the literature follows. A common thread with the newer ideas is that they all build on a foundation of critical thinking. Clinical reasoning Clinical reasoning is the ability of the nurse to use critical thinking skills in the ever-changing clinical environment. It should include the “. . . context and concerns of the patient and family” ( Benner , Sutphen, Leonard, & Day, 2010, p. 85). Clinical imagination and reflection are also part of clinical reasoning ( Benner et al., 2010). The thought is that critical thinking is more a snapshot in time while clinical reasoning can accommodate the changing nature in clinical settings. Clinical judgment Clinical judgment can be defined as “an interpretation or conclusion about a patient’s needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient’s response” ( Tanner , 2006, p. 204). Tanner acknowledges that problem solving, critical thinking, decision making, and clinical judgment are often used in the literature to mean the same thing. Metacognition Metacognition is the “self-communication process in which a person engages before, during and after performing a task” ( Beitz , 1996, p. 23) and more commonly thought of as thinking about thinking. It is an active process of monitoring your own thinking. Kuiper and Pesut (2004) contend that it is the combination of metacognition (reflective thinking) and critical thinking that better describes the thinking necessary in nursing. Clinical reasoning, clinical judgment, and metacognition are all important in nursing. However, the basis of all of these is critical thinking. This chapter focuses on critical thinking, the ideal critical thinker, and the related cognitive skills. The ideal critical thinker defined Most experts agree that if an individual is a critical thinker, he or she not only has well-developed critical thinking skills but also exhibits what are variously described as the disposition, attitude, or traits of a critical thinker ( Baron & Sternberg, 1986; Facione , Facione, & Sanchez, 1994; Ford & Profetto-McGrath, 1994; Kataoka-Yahiro & Saylor, 1994; Paul , 1995; Pless & Clayton, 1993; Turner , 2005; Watson & Glaser, 1984). This chapter uses Facione’s (1990) definition of an ideal critical thinker. This description was derived by a consensus of experts in critical thinking who participated in a Delphi study. The panel of experts included “46 scholars, educators and leading figures in critical thinking theory and critical thinking assessment research” (p. 34). The experts essentially agreed that The ideal critical thinker is habitually inquisitive, well-informed, trustful of reason, open-minded, flexible, fair-minded in evaluation, honest in facing personal biases, prudent in making judgments, willing to reconsider, clear about issues, orderly in complex matters, diligent in seeking relevant information, reasonable in the selection of criteria, focused in inquiry, and persistent in seeking results which are as precise as the subject and the circumstances of inquiry permit. (p. 3) Facione et al. (1994) suggest that the Delphi study description of an ideal critical thinker describes a nurse with ideal clinical judgment. Cognitive skills (subskills) of critical thinking were also delineated in Facione’s (1990) Delphi study. These include the cognitive skills and subskills of analysis (examining ideas, identifying arguments, analyzing arguments), evaluation (assessing claims, assessing arguments), inference (querying evidence, conjecturing alternatives, drawing conclusions), interpretation (categorizing, decoding significance, clarifying meaning), explanation (stating results, justifying procedures, presenting arguments), and self-regulation (self-examination and self-correction) ( Facione , 1990). Critical thinking in nursing and nursing education Nurses need a high level of critical thinking skills and a critical thinking disposition because nurses encounter multiple patients with the same health care needs. However, each patient responds to those needs differently. Therefore nurses are required to use their holistic nursing knowledge base to think through each situation to provide individualized, effective (evidence-based) care rather than simply to follow routine procedures. Jones and Brown (1993) believe that nursing is practiced in complex environments with humans, who are complex beings. Technological advances and a knowledge explosion have also changed the face of health care. Thinking skills of the nurse become more important than the ability to perform the associated psychomotor skills. Case (1994) discussed the changing arenas for decision making as being not only at the bedside but also in quality assurance processes, delegation activities, shared governance, and management and executive roles. As health care reform extends patient care from the predominantly structured inpatient arena to the more unstructured outpatient or community arenas, critical thinking skills and empowerment become even more important. Carlson-Catalano (1992), in discussing empowering nurses, believed that traditional curricula encourage students to be obedient, dependent, and fearful in caring for patients. She suggests that nurses in professional practice should be empowered and that students need to be treated as valued members of the profession. She offers analytic nursing, change activities, collegiality, and sponsorship as strategies for empowering nurses. These strategies would be addressed if nursing faculty adopted the principles of critical thinking as the foundation for practice. Students must develop higher-order thinking skills. Brigham (1993) contends that faculty need to assist students to recognize how systems respond to specific health problems. Students need to know what nursing measures will be needed when they read laboratory reports with abnormal results; they do not need to memorize normal laboratory values. Jones and Brown (1991) argue that nurse educators can no longer convey facts to nursing students. “There are far too many facts, but there are far too many facts that become erroneous over time” ( Jones & Brown, 1991, p. 533). Miller (1992) concurs: More emphasis should be given to the mental processes students engage in as they solve nursing problems and less given to simply identifying the correct answer. Focusing on making clinical inferences from given data, recognizing unstated assumptions, deductive reasoning, weighing of evidence and distinguishing between weak and strong arguments emphasizes the importance of the processes of thinking. (p. 1406) Scheffer and Rubenfeld (2000) conducted a Delphi study to develop a consensus statement about critical thinking in nursing education. A panel of 55 experts from 9 countries determined that Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice [possess] the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge. (p. 357) In summary, Jackson (1995) states, “Every patient deserves caregivers who think critically . . . . The ability to think critically can be empowering. Practitioners must commit to a struggle of balancing an explosion of objective and intuitive information in an explosive health care environment” (p. 187). Therefore nurse educators are challenged to help students develop necessary critical thinking skills as the students progress through the curriculum. Roles of faculty and students in developing critical thinking skills The development of students’ critical thinking skills and dispositions requires faculty to reconsider their philosophy of teaching. The faculty-dominated classroom is not conducive to development of critical thinking. It is the responsibility of faculty to think about the roles of the teacher and student, as well as to create an environment that empowers students. Transmitting information through rote lecture to students does not guarantee learning. Students must be actively engaged with the information for it to be transformed into knowledge. Lesson plans must be designed to foster the development of critical thinking skills (cognitive) and a critical thinking disposition (affective) as students engage with the theoretical, affective, and psychomotor content that is nursing. Students must become empathetic, empowered, and able to critically think about every situation if they are to succeed in nursing ( Bevis , 1993; Ford & Profetto-McGrath, 1994). Faculty roles Faculty must become facilitators of learning rather than teachers of content ( Bevis , 1993; Brigham , 1993; Brookfield , 1995; Creedy , Horsfall, & Hand, 1992; Jones & Brown , 1993). Ford and Profetto-McGrath (1994) believe that the teacher–student relationship must become a “working with” relationship—an egalitarian relationship. Burns and Egan (1994) suggest that faculty should demonstrate critical thinking as content is presented. For example, when teaching content such as medical acidosis and alkalosis, faculty could demonstrate their own problem-solving skills by thinking aloud as they discuss a relevant case study. Students should think aloud while interacting with the content so that faculty can identify inappropriate thinking processes and provide immediate constructive feedback. Creedy et al. (1992) propose that faculty can empower students by valuing their contributions, encouraging expression of their opinions, exploring mistakes objectively without demeaning the students, and promoting risk taking. Brookfield (1987) cites the following principles that will facilitate students to think critically: •  Affirm the critical thinkers’ self-worth ( p. 72 ). •  Listen attentively to critical thinkers ( p. 73 ). •  Show that you support critical thinkers’ efforts ( p. 74 ). •  Reflect and mirror critical thinkers’ ideas and actions ( p. 75 ). •  Motivate people to think critically ( p. 76 ). •  Regularly evaluate progress ( p. 78 ). •  Help critical thinkers create networks ( p. 79 ). •  Be critical teachers ( p. 80 ). •  Model critical thinking ( p. 85 ). Thus according to Brookfield (1987), the facilitator of learning must enter into an egalitarian relationship to support the learners’ attempts to engage in critical thinking. Faculty can only provide learning experiences for students; faculty cannot teach (impart knowledge); they can only share their knowledge. Students must transform the content into their own knowledge. Student roles Learning to think critically requires active student participation ( Meyers , 1986); students must become active creators of their own knowledge ( Creedy et al., 1992). At this time, it can be assumed most students have come from faculty-dominated classrooms in which the students have been the recipients of endless amounts of facts to be memorized and recalled for examinations ( Valiga , 1983). Students have probably not been asked to apply those facts to real-life situations. Therefore students will have to be assisted with the transition from the passive to active learner role. Faculty need to create a risk-free environment that is conducive to active student participation. The discussion later in this chapter related to creation of an anticipatory set serves as an example of helping students to make the transition from passive to active learners. Repeated encounters with active learning situations are needed before students can become comfortable with the active learner role. Active learners must come to class prepared. They cannot rely on the faculty to tell them what they need to know. “Preclass written assignments, study guides, quizzes and short in-class writings” ( Brigham , 1993, p. 52) are effective in stimulating students to come to class prepared to engage with the content while interacting with faculty and fellow students in planned learning activities. Classroom environment for the development of critical thinking skills The classroom environment changes when the principles of critical thinking are adopted. Active learning can be a very threatening situation. Faculty must create a risk-free environment that allows students to explore the content, make mistakes, reflect on the content, associate the content with experience, and transform the content into knowledge ( McCabe , 1992). Brigham (1993) suggests that faculty set the stage by sharing that their philosophy of teaching is to enhance critical thinking. This should be done when students are being introduced to the course. Students need to know that learning experiences have been designed for them to actively engage with the information and with each other while faculty facilitate the activities and learning process. Students must understand that, through the interactions, information will be converted into knowledge ( Bevis , 1993). Classroom environments should establish a sense of connection between faculty and students and among students themselves. Students should understand that neither faculty nor students have all of the answers and that no one answer is correct in all situations. Open discussion and student willingness to take risks should be supported while faculty guide the group toward the preestablished learning outcome. Students need to be aware that there are conflicting ideas about some concepts. Faculty at some schools of nursing do not adopt a specific textbook for their courses; rather, the bookstore stocks appropriate textbooks by different authors and students select the textbook they would like to use. This particular idea is intriguing because it certainly provides a basis for discussion of information from multiple points of view. When contradictions are found, it helps students recognize that the written word should be questioned. The physical component of the classroom is important; however, any classroom can be conducive to active student learning. Students should be able to make eye contact with each other and with faculty. MacIntosh (1995) suggests rearranging chairs into small or large circles. Faculty can be creative in modifying the physical characteristics of the classroom. For example, in classrooms where desks are bolted down, students could sit on the tops of the desks to be able to face others in the group. Student responses to active learning Beck (1995) conducted a study using a cooperative learning model based on feminist pedagogy that resulted in positive teacher–student and student–student interactions and satisfactory learning. Hezekiah (1993) cites the five basic feminist goals for the classroom—“atmosphere of mutual respect, trust and community, shared leadership, cooperative structure, integration of cognitive and affective learning, and action oriented field work” (pp. 55–56)—that would establish an environment for the development of critical thinking skills as the learner transforms information to knowledge. Wake , Coleman, and Kneeland (1992) discuss shared governance in the classroom. They note that shared governance in nursing education produces professional nurses who will be prepared to practice in an ever-changing health care environment. Price (1991) found that “interaction between the student and teacher ranked high as a positive contributor to learning” ( p. 170 ). Price cited the following student responses to the benefits of an interactive classroom: What’s good is your understanding of conflicts we may be facing as new students, your continual encouragement, and the fact that you’re always available to answer questions . . . I don’t function well, never have, when the question is memorizing. . . . I tend to learn very abstractly and not sequentially; my learning is not textbook learning. . . . I really find that I learn the most when I can apply it to myself and to someone else; that’s the thing I can underline and say, “Yes, I learned that very well.” . . . It’s practical application, where it’s applied to life, where your pattern of behavior is changed, something you can apply in your relationship with another human being. (pp. 170–171) Summary Nurses must possess a high level of critical thinking skills and a critical thinking disposition. Faculty must create opportunities for students to develop critical thinking as they progress through the curriculum. Faculty must become facilitators of learning and students must become active learners. Critical thinking should be at the forefront of planning learning experiences for nursing students. If educators believe that “students can and should think their way through the content of their courses, . . . gain some grasp of the logic of what they study, . . . develop explicit intellectual standards, then they can find many ways to move instruction in this direction” ( Barnes , 1992, p. 22). Faculty must create an environment that develops the traits of an ideal critical thinker and plan learning experiences that include strategies to develop the cognitive skills and subskills of critical thinking. Planning learning experiences Planning challenging encounters that will entice students to learn and develop critical thinking skills is a major task for any faculty member. Effective planning of any kind requires much time and effort; planning learning experiences is no exception. Careful planning of each learning experience gives teachers more self-confidence and aids in formative and summative evaluation of teaching. At least six steps are used in designing learning experiences: 1.  Determine the learning outcomes for the specific class period. 2.  Create an anticipatory set. 3.  Select teaching and learning strategies. 4.  Consider implementation issues. 5.  Design closure to the learning experience. 6.  Design formative and summative evaluation strategies. Each of the stages is discussed in detail. All steps can be planned by both students and faculty. Novice faculty may find it helpful to design learning experiences in great detail ( Table 15-1 ), whereas more experienced faculty may use only a more general outline form. Table 15-1 Sample Plan for a Learning Experience: Ethics in Leadership 1.  Outcomes: Identify ethical theory used for own decision making. Discuss implications of use of ethical theories in the workplace. Activity Content Time Strategies 2.  Anticipatory set a.  Preclass assignment b.  In-class exercise a.  Ethical theories b.  Ethical case examples c.  Ethical situations a.  2 hr b.  10 min a.  Text reading b.  Ethical survey c.  Individual reflection to identify the most difficult question on the survey and write how and why answered 3.  Implementation tools a.  Projector b.  PowerPoint slides a.  Three ethical theories from text b.  Application (1)  Identify own theory used. (2)  Apply to familiar situation. (3)  Apply to new situation. (4)  Apply to workplace decision making. a.  40 min b.  30 min a.  Large group discussion (1)  Slides of the theories’ main points (2)  At each main point ask, “What does this mean to you?” and “Give an example of how the point would be seen in practice.” b.  Small group discussion (1)  “Which theory do you use?” (2)  “Give example of how you used the theory.” (3)  “How would a nurse administrator use the theory to make ethical decisions?” (4)  “How could use of the theories lead to conflict in the workplace?” 4.  Closure Emphasize class outcomes. 20 min a.  Small group reports b.  Overall summary Determining the learning outcomes The first step is to determine the learning outcomes of the class. Several activities must be carried out before specific outcomes for any class period are developed. The first activity is assessment of the overall curriculum outcomes and the placement of the specific course in meeting these outcomes. Typically, general curriculum outcomes are stated in very broad terms and will likely not give the teacher any information about what to include in a specific class period. However, a thorough understanding of the broad curriculum goals is necessary so teachers can “connect” the specifics for the day to the broad curriculum outcomes. Course objectives and outcomes need to be reviewed to ascertain how the particular course “fits” within the curriculum ( Ayer , 1986; Torres & Stanton, 1982). See Chapters 8 to 11 for additional information. Teachers tend to design learning experiences within their own belief and value systems. Their own philosophies about teaching, learning, the curriculum, the ability of students, and how and what a nurse educator “should” do all influence the development of activities for a specific class period. Teachers need to be aware of these value systems and recognize the influence of them on their teaching and selection of teaching strategies ( Creedy et al., 1992). With these activities in mind, outcomes for a given experience can be established. There are several ways to identify outcomes. One way is to use behavioral objectives (see Chapters 9 and 10 ). For many, however, behavioral objectives imply rigid lists of specific content, faculty-dominated classrooms, and only one right answer to each examination question. Some believe that specific behavioral objectives need to be abandoned, given the important issue of development of critical thinking abilities in students ( Bevis , 1993). In another approach, general outcomes or competencies are identified, and the path to achieving them is left open. How they are written depends on individual school requirements, the overall curriculum design, the content of the course, and the beliefs or values of the individual faculty member. Creating an anticipatory set The second major step in planning a learning experience is to create an environment that invites all students to become interested in the content and to participate in the learning process. This activity is referred to as creating an anticipatory set ( Ayer , 1986; deTornyay & Thompson, 1982; Maas , 1990). The activity typically takes little in-class time and merely sets the stage for active involvement in the learning process. Maas (1990) includes three elements in an anticipatory set: active participation, relevance to the students, and relevance to the class period. Preclass readings; active, thought-provoking questions; and a class exercise that emphasizes students’ prior knowledge are examples of activities that can be used as an anticipatory set. The anticipatory set prepares students for the main activity or content of the class period. Selecting a teaching strategy Selecting the particular teaching strategy is the third step in lesson planning. Faculty must consider multiple factors as they select a particular strategy. The first factor is the content itself. For example, teaching abstract concepts is probably better accomplished through mind mapping ( Rooda , 1994), whereas psychomotor skills are better taught through demonstration ( Kelly , 1992). The philosophy underlying the broad curriculum outcomes also influences the selection of teaching strategies. In a school that has adopted the principles of critical thinking, the traditional lecture would seldom be used as a strategy. Last, faculty must consider teaching strategies that are feasible. Questions to consider may include the amount of time available, room size, distance learning delivery system being used, the availability of equipment, the number of students, time and money costs for both the teacher and the student, and learning styles of the students. With these factors in mind, many different teaching strategies would be appropriate for any student group and class content. Throughout the course it is important to vary the strategies. Using the same type of anticipatory set followed by lecture and then the same closure can be very boring for students. For example, faculty may create interest for the students by using lecture some of the time and role play, demonstration, and reflection at other times. Varying the strategies also has the advantage of appealing to all types of learners (see Chapter 2 ). Few of the teaching strategies are equally stimulating to all types of learners. It is not particularly important that teachers use strategies that appeal to all learners in every class, but it is important for them to use strategies that appeal to all types of learners throughout the course. Questioning is a teaching strategy that should be used consistently; it can even be used in every class ( Paul , 1995). “Helping students to ask their own questions should perfect their ability to think critically about information and how to process it” ( Hunkins , 1985, p. 296). Strategies that appeal to one type of learner can also be used for the preclass assignments or activities, and strategies for other types of learners can be used for the classroom experience. Teaching strategies and critical thinking The actual steps in designing learning experiences do not change when critical thinking concepts are applied to the curriculum. Teaching strategies should be selected for the development of critical thinking skills. Development of these skills in students should be a planned activity throughout all stages of the curriculum. Any strategy selected should be selected for a particular reason, and all strategies should lead to the development of advancing levels of critical thinking. Cognitive levels Cognitive levels must be considered during lesson planning. Several theorists have written about the various cognitive levels of students. Perry (1970) identifies four levels including nine stages of intellectual development. Belenky , Clinchy, Goldberger, and Tarule (1986) have demonstrated that women and men differ in intellectual development in several major areas. One example is that women typically have a silent stage of cognitive development, which is the first level. This stage is characterized by a powerless, dependent fear of authority figures. Men typically do not go through the silent stage. Hickman (1993) examined the theories of Perry (1970), Belenky et al. (1986), and others and integrated their thinking on cognitive levels with Benner’s (1984) levels of skill acquisition. Hickman’s (1993) thoughts are related directly to the licensed nurse, but her ideas can also be applied to the undergraduate nursing student. The beginning nursing student is a novice in critical thinking. Thinking is characterized as dualistic (everything is black or white). Little or no critical thinking is used. The novice depends on authority for knowledge and is usually silent. The next cognitive level is the advanced beginner. In this stage, thinking at the multiplicity level occurs. Students use subjective knowledge to begin seeing recurring themes, but they fail to differentiate important cues. Students at this level require assistance in establishing priorities. The next stage is the competent student nurse. At this stage, students continue to use subjective knowledge, but they do so consciously and they use the subjective knowledge in deliberate planning activities. The last cognitive level is the proficient student nurse, who is at the relativistic level of intellectual development. Relativism is the recognition that opinions differ in quality and require supporting evidence to be valid. Relativism is equated with procedural knowledge, connected knowledge, or both. Students no longer see information as only black and white; they begin to see how things “fit” together and notice where information is missing. They begin to think critically. It would be hoped that students completing a basic nursing education program would have attained the relativism level of cognitive development. Most undergraduate students will not have attained the final level, which is commitment in relativism. Commitment in relativism describes the expert nurse who integrates knowledge with experience and uses personal reflection to derive constructed knowledge ( Hickman , 1993). Many graduate students will have already moved to this level. Undergraduate nursing students will likely move to the final level of cognitive development after they are licensed and have many more real-life nursing experiences and the time to reflect on and integrate those experiences. The cognitive level of students must be addressed when learning experiences are designed. Moving students from the cognitive level of dualism to the level of relativism should be a major goal of nursing education. The level of cognitive development also influences the selection of teaching strategies. Bowers and McCarthy (1993) suggest that students who exhibit thinking at the informed commitment (relativistic) level would probably feel frustrated if they were expected to think at a dualistic level. For example, proficient student nurses would rather discuss implications of abnormal blood gas values (relativistic thinking) than respond to questions about normal findings (dualistic thinking). Implementation issues The fourth stage of lesson planning is implementation of the learning experience. In this stage, two major activities are considered. The first is the timing. How much time will be spent on the strategies selected to develop the anticipatory set? What backup plans are made to account for a lesson that takes much less or more time than anticipated? What can be cut or what can be added? What are the most crucial concepts to be covered if time is short? The sample plan (see Table 15-1 ) contains estimated times, with more detail included in a more extensive version of the plan. The second activity in this stage is to plan for the tools needed to implement the class. In this case, tools can refer to many things. Tools can be instructional media and equipment such as a projector, computer, or video information system (see Table 15-1 ). Tools can also refer to the information technology tools used to establish the learning community, such as computer conferencing or video conferencing. Plan to check the equipment for correct working order. Nothing can ruin a well-planned learning experience quite as effectively as instructional media that do not work! Tools could also be the classroom itself. How should the chairs be arranged? Do you want to use a podium? Does the screen for the projector or computer work? The last set of tools is the paper products. What handouts does the faculty member need? How much lead time is needed for typing and copying the handouts? Are the computer slides or transparencies ready? Are there items that need to have copyrights cleared? Who does that and how much time does it take? Assessing and planning for the amount of time and the tools necessary for implementation of the teaching strategy are activities that should not be left to the last minute. Designing closure The last step in designing the learning experience is planning for closure. Closure may be as simple as a few sentences that summarize the major concepts. In this case, the time allowed for closure would be very short. However, closure can take a large amount of class time, especially when dealing with sensitive or emotional content. Applying major concepts to similar or new areas of interest is another example of a closure technique ( deTornyay & Thompson, 1987). This time may also be used to create the anticipatory set for the next class period by discussing how the content of the class relates to the content of the next class period. Designing formative and summative evaluation strategies During the lesson planning phase, both formative and summative evaluation need to be considered ( Ayer , 1986). Chapter 16 contains information about classroom assessment, and Chapters 24 to 26 contain information about assessment of learning outcomes. These chapters should assist in this stage of planning. Evaluation activities should occur throughout the learning experience. Many formative evaluation techniques are available (see Chapter 16 ). Frequent formative evaluation is important for assessment of students’ understanding of content. Varying the types of formative evaluation used is important. For example, sometimes the objectives can be evaluated and at other times the teaching strategy used can be evaluated. Frequent self-evaluation is critical. Faculty should ask whether the time, tools, strategy, and content were organized and planned effectively and what could have been done differently to enhance student learning. Summary Designing effective learning experiences involves at least six distinct stages. A well-designed experience that enhances student learning cannot be done in a haphazard manner or at the last minute. Enhanced student learning and the development of critical thinking skills are the outcomes of well-planned learning experiences. Teaching strategies There are many different teaching strategies. Those with the most application to nursing education are presented throughout the rest of the chapter. Each strategy is described with its advantages and disadvantages, teaching tips, and additional references where the reader may find a more detailed description of the strategy. Simulation is a teaching strategy that is growing in use in nursing education; it is discussed in detail in Chapter 20 . Other teaching strategies may be more appropriate for the online learning environment. A detailed discussion can be found in Chapter 23 . Any discussion about teaching strategies would be incomplete without a review of learning resources, including instructional media or distance education delivery systems. These are discussed in Chapters 19 to 23 . The lecture is presented first, because this teaching strategy is frequently used by many teachers. Many other strategies can be used in nursing education. These strategies are alphabetized for ease of location. Each strategy discussed may have its place in a course, but its use depends on the content, the teacher, and the learners. Most of the strategies described after the lecture involve active learner participation in the learning process and emphasize adult learning and critical thinking concepts. Both teachers and students may resist this type of learning because the strategies are more flexible and less teacher centered than those typically used in the traditional college classroom. However, if one accepts that the learner must actively engage with the content or information to transform it into knowledge, the classroom should become student centered. Thus the traditional lecture may not always be the most appropriate strategy. Lecture Definition. Teacher presentation of content to students, usually accompanied by some type of visual aid or handout. Use. Clarify complex, confusing, or conflicting concepts; provide background information not available to students; change of pace from more experiential learning strategies; cover background information from scattered sources. Teaching Tips. 1.  Increased student participation can be achieved if the format of the feedback lecture is used ( Fuszard , 1995). For example, in a feedback lecture of 1 hour, a 6- to 10-minute group discussion period is inserted between two 20-minute lecture times. 2.  Use visual aids, handouts, and study guides so students can follow the sequence of the lecture. 3.  Students learn in various ways so add activities to the lecture that stimulate all learners. 4.  Read the article “What Is the Most Difficult Step We Must Take to Become Great Teachers?” by Nelson (2001) for some ideas on how to decrease the amount of class time devoted to lecture. Advantages. Time efficient for covering complex material; should raise further student questions that lend themselves to other teaching strategies. Disadvantages. Decreases student involvement in learning when content is readily available and easy to understand in a text or other reading assignment; lengthy preparation time for faculty; little involvement in the topic for students other than sitting through the lecture; may have a high cost in preparation and development of handouts and visual aids. Additional Reading. Amerson , 2006; Beers & Bowden, 2005; deTornyay & Thompson, 1982; Fuszard , 1995; Hoover , 1980; Johnson & Mighten, 2005; McKeachie , 1986; Nelson , 2001. Algorithms Definition. Step-by-step procedure for solving a complex procedure; breaks tasks into yes or no steps. Use. Any course in which frequent practice is required for student mastery of content, in which rules aid in problem solving, or in which the content can be broken into yes or no stages. Teaching Tips. 1.  Assess content for appropriate use of algorithm as a teaching strategy. 2.  Develop algorithm and accompanying student explanations of how to use. 3.  Allow 6 to 8 hours for the development of the first algorithms. 4.  Additional algorithms on similar content typically take less time to develop. Advantages. Shows students how to “spot” the most relevant information for problem solving; develops reliable, complex problem-solving abilities even in novice students; decreases the amount of one-on-one instruction often required when teaching problem-solving techniques; effective in teaching complex procedures that involve many steps; when used with case studies, may enhance learning; saves faculty teaching time over lecture type of presentations; saves student time in trying to remember and understand complex phenomena. Disadvantages. Teacher must clearly define the steps or students will not be able to complete the task accurately; students may need to be taught how to use algorithms in problem solving; development of algorithms can be time consuming for faculty. Additional Reading. Connor & Tillman, 1990; Rathbun & Ruth-Sahd, 2009. Argumentation, debate, structured controversy, and dilemmas Definition. The process of inquiry or reasoned judgment on a proposition aimed at demonstrating the truth or falsehood of something; involves the construction of logical arguments and oral defense of a proposition; requires the recognition of assumptions and evidence and use of inductive and deductive reasoning skills; allows identification of relationships. Teaching Tips. 1.  Strategy works best in an issues or topics course for students at a higher level of cognitive thinking. 2.  For the purpose of forming productive debate teams, it is helpful for students to know each other. 3.  Faculty should introduce the basic topics and structure the debate format early in the course to allow students adequate preparation time. 4.  Debate teams usually consist of five students: two students debate for the topic, two debate against the topic, and the fifth acts as the moderator. 5.  Debates follow a specified format, including opening comments, presentation of affirmative and negative viewpoints, rebuttal, and summary ( Fuszard , 1995). 6.  Encouraging students to debate the opposite of their personal opinion will increase student learning. Advantages. Develops analytical skills; develops ability to recognize complexities in many health care issues; broadens views of controversial topics; develops communication skills; increases student abilities to work in groups. Disadvantages. Requires a fairly high level of knowledge about the subject on the parts of both those presenting the debate and the audience; may require teaching students the art of debate; requires increased student preparation time; can create anxiety and conflict for students because of the confrontational nature of debate; students without adequate public speaking skills may also have increased anxiety; high time cost for students to work in groups. Additional Reading. Brookfield , 1992; Candela , Michael, & Mitchell, 2003; Fuszard , 1995; Garity , 2008; Garrett , Schoener, & Hood, 1996; Metcalf & Yankou, 2003; Mottola & Murphy, 2001; Pederson , 1993.

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Explore the essentials of Critical Thinking in Nursing with this comprehensive guide. In a field where informed, calculated decisions frequently tip the scale between life and death, mastering these skills is imperative. Delve into its definition, uncover key principles, and navigate your way towards effective application in your clinical placements. From formulating constructive questions to evaluating real-life examples, this guide will aid you in recognising the importance that critical thinking holds in the realm of nursing. Grasp its implications within practice and appreciate its indispensable role in nursing education .

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Understanding Critical Thinking in Nursing

Critical thinking in nursing is a quintessential skill that the aspiring nurses need to learn and incorporate into their practice. It entails a systematic, logical, and reflective approach towards nursing care and decision-making, thus facilitating optimum patient outcomes . Mastery of this vital skill will significantly improve not just the quality of care you provide to your patients, but also your efficiency and effectiveness as a healthcare professional.

Definition of Critical Thinking in Nursing

Critical thinking in nursing refers to the deliberate cognitive process that nurses use to gather, interpret and evaluate information about their patients' health. It informs decision-making, problem-solving, and planning in delivering patient-centered care .

As a nursing professional, you'll encounter complex and unique patient scenarios that require rational, informed, and swift decisions. By applying critical thinking, you can ascertain the most appropriate interventions based on individual patient needs , clinical evidence, and best practice guidelines .

Here is a practical example: if you are presented with a patient who has a high fever, cough, and difficulty breathing , critical thinking plays a key role in your approach. You don’t just see these symptoms as a common cold. Instead, you consider more severe conditions, such as pneumonia or COVID-19, based on the patient's medical history and recent environmental exposure. Determining the right diagnosis relies on your ability to critically think and analyze all the patient information available.

Key Principles of Critical Thinking in Nursing

The principles of critical thinking in nursing guide you as you assess, interpret, and make decisions in your nursing practice.

  • Integrity involves approaching situations with an open mind and a willingness to question your own assumptions.
  • Accountability stresses the importance of taking responsibility for your decisions and actions.
  • Clinical reasoning, which refers to applying reasoning and analytical skills in a clinical situation.
  • Evidence-based practice means basing your interventions on the best current evidence from professional literature and guidelines.

The importance of critical thinking extends beyond clinical care delivery. It significantly impacts ethical issues, team communication , and risk management. As you make decisions, you must consider ethical principles like the rights of patients, their dignity, and justice. Effective team communication also hinges on critical thinking, as it enables you to articulate your ideas clearly, listen to others, and resolve conflicts.

In conclusion, understanding and employing critical thinking in nursing can be the difference between ordinary and exceptional nursing care. By honing these skills, you can better anticipate patient needs , make better decisions, and provide superior patient care .

Developing Critical Thinking Skills in Nursing

Developing strong critical thinking skills is crucial to the practice of nursing. This skill enhancement involves a variety of strategies, practice, and awareness of your thought processes. The key is to question and reflect on your working practices, engage in continuing professional development, and use evidence-based guidelines.

Strategies to Enhance Critical Thinking Skills

Enhancing critical thinking requires a diligent and thoughtful approach to your nursing practice. This progression is made feasible by implementing several strategies:

Reflective Journaling: This activity encourages you to reflect systematically on your actions, thoughts, and experiences. It aims to improve your understanding and thereby enhance your practice.

Reflective journaling can be achieved by writing about your daily experiences, patient interactions, clinical decisions, successes and challenges. The goal is to foster self-awareness and enhance your critical thinking through contemplative and thoughtful examination of your nursing practice.

For instance, if a patient in your care experienced an unexpected health decline, you could write about the signs that led to the event, your response, and what you could do differently in the future. Analyzing such situations helps you develop better judgement and decision-making skills.

Peer Reviews: Participating in peer reviews allows for constructive feedback and diversifying perspectives. It provides an opportunity to evaluate and learn from other professionals' approaches to patient care .

You may also employ critical thinking exercises, case study analysis, and group discussions to improve these skills.

It is important to remember that developing critical thinking skills isn't a one-time event but a continual learning process that needs to be integrated into your everyday nursing practice. It will require patience, time, and consistent effort.

Applying Critical Thinking Skills in Clinical Placement

Clinical placement provides a fantastic opportunity for you to apply your critical thinking skills in a realistic and supportive environment. It's where theoretical knowledge meets practical learning.

Clinical Reasoning Cycle: Clinical reasoning cycle is a step-by-step process used by nurses to gather information, process the information, come up with interventions, and assess the outcomes. Critical thinking is intrinsic to this process.

Identifying significant cues and collecting pertinent patient information, interpreting and analysing gathered data, evaluating outcomes, and reflecting on your performance - all of these stages require in-depth thinking and evaluation.

Imagine you're on your clinical placement in an emergency ward. A patient arrives with distressing symptoms such as chest pain, palpitations, and dizziness. By exercising critical thinking skills, you quickly connect these symptoms to possibily indicate a cardiac event. You promptly inform the physician, ensuring timely management and potentially saving the patient's life.

To apply critical thinking in clinical placements, always stay curious, ask questions, seek evidence, and don’t shy away from complex situations. Remember, guided experiences are a nurse's most valuable tool for skill development.

Practical Critical Thinking Questions in Nursing

Practical critical thinking questions are instrumental tools that can be used by nurses to enhance their reasoning abilities. These questions can stimulate the thought process, encouraging you to organise your thoughts, focus on the details, and make responsible and evidence-based decisions.

Examples of Critical Thinking Questions

To gain a better understanding of how practical questions can aid in facilitating critical thinking, consider the following examples:

  • What are the patient's primary complaints and symptoms?
  • How do these symptoms correlate with the patient's medical history?
  • What could be the potential cause(s) of these symptoms?
  • What additional information can be useful in making evidence-based decisions?
  • What interventions are most suitable, and why?

These questions guide you in collecting relevant information, identifying potential issues, and making informed decisions regarding the plan of care. By regularly asking yourself these questions, you can develop a structured and consistent approach to patient care.

Implementing Critical Thinking Questions in Nursing Practice

Implementing critical thinking questions in your nursing practice can seem challenging at first, but with regular use, it can become second nature. It involves asking relevant questions concerning the patient's condition and reflecting on the responses to make a judgement.

To help with this, you can follow these steps:

  • Collect all the relevant information from the patient, including their symptoms, medical history, and current medications.
  • Analyse this information carefully and consider how it all connects. For instance, does the medical history explain the present symptoms?
  • Consider different possibilities. What could be the potential disease or condition?
  • Discuss your thoughts with your team or mentor. They may provide you with a different perspective or additional information that you might not have considered.
  • Reflect on all available information and use your judgement to arrive at a decision. Remember to base your decision on the best available evidence and guidelines.

For example, imagine you're taking care of a patient who displays signs of confusion, abnormal behaviour and unsteady gait. Instead of considering this as a psychiatric issue, you delve deeper, keeping a broad differential diagnosis in mind. You understand these symptoms could be due to a multitude of reasons, including neurological disorders, metabolic abnormalities, or even intoxication. You then proceed to gather all the relevant information including a thorough medical history, physical examination, and appropriate laboratory and imaging studies. By conducting a thorough evaluation and using critical thinking, you can reach a more accurate diagnosis.

Keep in mind, critical thinking is not about reaching a conclusion hastily; it's about taking the time to analyse all the information, consider all possible outcomes, and then make a reasoned judgement. Critical thinking questions are your ally in this process. They prompt you to go beyond surface-level observations and dig deeper, enabling you to provide the highest quality of patient care.

Evaluating Examples of Critical Thinking in Nursing

In nursing, critical thinking plays an immense role when it comes to patient care. Analysing clinical examples and case studies can prove to be an efficient way to understand and exercise this concept. These methods expose you to real-world situations where critical thinking is essential.

Clinical Examples of Effective Critical Thinking

There are countless clinical examples where effective critical thinking can define the difference between successful and unsuccessful patient outcomes .

Consider a patient who is experiencing severe abdominal pain on hospital admission. Their vitals are stable, but they're expressing an inability to urinate. They have no significant medical history, and initial investigations do not indicate any definitive diagnosis. It could be easy at this point to treat the situation as a case of urinary retention alone.

Nevertheless, by applying critical thinking, you point out that there is more to this situation than meets the eye. You are quick to understand that this could be an onset of an insidious condition such as abdominal aortic aneurysm (AAA). You take into account the patient’s age, the severity of the pain, its location, and the urinary symptoms. You call for immediate further investigations which confirm an emergent AAA that requires immediate surgical intervention.

Another common example is of a patient presenting with acute breathlessness and chest pain. Vital signs include tachycardia and decreased oxygen saturation levels. A routine approach might be to administer oxygen and provide symptomatic relief. However, you decide to critically analyse the entire situation with a broader perspective. You keep in mind the patient’s history of deep vein thrombosis and oral contraceptive use, eventually suspecting a pulmonary embolism . This leads to immediate administration of anticoagulation therapy, thus averting a potentially fatal outcome.

Case Studies Highlighting Critical Thinking

Case studies are a powerful tool that helps in understanding the application of critical thinking in nursing. They provide essential insights into real-life scenarios, demanding problem-solving and decision-making skills.

A case study may involve a patient with a long history of diabetes who presents with a non-healing wound on their foot. Routine wound care might help relieve the patient's discomfort temporarily, but it may not treat the underlying condition successfully. By engaging in critical thinking, you might suspect an undiagnosed case of diabetic foot and call for a comprehensive evaluation of peripheral blood circulation , foot sensation tests, and blood glucose control measures. This thought process not only initiates targeted treatment but also aids in preventing wound aggravation, possible infection, and serious consequences such as amputation .

Another case study could be a of a patient who is post-operative day 1 after abdominal surgery, presenting with confusion, restlessness and pallor. Unlike others who might suspect a reaction to anesthesia, considering the patient’s age and post-operative status, you think about acute blood loss and shock. You immediately assemble the surgical team and request re-evaluation. Your rapid decision-making, guided by critical thinking, results in detection of internal bleeding and the patient is swiftly taken for corrective surgery, averting a potential crisis.

Through these case studies and examples, it becomes clear that critical thinking can often mean the difference between life and death situations. It helps you to look beyond the obvious, encourages comprehensive patient assessment , facilitates recognition of potential complications, and promotes prompt intervention, thereby improving patient outcomes.

The Importance of Critical Thinking in Nursing

The realm of nursing inherently encompasses complexity and ambiguity. This is where the importance of critical thinking in nursing comes into play. This essential skill set empowers nurses to consider various factors that contribute to a patient's current health status, predict potential complications, decipher symptoms, and implement effective plans of care.

Implications of Critical Thinking in Nursing Practice

In nursing practice, critical thinking has widespread implications. From making accurate diagnoses to formulating efficient treatment plans, it plays an instrumental role.

Accurate Decision Making: Critical thinking aids in making accurate and informed decisions. These decisions impact patient care significantly and can enhance the quality of treatment provided.

Making accurate decisions requires one to analyse a range of information, consider potential consequences, and select an appropriate course of action. Such a practice can help prevent complications, minimise health risks, and promote recovery.

For instance, consider a patient admitted with fainting spells and bouts of dizziness. If you are quick to merely attribute these symptoms to dehydration without exploring other possibilities, you might miss an underlying cardiac problem. By thinking critically, you will consider all possible diagnoses, supporting investigations, and then decide the best approach.

Patient Safety : Critical thinking is instrumental in promoting patient safety . It enables nurses not only to detect impending health threats but also to act swiftly in the face of medical emergencies.

By using critical thinking, you can identify errors in medication administration , potential patient harm from treatment interventions, infection risks, and safety violations within the healthcare setting.

For example, a patient with a known allergy to penicillin has been mistakenly prescribed a medication containing a penicillin derivative. By critically examining the prescribed medications, you notice this error and prevent a possible allergic reaction, thereby ensuring patient safety .

Critical Thinking in Nursing Education: A Necessity

The integration of critical thinking in nursing education is now more crucial than ever. It is this skill that helps bring theoretical learning to practical fruition.

Theory-Practice Gap: Critical thinking aids in bridging the theory-practice gap in nursing education. It enables the application of theoretical knowledge into practical situations, enhancing learning and performance.

By employing critical thinking in education, students learn to analyse complex scenarios, solve clinical problems, and make informed decisions.

A nursing student in a pediatric rotation, for instance, comes across a child presenting with a high fever, irritability, and a rash. By critically thinking, the student can associate these symptoms to those learnt in theory, suspecting diseases like measles or roseola. Therefore, critical thinking helps to 'translate' classroom learning into a hands-on approach.

Preparing Future Nurses: Critical thinking education helps prepare future nurses to face the challenge of the ever-evolving healthcare environment. It enables them to grasp new concepts rapidly, adapt to change, develop innovative solutions, and engage in evidence-based practice.

To successfully navigate the complexities of the healthcare environment, nurses must master the ability to think critically, problem-solve, and make decisions based on solid evidence and sound reasoning.

Irrespective of the role or setting, critical thinking is a premier skill that every nurse must possess. It is the bedrock of nursing practice and education, forming the basis for maintaining standards, safety, and quality in patient care. Hence, cultivating these abilities must remain a prime focus in the journey of a nurse.

Critical Thinking in Nursing - Key takeaways

  • Critical Thinking in Nursing refers to the ability to apply reasoning and analytical skills in various healthcare situations.
  • Evidence-based practices are influential in enhancing critical thinking. These practices involve basing interventions on the current best evidence from professional literature and guidelines.
  • Developing critical thinking skills involves strategies like questioning and reflecting on your practices, engaging in continuing professional development, and utilizing evidence-based guidelines.
  • Practical critical thinking questions stimulate thought processes, enabling organization of thoughts, focusing on details, and making responsible decisions.
  • The importance of critical thinking in nursing ranges from ethical issues and team communication to risk management, thereby playing a huge role in improving patient care.

Frequently Asked Questions about Critical Thinking in Nursing

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Critical Thinking in Nursing is a cognitive process that involves systematic collection, interpretation, analysis, synthesis, and evaluation of accurate data related to patient care to make informed decisions for optimal health outcomes.

The elements include interpretation (understanding and explaining the meaning of information), analysis (identifying the intended and actual inferential relationships), and evaluation (assessing the credibility of statements and the logical strength of the inferential relationships).

Critical Thinking in Nursing leads to enhanced patient care as it helps in interpreting and analysing patient data, evaluating potential risks, and making informed decisions, thus contributing to optimal health outcomes.

What is the role of critical thinking in nursing?

Critical thinking allows nurses to analyse complex situations, make sound judgments, and provide the best possible care. It is the backbone of clinical judgement and professional autonomy, enhancing patient safety, clinical outcomes, and the delivery of high-quality care.

How do critical thinking skills enhance the quality of nursing care?

Critical thinking skills enable nurses to accurately assess a slew of patient data, make informed clinical decisions considering various treatment options, and problem solve in complex health care environments, enhancing the quality of care provided.

What is the impact of critical thinking on patient outcomes?

Critical thinking aids in revising care plans when treatments fail, helps manage patients with complex conditions, and allows for quick and sound decision-making in emergencies. It also promotes team collaboration, resource utilisation, and evidence-based practice.


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Applying critical thinking to nursing, bob price healthcare education and practice development consultant, surrey, england.

Critical thinking and writing are skills that are not easy to acquire. The term ‘critical’ is used differently in social and clinical contexts. Nursing students need time to master the inquisitive and ruminative aspects of critical thinking that are required in academic environments. This article outlines what is meant by critical thinking in academic settings, in relation to both theory and reflective practice. It explains how the focus of a question affects the sort of critical thinking required and offers two taxonomies of learning, to which students can refer when analysing essay requirements. The article concludes with examples of analytical writing in reference to theory and reflective practice.

Nursing Standard . 29, 51, 49-60. doi: 10.7748/ns.29.51.49.e10005

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All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

Received: 23 February 2015

Accepted: 10 April 2015

education - students - study skills - studying - academic assignments - continuing professional development - CPD - clinical reasoning - critical appraisal - learning outcomes - reflection - reflective practice

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student nurse critical thinking examples

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College of Nursing

Leveraging implementation science with using decision support technology to drive meaningful change for nurses and nursing leadership.

View as pdf A later version of this article appeared in  Nurse Leader ,  Volume 21, Issue 6 , December 2023 . 

Abstract Technology, such as clinical decision support, can play a role in supporting nurses’ decision making, but understanding the complexity and current challenges in nurse decision-making is needed to guide the implementation of technology interventions focused on supporting effective decision-making in practice and leadership. The purpose of this article is to discuss decision-making and information needs among nurses across roles and explain how technology and implementation science approaches can complement effective decision-making interventions.

Across settings and nursing roles, effective decision-making is fundamental to excellent nursing and patient care. For example, nurses in patient care roles often spend more time with patients than any other health discipline and frequently need to make decisions about when to inform the health care team with changes in a patient’s condition. Nurses in leadership roles must make a wide range of managerial decisions concerning nurse staffing, human resources, and which clinical technologies to advocate for the support direct care nurses’ decision-making. Factors such as increasing patient acuity, escalating evidence base, and global pandemics have led to increased complexity in nurse decision-making across roles. Technology can play a role in supporting nurses’ decision making, but understanding the complexity and current challenges in nurse decision-making is needed to guide the implementation of technology interventions focused on supporting effective decision-making in practice and leadership. The purpose of this article is to discuss decision-making and information needs among nurses across roles and explain how technology and implementation science approaches can complement effective decision-making interventions.

Decision-making Across Nursing

Decision-making, or executing a choice among options, is an essential process in nursing and numerous theories and models have been developed to describe and study nurse decision-making. 1-3 Approaches to decision-making can be broadly categorized as rational, using logical steps or rule-based thinking to determine the best option, or intuitive, which describes using instinct or subconscious pattern recognition to make a choice. 4  Over time, thinking has transformed from viewing nurse decision-making as primarily a rational process, to a process that is influenced by real-world demands, such as needing to make decisions with limited information, changing conditions, interruptions, and/or time pressure. 5,6 In these situations, experienced nurses rapidly apply insight from previous experiences to make decisions. 7,8  Given the variation in how decisions are made and real-world demands that nurses and leaders are faced with, a one-size-fits-all approach may not be useful when developing and implementing nurse decision-making interventions.

Information is a fundamental component of the decision-making process and is generated from diverse sources. Digital technologies (e.g., clinical decision support, telehealth, monitoring systems, artificial intelligence) can provide important new sources of information and address limitations to existing information sources, such as organizing EHR data to efficiently identify a patient’s risk for clinical deterioration. However, technologies that fail to adequately address information needs, or are difficult to use, will have limited adoption. Understanding the types of information nurses need in direct care and leadership roles, what information is available, and limitations to existing information sources is needed to evaluate interventions to support decision-making.

Technologic Considerations for Supporting Direct Care Nurses’ Information Needs

Nurses need timely, patient-specific clinical information to provide care. The electronic health record (EHR) is the primary source of patient data, however substantial documentation demands have significantly impacted nurse workload and workflows for finding relevant information. Studies estimate that nurses spend 35 to 41% of their time in the EHR documenting and reviewing patient information. 9,10 While nurses generate large amounts of data in the EHR, documenting an average of 631-875 flowsheet data points and spending an average of 21 minutes documenting notes per shift, there are significant challenges with organizing and synthesizing patient data. 11,12

An integrative review of EHR’s impact on nurses’ cognitive work identified the following limitations to meeting nurse information needs in the EHR: developing an overview of the patient’s history, current status, and plan; synthesizing information using EHR-generated reports to support information needs during a shift and at handoff; and achieving shared understanding of patient goals and care coordination. 13 Similar needs were found by Keenan et al. over a decade ago including the need for a centralized overview of patients accessible to all members of the healthcare team and effective technology to support nurse to nurse change of shift handoffs. 14   Given these challenges, work in two key areas – reducing documentation burden in the EHR and incorporating nurse information needs into EHR redesign are critical to support direct care nurse work.

Another critical area is related to nurses’ expectation to incorporate research into decision-making. This is commonly referred to as evidence-based practice: applying the best available evidence along with patient preferences in making clinical decisions and is a foundation of high-quality nursing care. 15 However, there is a persistent gap of 15 to 17 years between current best evidence and daily practice. 16,17   Studies of information needs and information use for evidence-based practice offer additional perspectives for understanding barriers to routinely using evidence in practice. Findings over the past 15 years indicate that nurses routinely seek out information from colleagues since they share clinical context and are accessible. 18,19  However, information shared by colleagues may be outdated or inaccurate when technology-based tools, such as clinical decision support, can provide nurses with up to date accurate information during a time that integrates well with nurses decision making workflow.

Technologic Considerations for Supporting Nurse Leaders’ Information Needs          

Nurse leaders across roles and settings must integrate patient and organizational data to optimize patient outcomes. Information needs vary by timing of decision. Nurse managers describe short-term information needs about patients related to throughput and staffing needs and long-term information needs focused on meeting organizational priorities, such as quality improvement initiatives and nurse retention. 20, 21 Whereas short-term information was commonly reported to come from the EHR and situational awareness, or understanding of the local environment, long-term information needs require leaders to search for information across sources. A recent review of nursing management information systems found that nursing leaders use information systems to manage human resources, determine nursing workload (nurse to patient ratio) and control costs. 22  These systems are largely based on two sources of data: patient classification measures and hospital resource measurement. The authors did not find a central database or decision support tool to support the work of nurse leaders, suggesting a critical need for new technology to address this gap.

In addition to their own information needs, nurse managers play a critical role in advocating for the information needs of the direct care nurses. For example, in the United States there are an increasing number of mandates and digital technologies related to care quality issues such as central line infection and hospital acquired pressure ulcer prevention. Nurse leaders must appraise digital technologies to determine whether the technology supports the direct care nurses’ information needs, ensure that it is easy to use and does not add to nursing workload as well as providing a return on investment.

A Role for Clinical Decision Support 

One technology-based intervention to assist nurses in complex in decision-making processes is clinical decision support (CDS) systems. CDS systems are computer-based tools to organize person-specific data and knowledge for clinicians and patients to improve the quality and safety of health care. 23 CDS is delivered in a variety of formats, such as through order sets, documentation templates, computerized alerts, dashboards, and visualizations, which may be integrated in electronic health record (EHR) systems or exist as applications or technologies outside the EHR. In general, CDS is composed of three key parts. 24

  • Data management: clinical data and decision rules or logic. Decision rules or logic may be developed using literature and current practice (knowledge-based) or artificial intelligence (non-knowledge-based).  
  • Processing: applies the knowledge or algorithms with patient data
  • User interface: the part of the system that communicates a recommendation and is the point the user interacts with (e.g., computer display, mouse).

Guiding principles for developing effective CDS are known as the CDS Five Rights, and state that CDS should communicate the right information, to the right person, in the right format, through the correct channel at the right time in the workflow. 25 These principles provide a valuable framework for nurse leaders to consider in evaluating potential CDS tools.

CDS tools support information management, which is an increasing need in healthcare given the large volumes of clinical, administrative and research data that is generated. Therefore, tools which filter relevant patient data and apply logic to determine a recommendation are needed. However, fewer CDS tools have been developed for nurses than have been for physicians and other members of the health care team. 26

Current Challenges and Opportunities in Nursing Clinical Support

Recognizing the opportunities for CDS to supporting decision-making must be balanced with the reality that gaps in developing and using CDS exist in nursing. A recent review of CDS tools across multiple disciplines found that only two-thirds of clinicians’ report using available CDS. 27 While understanding of CDS usage specifically among nurses is limited, several nurse, patient, organization, and technology factors have been identified to influence nurses’ use of CDS. 28 Given these challenges, the role of implementation science is emerging as an important approach to inform future CDS design and use. 29

Implementation Science

Implementation science centers on how evidence-based practices are adopted and sustained across specific settings. 30 Whereas evidence-based practice describes what recommendation should be used, implementation science focuses on how to best help people consistently do a particular recommendation in their work environment. 31 Implementation science frameworks provide guidance for understanding key components of implementation, such as describing the implementation process, identifying barriers and facilitators to implementation, or conducting an implementation evaluation. 32 Implementation strategies and context important concepts across most implementation science frameworks. Implementation strategies describe the specific interventions chosen to facilitate change. For example, the Iowa Implementation Model for Sustainability Framework provides an organized approach for selecting an implementation strategy based upon phases of implementation. 33 For example, after nurses have obtained knowledge about a practice change, audit and feedback may be one implementation strategy to promote adoption. Related, is the concept of context, or the unique local factors (e.g., unit culture, work environment, resources) that influence how or why implementation is achieved. 34 In partnership with implementation scientists, nurse leaders can identify unique barriers and facilitators to implementation in the local environment and then match the needs to implementation strategies.

Leveraging User-Centered Design

View Figure 1 as pdf

please see pdf

Considering the unique needs of users, or user-centered design, is a concept central to implementation science and CDS design (Figure 1). The goal of user-centered design is to make interventions “useable and useful” by focusing on user needs throughout the design and development process. 35 Implementation science and user-centered design use a variety approaches to obtain end-user input, which may include, workflow mapping, participatory design, rapid prototyping, and usability testing. 36, 37 However, methods to engage nurses early in CDS design and implementation are inconsistently applied.

Nurse leaders are in a key position to advocate for greater involvement of nurses, early and throughout the process of developing and implementing CDS. This may include developing processes for nurses to provide feedback about information needs in their settings, workflow considerations, and opportunities to test and refine CDS prototypes. Greater involvement of nursing informatics within organizations and including opportunities for nurses to receive training in implementation science and user-centered design are additional strategies to support integration of these concepts in CDS design and use. 38-40  An organizational culture that supports nurse information needs by considering both the types of CDS that nurses need and how CDS will be used in daily practice is critical, especially as new technologies are developed and CDS becomes more complex.

Nurses and nurse leaders need to make numerous decisions in highly complex work environments. CDS has an expanding potential to augment decision-making across roles by providing nurses with meaningful, person-specific information in a usable format to positively impact care and outcomes. Nurses that will be the eventual user of the CDS need to be involved early and throughout CDS development to ensure that CDS tools are usable, useful, align with workflow as a part of routine work. Implementation scientists, who understand the local context, are needed to design and test strategies for using CDS, both in specific settings and diffusing CDS use across settings. Approaches which consider both how CDS is designed for nurse users and how CDS is used and implemented across health systems is needed to support effective decision-making for driving change in nursing practice and leadership settings.

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  • v.4(1); 2015 Mar

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Critical Thinking Skills in Nursing Students: a Comparison Between Freshmen and Senior Students

Ismail azizi-fini.

1 School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, IR Iran

Ali Hajibagheri

2 Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, IR Iran

Mohsen Adib-Hajbaghery

3 Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, IR Iran


Critical thinking is one of the most important concepts in the field of education. Despite studies published on nursing students’ critical thinking skills (CTS), some suggest that there is not enough evidence supporting the relationship between content of nursing education programs and nursing students’ CTS.


Given the existing discrepancies, this study aimed to compare the critical thinking skills of freshmen and senior nursing students.

Patients and Methods:

This comparative study was conducted on 150 undergraduate freshmen and senior nursing students in Kashan University of Medical Sciences, during 2012. The students in the first and the last semesters of their study in nursing were entered in the study using the census method. Data were collected using a questionnaire including questions on demographic data and the California Critical Thinking Skills Test, form B. Data analysis was performed using the SPSS v.13 software. Descriptive statistics were calculated. Moreover, independent sample t-test and Spearman and Pearson’s correlation coefficients were used in the data analysis.

Both the freshmen and senior nursing students had low CTS. The mean critical thinking scores were 11.79 ± 4.80 and 11.21 ± 3.17 for the freshmen and the senior students, respectively (P = 0.511). Moreover, no significant correlation was found between the students’ score in CTS and their age, gender, high school grade point average (GPA), rank in university entrance examination (RUEE) and interest in the nursing profession.


The students were low skilled in critical thinking and their CTS did not significantly change during their nursing degree. Thus it may be concluded that the nursing education program did not affect the CTS of its students. Longitudinal studies are suggested for assessing nursing students’ critical thinking over time. Moreover, revising the curriculum and preparing nursing educators for implementing innovative and active teaching strategies are suggested.

1. Background

Critical thinking is one of the most important concepts involved in the field of education. Enabling students to think critically is not only a primary purpose of higher education, but also facilitates the dynamics of academies and universities and helps them survive, develop and promotes scientific societies ( 1 ).

Introducing the concept of critical thinking into nursing education is a turning point in the process of professionalization. Despite different definitions for critical thinking, no consensus has yet been reached ( 2 , 3 ). However, critical thinking is generally defined as "a process of purposeful, interactive reasoning, criticism and judgment about what we believe and do" ( 4 ). Some have also defined critical thinking in nursing as "the process of reflective and reasonable thinking about nursing problems without a single solution and is focused on deciding what to believe and do" ( 5 ).

In the recent decades, as a result of the rapid advances in knowledge and technology, dramatic changes have occurred in healthcare organizations. Consequently, people’s demand has been increased for higher quality healthcare services, with lower costs and shorter length of hospital stay. Moreover, the aging population, complex disease processes and increased patients’ awareness, have evolved modern nursing. Thus, nurses are in need to continually improve their knowledge and competencies, to be able to provide safe and quality care in a context of constantly changing clinical situations ( 6 ).

In this changing environment, nurses need to develop their thinking and reasoning skills in order to meet the patients and families’ caring needs in collaboration with other healthcare professionals ( 7 ). Nurses as healthcare providers should be creative, self-directed and critical thinkers to be able to make appropriate decisions and solve clinical problems ( 8 ).

Karadag et al. investigated nurse educators and clinical nurses’ attitudes towards critical thinking and reported that both nurses and nurse educators believed in the crucial role of critical thinking skills (CTS) in the context of increasing complexity in modern healthcare ( 9 ). Simpson et al. also stressed that nurses should be skilled in reasoning and critical thinking to be able to appraise new knowledge. Highlighting the vital importance of CTS, the American Nurse Association also emphasizes that the nurses’ CTS should be measured as a criterion for validating outcomes of nurse education programs ( 6 ).

Several nursing authors have written about teaching methods used to strengthen CTS ( 4 ). According to Alfaro-LeFevre ( 10 ), there are at least two main reasons for nurses to learn CTS. Firstly, thinking is the key for problem solving; while, nurses without such skills are themselves part of the problem. Secondly, in critical situations, nurses should be able to take major decisions, independently and quickly. Critical thinking skills enable them to identify necessary data and distinguish problems requiring immediate intervention from those that are not life threatening. Thus, they will be able to consider the possible consequences of each action and make the right decision ( 3 ).

Bakalis et al. suggest that it is essential to establish a dialogue between teachers and students to promote CTS among learners ( 11 ). Studies have also shown a link between the students’ level of CTS and their level of academic education, age and clinical experience ( 4 , 12 ).

Despite many studies published on nurses and nursing students’ CTS, Duchscher suggests that there is no strong evidence supporting the relationship between content of nursing education programs and the nurses or nursing students’ CTS ( 12 ). Some other authors believe that there is a lack of appropriate tools for assessing nurse's CTS ( 13 , 14 ). However, Magnussen et al. ( 15 ) have reported that traditional teaching methods may hinder the ability of critical thinking while research-based learning, as a teaching method, can increase CTS.

Studies in Iran have shown mixed results in terms of nursing students’ critical thinking. Two studies by Rezaei et al. ( 16 ) and Eslami et al. ( 3 ) reported that nursing students had poor CTS. They found no significant difference between the levels of CTS in freshmen and senior nursing students. However, in two other studies, Khalili et al. ( 17 ) and McCarthy et al. ( 18 ) reported that the levels of CTS were significantly higher among senior compared to junior nursing students. Therefore, the question is whether CTS differs among nursing students at the start and the end of their nursing studies. The answer of this question would not only be important globally but also at the national level because this answer might help us evaluate the nursing curriculum and nursing educators as the main role models in the process of nursing education.

2. Objectives

Given the importance of CTS in nursing, and discrepancies in previous studies, this study aimed to compare the CTS of freshmen and senior nursing students of Kashan University of Medical Sciences (KAUMS), during year 2012.

3. Patients and Methods

A comparative study was conducted on 150 undergraduate freshmen and senior nursing students at KAUMS. All nursing students in the first and the last semester of their nursing program were entered in this study using the census method. Exclusion criteria were: being a guest student or being transferred from other universities, having an additional academic degree, and having passed some courses on critical thinking.

Data were collected using a two-part questionnaire. The first part of the questionnaire consisted of questions on demographic data (i.e. gender, age, the students’ high school grade point average (GPA), the students’ rank in university entrance examination (RUEE), and interest in the nursing profession). The second part of the questionnaire was the California Critical Thinking Skills Test, form B (CCTS form B). The CCTS form B is frequently used to assess the students' CTS ( 3 ). This scale consists of 34 questions, each with options, which are designed to evaluate critical thinking at the post-secondary level.

The CCTS form B was specifically designed to assess CTS in five areas of interpretation, analysis, evaluation, inductive reasoning and deductive reasoning. Each question is scored either one or zero for each correct or wrong answer, respectively. Thus, the lowest overall score is zero and the highest is 34 ( 19 ). The time each student spent to respond to the questionnaire was about 45 minutes.

The CCTS form B was previously translated to the Persian language by Akhoundzadeh et al. ( 20 ), and showed appropriate psychometric properties. They also confirmed the instrument’s content validity and reliability using the Kuder-Richardson coefficient, which was 0.62. The test was able to distinguish between CTS of nursing and philosophy students ( 21 ).

After obtaining permission from the authorities of the university, the instrument was passed to selected students in their breaks between classes. All students were asked to respond to the questionnaires in a private environment and returned their answers back to the researchers (the first or the second authors of this manuscript) or the secretary of the nursing department on the same day.

3.1. Ethical Considerations

Permission for this study was through the ethics committee of KAUMS. Other ethical issues in this study involved the assurance of confidentiality and anonymity of the participants. All participants were informed about the purpose and design of this research, and that their participation was voluntary. Participants signed a written informed consent for their participation.

3.2. Data Analysis

Data analysis was performed using the SPSS v.13 software. Descriptive statistics were calculated. Independent sample t-test was used to examine significant differences between mean quantitative variables of the two groups. Moreover, the Spearman and Pearson’s correlation coefficients were used to examine the correlation between the students’ scores in CTS and their age, gender, high school GPA, RUEE and interest in the nursing profession. The level of significance was considered less than 0.05.

Among all participants, 24.6% (n = 37) were freshmen and 75.4% (n = 113) were senior students. In total, 65.5% of the freshmen students and 65.3% of the seniors were females (P > 0.05). The mean age of the students was 20.5 ± 1.73 years and 22.41 ± 1.51 years, for freshmen and senior students, respectively (P > 0.05). The mean high school grade point averages of the students were 17.58 ± 1.65 and 18.38 ± 1.03 for the freshmen and seniors, respectively, (P > 0.05). The students’ mean ranks in the university entrance examination were 5186.6 and 6283.1 for the freshmen and seniors, respectively, (P > 0.05). Overall, 10.8% of freshmen students reported that they are very interested in the nursing profession, while 10.8% and 78.4% were moderately interested in or uninterested in the profession, respectively. In terms of senior students, 27.4% were very interested in the nursing profession, while 61.1% and 11.5% were moderately interested or uninterested in the profession, respectively.

The mean critical thinking scores were 11.79 ± 4.80 and 11.21 ± 3.17 for freshmen and senior students, respectively (P = 0.511). As shown in Table 1 , no significant differences were found between freshmen and senior students in terms of their mean scores for the interpretation, analysis, evaluation, inductive reasoning and deductive reasoning subscales. Both freshmen and senior students obtained the highest and the lowest mean scores in deductive reasoning and analysis subscales, respectively.

a All values are presented as Mean ± SD.

Using Pearson’s correlation coefficient, no significant correlation was found between the students’ CTS scores and their age, high school GPA, and RUEE ( Table 2 ). Moreover, using Spearman’s correlation coefficient, no significant correlation was found between the students’ CTS score and their gender and interest in the nursing profession ( Table 2 ).

5. Discussion

This study aimed to compare the CTS of freshmen and senior nursing students to determine if the current nursing education program is effective on its students CTS. Results showed that the mean critical thinking scores of freshmen and senior nursing students were at a low level. Moreover, no significant difference was observed between the mean critical thinking scores of freshmen and senior nursing students. In addition, no significant association was found between the students’ scores in CTS and variables such as gender, high school GPA, RUEE and level of interest in the nursing profession. These findings are consistent with the results of previous studies ( 22 ). Previous studies on the assessment of Iranian nursing students and nurses’ CTS have reported that the majority of nursing students and nurses in Iran have poor CTS ( 3 , 23 - 25 ). Consistent with this study, other studies have also found no significant difference between freshmen and senior nursing students' CTS ( 3 , 26 ). However, Khalili et al. ( 17 ), Babamohamadi and Khalili ( 23 ) have reported significant differences between the critical thinking scores of freshmen and senior nursing students, which is not in line with the results of the present study. These inconsistencies might not only be attributed to probable differences in learning styles of students ( 27 ) but also to the relatively different teaching styles of different nursing schools.

The results of this study showed no statistically significant positive correlations between demographic data and CTS. While Zhang and Lambert ( 27 ) and Noohi et al. ( 28 ) reported that a number of positive and negative correlations exist between demographic data and critical thinking skills. The lack of correlation between demographic data and CTS in the present study might be attributed to the characteristics of universities and their students; Mahmoodabad et al. ( 29 ), in a study from Iran, reported that students attending larger universities are somewhat different considering their GPA and RUEE, and this may affect their CTS. Another probably reason is that many of the senior students in Kashan are employed as part time nurses in healthcare centers. Therefore, as Bittencourt and Crossetti ( 30 ) have reported, students that work part time have less time to spend on intellectual activities. It seems that when students are employed in clinical settings, they spend more time in performing nursing techniques and following the routines instead of using the scientific knowledge they learned at the university. Working according to the routines usually does not need much thinking skills, and nurses simply follow the doctors’ orders. Working in this manner, would gradually affect the nurses cognitive, critical thinking and humanistic skills such as communication skills.

Furthermore, studies have reported that not only the content of education but also the teaching-learning methods at all levels of the education system in Iran (i.e. elementary, secondary and university) basically concentrate on transferring theoretical knowledge and do not focus on development of critical thinking and problem-solving skills in learners (4). Amini et al. ( 31 ) reported that this is a global problem in nursing education, and several studies indicate a lack of critical thinking and problem solving skills in undergraduate nursing programs. It has also been reported that although basic skills of critical thinking are taught to nursing students, they cannot apply them in solving problems they commonly encounter, and this may be considered as a sign of failure in nursing education systems ( 32 ). Moreover, overuse of lectures and multiple choice questions, and overlooking the nursing process in education may be among other possible reasons for the lack of CTS in Iranian nursing students ( 23 , 33 ).

It seems that nursing students have less opportunity to apply CTS in clinical settings. While techniques, such as questioning, Socratic method, learning in small groups, discussions and debates, writing diaries, problem based teaching and learning, use of case studies and other types of participative learning, have been shown to be effective in developing CTS ( 20 , 34 ). Previous studies have shown that the nursing curriculum in Iran contains a considerable amount of theoretical, redundant, unnecessary and inapplicable knowledge and nurse educators are under pressure to teach a large content in a limited time ( 4 , 35 ). Thus, making a balance between the course content and time available may be the first step in preparing the context for educators to assign more time for the development of the students’ CTS. Moreover, as Moattari et al. ( 35 ) reported, nurse educators should be prepared to implement active, student-centered, collaborative and problem-focused teaching strategies to foster the students’ CTS.

The results showed that nursing students had low CTS and these skills did not significantly change during their studies in nursing. Therefore, it may be concluded that the studied nursing education program did not affect its students’ CTS. However, the low critical thinking scores of the participants in the present study and other studies conducted in Iran may be attributed to the instruments used by these studies. Most of these studies used instruments such as CCTS Form B, and as mentioned previously, some nursing researchers believe that this instrument is not appropriate for assessing nurses or nursing students’ CTS. Thus, appropriate indigenous instruments should be developed for assessment of critical thinking in nurses. In addition, we tested our participants only one time. It is better to evaluate the evolution of critical thinking over time. Longitudinal studies are suggested for assessing the nursing students’ critical thinking over time. Moreover, revising the curriculum and preparing nurse educators for implementation of innovative and active teaching strategies are suggested. Then, the effects of such interventions can be assessed.


The researchers would like to express their gratitude to all the participants who were involved in this study.

Authors’ Contributions: All authors contributed equally in this study.

Funding/Support: This project was funded by the research deputy of Kashan University of Medical Sciences (grant No. 9017).


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    4. Critical thinking skills in nursing contribute to rational decision-making, which improves patient outcomes. Although nursing is considered a science, there are instances that require split-second decisions. Nurses who are critical thinkers are more likely to make rational, patient-centered decisions that benefit the client and healthcare team.

  3. Critical thinking skills of nursing students: Observations of classroom

    1. INTRODUCTION The ever‐changing and complex healthcare environment requires that nurses acquire critical thinking (CT) skills to meet the complex challenges of the environment (Von Colln‐Appling & Giuliano, 2017 ).

  4. Developing Critical-Thinking Skills in Student Nurses

    Analysis Critical thinkers can examine varying ideas, statements, questions, descriptions and concepts and analyze the reasoning. Inference Critical thinkers consider relevant information from evidence to draw conclusions. Explanation Critical thinkers state the results of their reasoning through sound arguments. Self-regulation

  5. Two Examples of How I Used Critical Thinking to Care for ...

    Critical Thinking in Nursing: Example 1 I had a patient that was scheduled to go to get a pacemaker placed at 0900. The physician wanted the patient to get 2 units of blood before going downstairs for the procedure. I administered it per protocol.

  6. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and

    Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically - Patient Safety and Quality - NCBI Bookshelf equates intuition with direct perception. Direct perception is dependent upon being able to detect complex patterns and relationships that one has learned through experience are important.

  7. How to Get Your Nursing Students to Think Critically

    One must know the patterns to problem solve and act appropriately for the patient. One could also use a short patient scenario or NCLEX-style question at the beginning of class as the "problem of the day.". Present this and ask each learner to record what he or she thinks the answer to the question before you lecture.

  8. Critical Thinking: The Development of an Essential Skill for Nursing

    The main critical thinking skills in which nursing students should be exercised during their studies are critical analysis, introductory and concluding justification, valid conclusion, distinguish of facts and opinions, evaluation the credibility of information sources, clarification of concepts and recognition of conditions.

  9. Creative Ways to Enhance and Assess Critical Thinking in Nur ...

    11/12 2021 - Volume 42 - Issue 6 - p E145-E146. doi: 10.1097/01.NEP.0000000000000830. Metrics. Nursing students should be challenged to implement critical thinking decisions regarding conclusions they implement for patient care. This article reinforces common techniques and introduces new practices to teach critical thinking.

  10. Teaching strategies and outcome assessments targeting critical thinking

    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 ...

  11. Critical Thinking in Nursing: Key Skills for Nurses

    Some of the most important critical thinking skills nurses use daily include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Interpretation: Understanding the meaning of information or events. Analysis: Investigating a course of action based on objective and subjective data.

  12. PDF Critical Thinking and Writing for Nursing Students

    This example of an analytical essay is presented in association with Price, B and Harrington, A (2010) Critical Thinking and Writing for Nursing Students, Exeter, Learning Matters. Readers are introduced to the process of critical and reflective thinking and the translation of these into

  13. What is Critical Thinking in Nursing? (Explained W/ Examples)

    They can express complex ideas in a coherent and understandable manner. Continuous Learning: Critical thinking encourages a commitment to ongoing learning and intellectual growth. It involves seeking out new knowledge, refining thinking skills, and staying receptive to new information. Definition of Critical Thinking

  14. How To Improve Critical Thinking Skills In Nursing? 24 Strategies With

    How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples by Ummu, MN, BSN, CCN, RN Last updated on August 19th, 2023 Nurses play a critical role in making critical decisions that directly impact patient outcomes in the dynamic field of healthcare.

  15. Development of nursing students' critical thinking and clinical

    The course Fundamentals of Nursing is a course that aims to focus on the concepts, theories, principles, and methods constituting the core and fundamental elements of nursing, and to teach the new nursing students the theoretical concepts such as critical thinking, ethics, and values, and to enable them to perform the daily life activities and ...

  16. Strategies to promote critical thinking and active learning

    15 Strategies to promote critical thinking and active learning Connie J. Rowles, DSN, RN Nursing faculty spend a considerable amount of their time planning experiences to facilitate student learning. The selection of teaching strategies and learning experiences traditionally has been governed by behavioral objectives. However, nursing education has been undergoing a major revolution, with ...

  17. Critical Thinking in Nursing: Skills, Questions & Examples

    1 / 3 What is Critical Thinking in Nursing? Critical Thinking in Nursing is a cognitive process that involves systematic collection, interpretation, analysis, synthesis, and evaluation of accurate data related to patient care to make informed decisions for optimal health outcomes.

  18. A guide to nursing students' written reflections for students and

    Experiences from nursing students' clinical settings are ideal for building critical thinking skills if reflection is used as a teaching tool. Reflection occurs before, during, and after experiences, with the expectation of informing future encounters and helping a person to understand him/herself.

  19. Applying critical thinking to nursing

    It explains how the focus of a question affects the sort of critical thinking required and offers two taxonomies of learning, to which students can refer when analysing essay requirements. The article concludes with examples of analytical writing in reference to theory and reflective practice. Nursing Standard. 29, 51, 49-60.

  20. Curriculum framework to facilitate critical thinking skills of

    In many developing countries, nursing schools encounter challenges that may further compound the challenge of assisting students to engage in CT skills. For example, ... A systematic review of critical thinking in nursing education. Nurse Education Today, 33 (3), 236-240. 10.1016/j.nedt.2013.01.007 ...

  21. FA DAVIS Chapter 2 assignment Flashcards

    Study with Quizlet and memorize flashcards containing terms like What is the best way for student nurses to improve critical-thinking skills?, What considerations are included in the critical-thinking process of a nurse? Select all that apply., Which examples best demonstrate the use of critical thinking? Select all that apply. and more.

  22. Critical Thinking Activities For Student Nurses

    Practicing the Concept: Example Activities About halfway through nursing school. students are exposed to simulated environments to apply theory by practicing skills. CNEs can promote critical. . . As such. nurse educators must also ensure that students can incorporate critical thinking skills into everyday practice.

  23. Leveraging implementation science with using decision support

    For example, nurses in patient care roles often spend more time with patients than any other health discipline and frequently need to make decisions about when to inform the health care team with changes in a patient's condition. ... nurse managers play a critical role in advocating for the information needs of the direct care nurses ...

  24. Critical Thinking Skills in Nursing Students: a Comparison Between

    Despite studies published on nursing students' critical thinking skills (CTS), some suggest that there is not enough evidence supporting the relationship between content of nursing education programs and nursing students' CTS. ... Moreover, independent sample t-test and Spearman and Pearson's correlation coefficients were used in the data ...