- Open access
- Published: 10 April 2023
Assessing perceptions about critical thinking, motivation learning strategies in online psychiatric and mental health nursing education among Egyptian and Saudi undergraduate nursing students
- Nora Ghalib AlOtaibi 1 ,
- Amira Alshowkan 1 ,
- Neama Kamel 1 ,
- Ayman Mohamed El-Ashry 3 ,
- Nagla Saleh AlSaleh 1 &
- Eman Sameh Abd Elhay 2
BMC Nursing volume 22 , Article number: 112 ( 2023 ) Cite this article
The pandemic context prompts nursing students to be involved in online learning. Researchers indicated that critical thinking develops through the learning process, but the link between critical thinking and online learning in nursing does not have sufficient evidence.
Aim of Study
This research examines student perceptions about critical thinking, motivation, and learning strategies in online psychiatric nursing education among nursing students at Imam Abdulrahman bin Faisal University in Saudi Arabia and Alexandria University in Egypt.
Subject and Methods
An online survey was designed to collect data anonymously. A total of 75 Saudi undergraduates and 105 Egyptian nursing students who met the inclusion criteria participated. The online survey assessed three parts: socio-demographic data, critical thinking motivational, and cognitive processing strategy scales.
The current study found that using a motivating method for online learning inspired students to engage in critical thinking and cognitive processing strategies in a psychiatric and mental health nursing course, even in two different contexts.
This study demonstrates that using motivational methods for online learning encourages students to engage in critical thinking and cognitive processing strategies in psychiatry and mental health care courses, even in two different settings.
Peer Review reports
COVID-19 has a global impact on education; learning has been disrupted in several institutions, most notably nursing colleges in Saudi Arabia and Egypt. Conventional in-person classes had to be suspended to maintain the welfare of all students, teaching faculty, and patients [ 1 , 2 ]. In response to the pandemic, more than 170 countries now rely on online learning [ 3 ]. As a result, the psychiatric nursing course has been taught virtually at Imam Abdulrahman and Alexandria University. In psychiatric nursing curricula, nurses must be able to think critically to carry out complex nursing actions that affect patient safety and satisfaction [ 4 ].
The pandemic context prompts nursing students to address different approaches to learning strategies used by educational institutions to take full advantage of the learning experience by getting students involved in this new virtual learning setting [ 5 ]. Critical thinking is “the act of formulating a reflective judgment about what to believe or what is the priority action based on specific situations” [ 6 ]. It’s crucial to be mastered by nursing students [ 7 , 8 ].
In the literature, critical thinking (CT) can be traced back to 1965 in nursing education, but it became more prominent in the 1980s as researchers endeavored to understand CT in nursing education. The use of CT during online nursing education was closely investigated in the 1990s as a result of the development of online modes, such as electronic learning systems and online audiovisual programs, which allowed students and teachers to interact as if they were in a real-world setting [ 9 , 10 ]. CT is the method of self-regulatory decision-making with intent [ 11 ]. Interactive interpretation, presumption, analysis, and assessment are rationally regarded as part of the logical thinking process [ 11 ]. People are directed to make centering and informed decisions based on their beliefs using this approach [ 11 , 12 ]. The foundation of professional judgment is known as CT [ 13 ]. For nurses to correctly assess nursing diagnoses, CT skills are necessary because accurate analysis of patient data can be difficult. After all, high levels of thinking and intellect are needed; the thinking skills of nurses differ and can be enhanced, and the best use of CT abilities encourages the validity of the diagnosis based on the evidence used in research [ 14 ]. Several studies reported the importance of the use of critical thinking in psychiatric and mental health nursing [ 15 , 16 ]. For example, the use of well-designed simulations in psychiatric and mental health nursing education was found to enhance students’ critical thinking, decision-making, and communication skills [ 17 ]. Therefore, this study will enhance the previous studies regarding the importance of the use of critical thinking during online education.
Online learning refers to using cyberspace to reach educational resources and interact with the content, teachers, and other pupils. It helps students and instructors interact during the learning session to obtain information and build personal meaning [ 18 ]. Nurse educators play a vital role in identifying and implementing learning modifications in acquiring CT, besides focusing on innovative methods of teaching [ 19 ]. Since 2013, CT research focusing on the use of online education for psychiatric nursing has been infrequent and vague, as some studies focus on online education while others use blended methods with little evidence of their effectiveness [ 20 , 21 ]. Even though there have been several systematic reviews on CT in the field of nursing studies, only a tiny number have focused on the concepts and approaches for instructors to improve online technology utilization [ 19 ]. Furthermore, it has been reported that there needs to be more research on the predictors of CT, not only in online nursing education but also in nursing education in general [ 22 ].
The academic motivation was identified as an inherent and persistent desire of the learner to investigate new concepts [ 23 ]. There are three domains of academic motivation which are intrinsic and extrinsic motivation and lack of motivation which has been proven related to self-learning of students [ 24 , 25 , 26 ]. In nursing students, academic motivation has been studied and showed that motivational strategies are the most important elements that enhance student self-learning skills [ 27 , 28 ]. However, no published research was found to focus on the motivation strategies in psychiatric and mental health nursing during online teaching, so, this research will help to fill in the gap in this regard.
Strategies of online learning in form of self-directed learning skills and motivational approaches were used widely and proved to be effective. The use of self-directed strategies was established to enhance students learning autonomy to meet any changes in learning setting [ 29 ]. This strategy of learning enhances students’ thinking ability and self-management which was used during online education [ 30 , 31 ]. For instance, during the COVID-19 epidemic, self-directed learning, and motivational learning strategies among 1187 nursing students from Saudi Arabia, the Philippines, and Thailand were examined and found that the predictors of nursing students’ self-learning were the intrinsic motivation [ 32 ].
Critical thinking is essential in clinical nursing and a core part of an online nursing education program because it can help students learn more than traditional classroom teaching can [ 33 , 34 ]. According to Salyers et al. (2014), students are looking for ways to better incorporate technology into education as they become more technologically savvy [ 35 ]. According to Guri-Rosenblit, (2014), several online technologies used to aid the development of higher-order thinking skills in nursing education are used primarily to provide lectures and discussion groups rather than as the primary educational medium that would enhance CT [ 36 ]. It is worth noting that student’s perception of constructivist learning environments was related to critical thinking self-management strategies [ 37 ].
Researchers indicated that CT develops through the learning process, but the link between CT and online learning in nursing does not have sufficient evidence [ 33 , 38 ]. While the literature agreed that CT could occur in an online environment, more current research on the outcomes of online learning as they relate to the CT process is needed, as this has implications for its future use in nursing education [ 20 , 21 ]. However, it has been reported that the traditional educational approach impedes the development of CT skills, such as classroom teaching and the instructor-student power dynamic [ 19 ]. On the other hand, Gould et al. (2014) recommended that nursing online education and learning have definitely improved students’ learning and ability to gain CT and nursing competency, in addition to improving student satisfaction concerning accessibility and the capability to work remotely [ 39 ]. Lahti et al. (2014) also revealed that e-learning might help students gain knowledge and skills more quickly than face-to-face, teacher-centered methods [ 40 ].
The flexibility of online education for students and instructors has been studied. The positive aspect of learning has been reported as it provides flexibility in the use of different educational strategies, time, duration, and space conveniences, quick access for both instructors and students, and enhances the profound learning experience [ 35 , 41 , 42 ]. In addition, online learning stimulates student-centered learning, as the student manages online courses efficiently, which improves knowledge gain; self-efficacy, enhances performance, fosters CT, and enhances writing skills for the majority of students [ 43 , 44 ].
As a result of the coronavirus pandemic (COVID-19), governments released decrees on quarantine, social distancing, and staying at home; therefore, colleges and universities worldwide were closed [ 45 ]. COVID-19 has imposed education schemes worldwide to use alternatives for teaching and learning [ 46 ]. As a result, during the extraordinary COVID-19 outbreak, online distance learning programs were the only available mode of education [ 47 , 48 , 49 ]. Therefore, IAU, Alexandria University, and its College of Nursing have been involved in developing dynamic and contemporary online clinical curricula by applying CT and solving clinical problems.
In Saudi Arabia and Egypt, online modalities in clinical and mental health nursing are still relatively new. Since then, no research has been done on the usefulness of learning approaches for improving CT abilities that aid student’ professional problem-solving abilities [ 50 , 51 ]. As a result, this study aims to evaluate students’ attitudes toward critical thinking, motivation, and learning strategies in online psychiatric and mental health nursing education at Imam Abdulrahman Bin Faisal University in Saudi Arabia and Alexandria University in Egypt.
Study design and setting
A comparative cross-sectional research design was conducted among nursing students registered to take the Psychiatric Nursing and Mental Health course between Imam Abdulrahman Bin Faisal University (IAU) in Saudi Arabia and Alexandria University in Egypt. All nursing students were registered in the Psychiatric Nursing and Mental Health course for 2021–2022. The Psychiatric Nursing and Mental Health course was taught through 6 credit hours (3 h theatrical and 3 h clinical) in both universities. Both universities taught the same course description based on the same National Academic Reference Standard (NARS), with the primary focus being the integration of knowledge and skills to provide high-quality nursing management to clients with emotional and psychiatric problems in various healthcare settings. Clients with various mental disorders and their families will receive high-quality, secure home health care. Emphasis will be placed on the fundamental understanding of the mental illness concept, mental disorder classification, clinical illustrations, critical thinking, and treatment options. The course covers ideas about the nursing process, which serve as a framework for the psychiatric nursing care plan. Additionally, the course aims to assist students in promoting mental health, recognizing and preventing mental illness, and participating in mental health restoration [ 52 , 53 ].
Participants: sample size calculation and sampling technique
Based on data from literature Charan, & Biswas, )2013) [ 54 ], considering level of significance of 5%, and power of study of 80%, and based on data from literature, the sample size can be calculated using the following formula:
Where, Z 1-α/2 = is the standard normal variate, at 5% type 1 error it is 1.96, SD = standard deviation of variable and d = absolute error or precision. So,
Based on the above formula, the sample size required for the study is 180.
All participants were chosen conveniently. A total of 75 Saudi undergraduate students responded out of 115 with a response rate of 65.2%, and 105 Egyptian undergraduate students responded out of 140 with a response rate of 75% (Fig. 1 ) . Finally, 180 nursing students representing two distinct countries and universities (IAU) in Saudi Arabia and Alexandria University in Egypt produced sufficiently detailed responses to be included in the study. The Psychiatric and Mental Health Nursing course was taught in English. The following criteria were used to determine the inclusion of the studied subject: Enrolled in psychiatric and mental health nursing at both IAU and Alexandria Universities in the second semester of the academic year 2021–2022 and willing to be involved in the study.
Participants’ Recruitment Process Flow Chart
The researchers used a three-section-based questionnaire for data collection. Part 1 includes the socio-demographic data which includes the following questions: gender, marital status, age, university, which nursing course the student is studying, current GPA, hours of study, and if the student was transferred from another college or university ( supplementary file ).
Part 2 includes Critical thinking motivation scale and The Cognitive Processing Strategies Scale
Critical thinking motivation scale (ctms) (english version).
It was developed by Valenzuela et al., 2011. The scale is based on a theoretical option that gives the perspective of motives primacy over the perspective of attitudes, with the aim of acquiring insight into students’ motivation levels and determining the specific component that influences their performance. [ 55 ]. CTMS measures the different components of motivation with respect to critical thinking. This scale contains 19 items on a 6-point Likert scale that allow participants to express their level of agreement or disagreement with a set of statements relating to each participant’s expectations of thinking in a critical or rigorous manner (expectation) and the importance (value) of thinking in this manner. The rest of the statements are about the value and utility (utility) they notice in thinking, the cost they are willing to take for thinking in that way thoroughly, and the interest this method of thinking arouses in them. The reliability for the scale is 0.77, and the validity has shown a significant correlation (r = 0.50–0.57) between motivation and critical thinking [ 55 ]. The Cronbach’s alpha reliability estimate in the present study was 0.912.
The cognitive Processing Strategies Scale (CPSS) (English version)
It was a modified version of the Motivated Strategies for Learning Questionnaire (MSLQ) of Pintrich’s instrument. Pintrich et al. (1991) proposed five sub-scales (i.e., rehearsal (REH), elaboration (ELA), organization (ORG), critical thinking (CT), and metacognitive self-regulation (MSR); it had 31 items, each item on a seven-point Likert scale [ 56 ]. Compared with the original MSLQ, the 18-item Cognitive Processing Strategies Scale modified by Professor Jiling Liu in 2019 has a different aim: to improve equivalence and efficiency in measuring cognitive and motivational learning processes by using more cost-effective analytical procedures and minimizing the number of tests taken. The scale has 18 items on a 7-point Likert-type scale with scores ranging from 1 to 7, and the statement “When I study for this class, I practice saying the materials to myself over and over” has a score of 1 for not at all true of me and a score of 7 for very true of me. The modified scale of the Cognitive Processing Strategies Scale (CPSS) proposed five sub-scales like the original one: rehearsal (REH), represented by 2 items; elaboration (ELA), represented by 7 items; organization (ORG), represented by 2 items; critical thinking (CT), represented by 6 items; and general cognitive strategies (GCS), represented by 13 items. A lot of items had bi-factor and tri-factor categories in the subscales. The scale’s validity is 0.892, and the reliability is 0.825 [ 57 ]. In addition, Cronbach’s alpha reliability estimate in the present study was 0.892.
This study was approved by institution review board of Imam Abdulrahman Bin Faisal University (IAU) research Ethical Committee for the study settings to gather the necessary data (11/2022). The study’s goal was communicated to the participating nursing students through their official emails. Every student was informed that they had the right to decline participation or quit at any time before finishing the study materials without repercussions. Nursing students who agreed to participate in the study provided electronic, signed, informed consent. The concept of anonymity was honored. During the study, data privacy was guaranteed.
Data collection phase
Official permissions from the faculty of nursing IAU and Alexandria University were obtained to conduct the study. A list of the official emails of all enrolled nursing students at the psychiatric and mental health nursing course from the registration desk was obtained. The questionnaire link was sent individually to every student official university emails. It was worse mentioned that the email of nursing students was linked with national identifier.The nursing students who clicked the link were directed to the Microsoft Office Forms. To minimize the missing data, the participants were requested to fill in all items in the online questionnaire or else they could not proceed to the next page; a notification box indicated a warning note that one or more items were not answered. On completion of the questionnaire, the participant was directed to click the submit option, and finally, the online questionnaire was sent to the drive.
A pilot study was conducted to evaluate the applicability, clarity, and usefulness of the study tools. The test was administered to 30 nursing students who were not research participants. The results of the pilot showed that no modifications were required. The Alpha Cronbach’s test, which was used to evaluate the internal consistency of the research instruments, indicated that the study tools had excellent reliability. Moreover, the information was gathered at the end of semester 2021/2022.
Psychiatric and mental health nursing courses are offered in an online education mode even after the era of COVID-19.The online education modality was formed in both universities on the Blackboard platform, Zoom, and Microsoft Teams, where academic materials and assignments were posted and class activities could be completed. Reference, guidance, and effective communication were available to students. The online course content was given weekly and had the same objectives and outline as the traditional face-to-face content, but the delivery mode was different. Before starting the course, the course coordinators prepared the time plan, the schedule of theory lectures, and all teaching materials and posted them on the blackboard. First, each rotation’s objectives, time plan, and rubrics were posted on the board as a pdf file to give the students holistic information about the rotation. Secondly, the theory lecture schedule list was posted to the platform as a PDF document. Finally, all lectures were uploaded as PowerPoint files, with assignments for each lecture, videos, and references.
Comparing the socio-demographic features of the students at IAU University and Alexandria University necessitated the analysis of demographic data using the percent (%) and chi test. The statistical analysis was conducted using SPSS V.24 (IBM Corp., Armonk, NY). To accurately describe the data, descriptive statistics revealed that the average values of continuous variables produced the correct results. Furthermore, the Critical Thinking Motivational Subdomains Scale was compared using the mean and standard deviation. The correlation coefficient was employed to compare the critical thinking motivating scale with the student assessments of the cognitive processing techniques scale. Moreover, the T- and ANOVA tests were utilized to demonstrate the connection between the students’ socio-demographic characteristics and the Critical Thinking Motivational Domains subscale. The dependability of the scale was assessed using an internal consistency and reliability test.
Table 1 shows the comparison of the socio-demographic characteristics of the students at IAU and Alexandria University: Of the 180 students surveyed, 75 were from IAU and 105 were from Alexandria University. The age range of the participants was 20 to 23 years. (69.3% and 81.0%) of IAU and Alexandria students were female, respectively. The majority of them (85.3 and 90.5%) were not married. As for GPA, (78.7%) obtained a 3.6–4.5 from IAU students, while (87.6%) of students obtained a 3.6 or less from Alexandria University. Approximately half (50.7% and 53.3%) of students reported studying 3–4 h a day. And most of them have not transferred from another university or college to the faculty of nursing. In terms of age and GPA, there is a significant difference between students at IAU University and Alexandria University (p = < 0.001**).
Test of normality
Table 2 shows the normality test of the critical thinking motivational scale and student perception of the cognitive processing strategies scale. The table revealed that the test of normality by Shapiro-Wilk value was insignificant, which reflects that it is reasonable to behave as if the data set is (sufficiently close to being) normally distributed.
Comparison of the critical thinking motivational scale domains
Table 3 compares the averages of the Critical Thinking Motivational Scale domains. According to the data in Table 2 , the mean IAU score in the expectancy and cost domains is (4.2) and (4.6), respectively, higher than the mean score of Alexandria University (4.0) and (4.5). However, these differences don’t reach a statistically significant level. It also appears from the table’s data that the mean IAU score according to attainment domain, utility domain, and interest domain (5.1), (5.2), and (5.1) is less than the mean score among Alexandria University (5.2), (5.4), and (5.2). However, these differences don’t reach a statistically significant level.
Comparison of the student perceptions about cognitive processing strategies
The results of the T-test from Table 4 show the number and distribution of student perceptions about cognitive processing strategies between IAU and Alexandria University. In the IAU, the mean total score of items was (92.1 ± 22.5). It is less than the mean total score of items at Alexandria University (94.1 ± 18.5), and the result of the t-test (0.636) came with a probability value of (0.526) more significant than the significance level (0.05), and accordingly, there are no significant differences.
Correlations among critical thinking motivational scale score and the student perception of cognitive processing strategies, Imam Abdulrahman bin Faisal University
As shown in Fig. 2 , the Critical Thinking Motivational Scale Score is significantly correlated with the student perception of cognitive processing strategies as measured by the correlation coefficient (0.597) at the significance level of < 0.001. This correlation suggests that students with higher levels of critical thinking motivation are more likely to perceive that they use cognitive processing strategies when studying.
Correlation between Critical thinking motivational scale and student perceptions about Cognitive processing strategies faculty of nursing, Imam Abdulrahman bin Faisal University
Correlations among critical thinking motivational scale score and the student perception of cognitive processing strategies, Alexandria University
It is clear from Fig. 3 that there is a positive correlation between the critical thinking motivational scale and student perceptions of cognitive processing strategies, scaling the Alexandria University correlation coefficient function value (0.513) to a significance level of < 0.001. This suggests that when students perceive themselves to be more motivated to engage in critical thinking, they are more likely to use effective cognitive processing strategies.
Correlation between Critical thinking motivational scale and student perceptions about Cognitive processing strategies faculty of nursing, Alexandria University
Relationships between socio-demographic characteristics of the students and student perceptions about cognitive processing strategies Scale, IAU and Alexandria University
T-Test and ANOVA results from Table 5 revealed an association between IAU students that how many hours a day do you spend studying and Critical Thinking Motivational Scale Domains Average (6.027, p = < 0.001). Specifically, the results showed that IAU students who are spent more hours studying, they had a higher average on the Critical Thinking Motivational Scale Domains.
Relationships between socio-demographic characteristics of the students and critical thinking motivational scale domains average, IAU and Alexandria University
T-test and ANOVA result from Table 6 revealed an association between the Alexandria University students transferring from another university or college into the nursing program and their perceptions of the Cognitive Processing Strategies Scale (2.130, p = 0.036). These results indicate that students’ transfers from another university or college to the nursing program affect their perceptions of cognitive processing approaches.
A nurse’s competency involves various components, such as academic concepts, professional judgment, a combination of skills, moral and ethical values, and the synthesis of all elements to define holism [ 23 ]. Educating students on thinking critically has become a crucial issue in today’s environment and has been represented as one of the core educational goals. Competence-based learning allows the incorporation of functionalist, behaviorist, and constructivist learning theories. Constructivist curricula attempt to allow students to learn new knowledge using their mental processes and in light of their previous learning experiences. As a result, students are expected to acquire questioning and thinking skills while learning [ 58 ]. Coronavirus (COVID-19) has caused chaos in educational systems worldwide. It resulted in a succession of pedagogical reforms that presented both opportunities and risks to educational quality [ 59 ]. So the present study aimed to assess students’ perceptions about critical thinking as well as the impact on motivation and learning strategies in the online psychiatric and mental health nursing program among Egyptian and Saudi undergraduates.
It can be noticed that both Egyptian and Saudi undergraduates displayed high mean scores in different subdomains of critical thinking motivation. The evidence suggests that students’ perceptions of critical thinking motivation were similar in the two cultures. It includes the expectations that all participants have about critical thinking (expectancy), the value of this skill (attainment), the benefit of using that skill (utility), how much I care and love to use that skill (interest), and their willingness to put time and effort into using that skill (cost domain). Furthermore, comparing both studied subjects revealed no statistically significant difference between them. This may be because teaching a psychiatric and mental health nursing course heavily depends on simulating reality by using different vignettes and case studies and urging students to discuss and interact by reflecting on their learning experiences and giving narrative feedback. Thus, this increased the students’ level of critical thinking, even if teaching was done online [ 60 ].
The same was reported by Guise et al., (2012), who indicated that the simulation type is well-suited to fostering critical thinking, communication, and decision-making skills in mental health nurses. It is also said that it is well-suited to e-learning and mixed-learning environments and is an excellent tool for multilingual simulations [ 61 ]. Similarly, it was found in different studies [ 62 , 63 ]. The expansion of online courses in universities, partly due to the COVID-19 epidemic, has created a new environment for learning, allowing students to complete course-related work at their leisure and in their preferred location. This new setting may be beneficial or troublesome, depending on students’ motivation and ability to self-regulate their learning [ 64 ]. With the current epidemic states of COVID-19 raising the need for online psychiatric and mental health nursing, IAU college professors have been charged with developing dynamic and contemporary online clinical curricula by applying critical thinking and solving clinical problems. The course coordinators have worked on increasing the interaction and engagement of students, even if it was online, by making a link between the goals and future expectations. The anticipation and management of emotions are considered critical elements of success in an educational system, and teachers emphasize the importance of adopting a new mode in an educational system. This may also be due to the opportunities given to students to construct different alternatives to stimulate the natural environment.
There is a strong relationship between research competencies, age, and nursing research course grades. Grande et al., 2021, used a CBE approach to investigate the predictors and associations of Saudi nursing students’ research competencies. The majority of nursing students were already familiar with the nursing research process. Nursing research competency was significantly predicted by age and nursing research course grades (A+/A). As a result, students with A + or A grades were three times more likely to be competent than those with lower grades. Similarly, nursing students over 20 are twice as likely as those under 20 to be competent in research [ 23 ].
The present study also revealed that students displayed a high mean score in different cognitive processing strategies, including when I study for this class, I repeat the materials to myself several times. I make lists of essential items for this class and memorize the lists. When I study for this class, I gather information from different sources, such as lectures, readings, and discussions. I relate the materials to what I already know when studying for this class. When I study for this class, I write brief summaries of the main ideas from the materials and my class notes. I try to understand this class’s materials by connecting the readings and the concepts from the lectures. I apply ideas from other class activities, such as lectures and discussions. I make simple charts, diagrams, or tables to help me organize class materials. When I study for this class, I review my class notes and outline essential concepts. I often question things I hear or read in this class to decide if I find them convincing.
Furthermore, they reflect the use of cognitive processing strategies concerning a theory or conclusion when presented in class or in the readings, making decisions with supporting evidence, developing their own ideas, and so on. Fajari, (2020) studied students’ critical thinking abilities and the impact of learning motivation on critical thinking skills [ 65 ]. The findings of this study revealed that learning motivation has an impact on critical thinking abilities. Students’ critical thinking skills improve as their motivation to learn increases.
The modes of learning and instructing have a direct impact on each other. Three distinct learning styles affect learners’ cognitive information in eight aspects: the alignment of learners’ liberal and conservative values. Loyens, Rikers, & Schmidt, (2008) examined the relationship between students’ conceptions of constructivist learning and their regulation and processing strategies. They examined the relationship between students’ perceptions of constructivist learning and their regulation and processing strategies [ 66 ]. The findings revealed that constructivist learning and regulations, as well as processing techniques, have structural relationships. Furthermore, students who are unsure of their learning abilities are more likely to select an ineffective regulating strategy.
Generally, the present study finding may be explained by several aspects, including the students’ accustomedness to this system in teaching since the occurrence of the Corona pandemic, or it may be attributed to the efficiency of the performance of faculty members in the online teaching classroom management, having gone through the actual experience. This is in addition to the work of universities to develop the capabilities of faculty, staff, and students in managing the new requirement, not only because of the pandemic but also because this is in line with the needs of the new labor market requirement. In closing, combining online learning with a motivational approach to students will encourage participants to actively engage in critical thinking and cognitive processing processes.
This study found that using a motivating method for online learning inspired students to engage in critical thinking and cognitive processing strategies in a psychiatric and mental health nursing course, even in two different contexts.
Limitations of the study
The sample of this study was limited in number because it was obtained from nursing students in specific nursing colleges at Imam Abdulrahman Bin Faisal University in Saudi Arabia and Alexandria University in Egypt who undertook a specific psychiatric and mental health nursing course. The results obtained from this study may not apply to students studying different online nursing courses. Furthermore, this quantitative study does not help us better understand students` perceptions of critical thinking, motivation, and learning strategies in online psychiatric and mental health nursing education. In the future, it can be further improved by adding qualitative research.
The recommendations for future study should broaden the subject by including more areas, more significant samples, and additional baccalaureate nursing programs. In addition, more investigation is required into how online learning experiences are perceived by both learners and educators and how this impacts how higher-level reasoning is developed in psychiatric nursing students. Several evaluations throughout the four-year nursing curriculum and the retention of critical thinking data by individual students would enable the monitoring of longitudinal developmental trends, individually and collectively, by class, gender, or any other crucial student factors.
Implication in nursing practices
This research was one of the few distinctive areas of psychiatric nursing education. Because there is a lack of broad agreement about the progress and assessment of students’ perceptions of critical thinking and motivation learning strategies in this course because there are no evidence-based best practices for online learning, conventional ways of teaching psychiatric nursing have persisted, possibly failing to meet the demands of today’s technologically aware psychiatric nursing students in the future. Additionally, there is a need for a more recent study on online learning’s efficacy regarding the growth of critical thinking abilities and motivation through the use of online modalities in different nursing courses.
The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.
Alqahtani N, Innab A, Bahari G. Virtual education during COVID-19: Exploring factors associated with e-learning satisfaction among Saudi nursing students. Nurse educator. 2021 Mar 1;46(2):E18-22. https://doi.org/10.1097/NNE.0000000000000954
Diab GM, Elgahsh NF. E-learning during COVID-19 pandemic: Obstacles faced nursing students and its effect on their attitudes while applying it.American Journal of Nursing. 2020 Aug17; 9(4):300–14. https://doi.org/10.11648/j.ajns.20200904.33
Wang S, Du M, Yu R, Wang Z, Sun J, Wang L. Exploration of the multiple impact of learning styles on learners’ cognitive information processing.Interactive Learning Environments. 2020 Dec16:1–6. https://doi.org/10.1080/10494820.2020.1855205
Naber JL, Hall J, Schadler CM. Narrative thematic analysis of baccalaureate nursing students’ reflections: critical thinking in the clinical education context.Journal of Nursing Education. 2014 Sep1; 53(9):S90-6. https://doi.org/10.3928/01484834-20140806-06
Brown M, McCormack M, Reeves J, Brook DC, Grajek S, Alexander B, Bali M, Bulger S, Dark S, Engelbert N, Gannon K. 2020 educause horizon report teaching and learning edition. Educause; 2020. https://www.learntechlib.org/p/215670/ .
Facione PA, Crossetti M, Riegel F. Holistic critical thinking in the nursing diagnostic process. Pensamento Crítico Holístico no Processo Diagnóstico de Enfermagem. Revista gaucha de enfermagem. 2017;38(3):e75576. https://doi.org/10.1590/1983-1447.2017.03.75576 .
Article PubMed Google Scholar
Moore ZE. Critical thinking and the evidence-based practice of sport psychology. J Clin Sport Psychol. 2007;1:9–22. https://doi.org/10.1123/jcsp.1.1.9 .
Article Google Scholar
Gonzalez HC, Hsiao EL, Dees DC, Noviello SR, Gerber BL. Promoting critical thinking through an evidence-based skills fair intervention.Journal of Research in Innovative Teaching & Learning. 2020 Nov 23. https://doi.org/10.1108/JRIT-08-2020-0041
Lewis ML, Kaas MJ. Challenges of teaching graduate psychiatric-mental health nursing with distance education technologies. Archives of psychiatric nursing.1998 Aug1; 12(4):227–33. https://doi.org/10.1016/S0883-9417(98)80028-9
Mallow GE, Gilje F. Technology-based nursing education: Overview and call for further dialogue.Journal of Nursing Education. 1999 Sep1; 38(6):248–51. https://doi.org/10.3928/0148-4834-19990901-04
Profetto-McGrath J, Smith KB, Hugo K, Patel A, Dussault B. Nurse educators’ critical thinking dispositions and research utilization. Nurse Educ Pract. 2009;9(3):199–208. https://doi.org/10.1016/j.nepr.2008.06.003 .
Facione NC, Facione PA. Critical thinking and clinical judgment. Critical thinking and clinical reasoning in the health sciences: A teaching anthology. 2008; 2008:1–3. ISBN: 1-891557-60-2
Facione PA. Critical thinking: What it is and why it counts. Insight assessment. 2015 Jun; 2007(1):1–23. https://www.academia.edu/download/71022740/what_why98.pdf
Lunney M. Critical thinking and accuracy of nurses’ diagnoses. Int J Nurs Terminologies Classifications. 2003;14(3):96–107.
Park HR, Park E. Nursing students’ perception of class immersion facilitators in psychiatric nursing: Team-based learning combined with flipped learning. Nurse Educ Today. 2021 Mar;1:98104653. https://doi.org/10.1016/j.nedt.2020.104653 .
Hwang B, Choi H, Kim S, Kim S, Ko H, Kim J. Facilitating student learning with critical reflective journaling in psychiatric mental health nursing clinical education: A qualitative study. Nurse education today.2018 Oct1; 69:159 – 64. https://doi.org/10.1016/j.nedt.2018.07.015
Guise V, Chambers M, Välimäki M. What can virtual patient simulation offer mental health nursing education? Journal of psychiatric and mental health nursing. 2012 Jun; 19(5):410–8. https://doi.org/10.1111/j.1365-2850.2011.01797.x
Coman C, Țîru LG, Meseșan-Schmitz L, Stanciu C, Bularca MC. Online Teaching and Learning in Higher Education during the Coronavirus Pandemic: students’ perspective. Sustainability. 2020;12(24):10367. https://doi.org/10.3390/su122410367 .
Chan Z. A systematic review of critical thinking in nursing education. Nurse Educ Today. 2013;33:236–40. https://doi.org/10.1016/j.nedt.2013.01.007 .
Carter LM, Hanna M, Warry W. Perceptions of the impact of online learning as a distance-based learning model on the professional practices of working nurses in Northern Ontario. Can J Learn Technol. 2016;42(3). https://doi.org/10.21432/t2q90m .
McCutcheon K, Lohan M, Traynor M, Martin D. A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education. J Adv Nurs. 2015;71(2):255–70. https://doi.org/10.1111/jan.12509 .
Costello E, Corcoran M, Barnett JS, Birkmeier M, Cohn R, Ekmekci O, Walker B. Information and communication technology to facilitate learning for students in the health professions: current uses, gaps and future directions. Online Learn J. 2014;18(4):1–18. https://doi.org/10.24059/olj.v18i4.512 .
Grande RA, Berdida DJ, Susanto T, Khan A, Waelveerakup W, Saad Z. Nursing competency inventory and professional competence of graduating students in six Asian countries: A cross-sectional study.Nurse Education Today. 2022 Sep1;116:105470. https://doi.org/10.1016/j.nedt.2022.105470
Saeid N, Eslaminejad T. Relationship between student’s self-directed learning readiness and academic self‐efficacy and achievement motivation in students. Int Educ Stud. 2017;10(1):225–32. https://eric.ed.gov/?id=EJ1124824 .
Heo J, Han S. Effects of motivation, academic stress and age in predicting self-directed learning readiness (SDLR): focused on online college students. Educ Inf Technol. 2018;23(1):61–71. https://doi.org/10.1007/s10639-017-9585-2 .
Adib M, Ghiyasvandian S, Varaei S, Roushan ZA. Relationship between academic motivation and self-directed learning in nursing students. J Pharm Res Int. 2019;30(5):1–9. https://doi.org/10.9734/jpri/2019/v30i530281 .
Karabenick S, Urdan TC, editors. Decade ahead: theoretical perspectives on motivation and achievement. Emerald Group Publishing; 2010.
Schunk DH, Meece JR, Pintrich PR. Motivation in education: theory, research, and applications. Pearson Higher Education; 2012.
Knowles M. Self-directed learning: a guide for learners and teachers. Group Organ Manag. 1977;2(2):256–7. https://doi.org/10.1177/105960117700200220 .
Deniz Kocoglu R, et al. Problem solving training for first line nurse managers. Int J Caring Sci. 2016;9(3):955.
Mahoney C, Brady L, Guisinger D, Abram R, Lane R, Graham-Pole J. Implementing an ‘arts in nursing ‘program on a medical-surgical unit. Medsurg Nurs. 2011 Sep;1(5):273–4.
Grande RA, Berdida DJ, Cruz JP, Cometa-Manalo RJ, Balace AB, Ramirez SH. Academic motivation and self‐directed learning readiness of nursing students during the COVID‐19 pandemic in three countries: a cross‐sectional study. InNursing Forum. 2022;57(3):382–92. https://doi.org/10.1111/nuf.12698 .
Lee M, Kim H, Kim M. The effects of socratic questioning on critical thinking in web-based collaborative learning. Educ as Change. 2014;18(2):285–302. https://doi.org/10.1080/16823206.2013.849576 .
Nussbaum M, Barahona C, Rodriguez F, Guentulle V, Lopez F, Vazquez-Uscanga E, Cabezas V. Taking critical thinking, creativity and grit online. Education Tech Research Dev. 2021 Feb;69(1):201–6. https://doi.org/10.1007/s11423-020-09867-1 .
Salyers V, Carter L, Carter A, Myers S, Barrett P. The search for meaningful e-learning at canadian universities: a multi-institutional research study. Int Rev Res Open Distance Learn. 2014;15(6):313–37. https://doi.org/10.19173/irrodl.v15i6.1713 .
Guri-Rosenblit S. Distance education systems and institutions in the online era: An identity crisis. Online distance education: Towards a research agenda. 2014:109 – 30.
Dökmecioğlu B, Tas Y, Yerdelen S. Predicting students’ critical thinking dispositions in science through their perceptions of constructivist learning environments and metacognitive self-regulation strategies: a mediation analysis.Educational Studies. 2022 Nov2; 48(6):809–26. https://doi.org/10.1080/03055698.2020.1833838
Andreou C, Papastravrou E, Merkouris A. Learning styles and critical thinking relationship in baccalaureate nursing education: a systemic review. Nurse Educ Today. 2014;34:362–71. https://doi.org/10.1016/j.nedt.2013.06.004 .
Gould D, Papadopoulos I, Kelly D. Tutors’ opinions of online learning programs in continuing professional development for midwives. Nurse Educ Today. 2014;34:613–8. https://doi.org/10.1016/j.ijnurstu.2012.12.017 .
Lahti M, Hätönen H, Välimäki M. Impact of e-learning on nurses’ and student nurses knowledge, skills, and satisfaction: a systematic review and meta-analysis.International journal of nursing studies. 2014 Jan1; 51(1):136–49. https://doi.org/10.1016/j.ijnurstu.2012.12.017
Bozkurt A, Sharma RC. Education in normal, new normal and next normal: Observations from the past, insights from the present and projections for the future.Asian Journal of Distance Education. 2020 Dec20; 15(2):i-x. https://doi.org/10.5281/zenodo.4362664
Dhawan S. Online learning: A panacea in the time of COVID-19 crisis.Journal of educational technology systems. 2020 Sep; 49(1):5–22. https://doi.org/10.1177/0047239520934018
Mukhtar K, Javed K, Arooj M, Sethi A, Advantages. Limitations and Recommendations for online learning during COVID-19 pandemic era. Pakistan journal of medical sciences. 2020 May; 36(COVID19-S4):S27. https://doi.org/10.12669%2Fpjms.36.COVID19-S4.2785
Tannenbaum C, Van Hoof K. Effectiveness of online learning on health researcher capacity to appropriately integrate sex, gender, or both in grant proposals. Biology of sex differences. 2018 Dec; 9(1):1–8. https://doi.org/10.1186/s13293-018-0197-3
Rajab MH, Gazal AM, Alkattan K. Challenges to online medical education during the COVID-19 pandemic.Cureus. 2020 Jul2; 12(7). https://doi.org/10.7759/cureus.8966
Manca F, Meluzzi F. Strengthening online learning when schools are closed: The role of families and teachers in supporting students during the COVID-19 crisis. 2020. Available online: http://www.oecd.org/coronavirus/policyresponses/strengthening-online-learning-when-schools-are-closed-the-role-of-families-and-teachers-in-supporting-studentsduring-the-covid-19-crisis-c4ecba6c/
Mahdy MAA. The impact of COVID-19 pandemic on the academic performance of Veterinary Medical Students. Front veterinary Sci. 2020;7:59: 42–61. https://doi.org/10.3389/fvets.2020.594261 .
Son C, Hegde S, Smith A, Wang X, Sasangohar F. Effects of COVID-19 on college students’ mental health in the United States: Interview survey study.Journal of medical internet research. 2020 Sep3; 22(9):e21279. https://doi.org/10.2196/21279
Shawaqfeh MS, Al Bekairy AM, Al-Azayzih A, Alkatheri AA, Qandil AM, Obaidat AA, Al Harbi S, Muflih SM. Pharmacy students perceptions of their distance online learning experience during the COVID-19 pandemic: a Cross-Sectional Survey Study. Journal of medical education and curricular development. 2020 Oct; 7. https://doi.org/10.1177/2382120520963039
Carter AG, Creedy DK, Sidebotham M. Critical thinking evaluation in reflective writing: Development and testing of Carter Assessment of Critical Thinking in Midwifery (Reflection).Midwifery. 2017 Nov1; 54:73–80. https://doi.org/10.1016/j.midw.2017.08.003
Radu MC, Schnakovszky C, Herghelegiu E, Ciubotariu VA, Cristea I. The impact of the COVID-19 pandemic on the quality of educational process: A student survey.International Journal of Environmental Research and Public Health. 2020 Jan; 17(21):7770. https://doi.org/10.3390/ijerph17217770
Charan J, Biswas T. How to calculate sample size for different study designs in medical research? Indian J Psychol Med. 2013 Apr;35(2):121–6. https://doi.org/10.4103/0253-7176.116232 .
Valenzuela J, Nieto AM, Saiz C. Critical thinking motivational scale: a contribution to the study of relationship between critical thinking and motivation. Electron J Res Educational Psychol. 2011;9(2):823–48. https://doi.org/10.25115/ejrep.v9i24.1475 .
Pintrich PR, Smith DAF, Garcia TD, McKeachie WJ. A manual for the use of the Motivated Strategies for Learning Questionnaire (MSLQ). University of Michigan, National Center for Research to Improve Postsecondary Teaching and Learning. 1991. https://eric.ed.gov/?id=ED338122 .
Liu J, Mcbride R, Chen H. Psychometric properties of the Cognitive and Metacognitive Learning Strategies Scales among preservice physical education teachers: A bifactor analysis. 2019; 25(3):616–639. https://doi.org/10.1177/1356336X18755087
Dökmecioğlu B, Tas Y, Yerdelen S. Predicting students’ critical thinking dispositions in science through their perceptions of constructivist learning environments and metacognitive self-regulation strategies: a mediation analysis. Educational Stud. 2020 Oct;21:1–8. https://doi.org/10.1080/03055698.2020.1833838 .
Avila EC, Abin GJ, Bien GA, Acasamoso DM, Arenque DD. Students’ Perception on Online and Distance Learning and their Motivation and Learning Strategies in using Educational Technologies during COVID-19 Pandemic. InJournal of Physics: Conference Series 2021 Jun 1 (Vol. 1933, No. 1, p. 012130). IOP Publishing. https://doi.org/10.1088/1742-6596/1933/1/012130
Al-Eraky MM, Mohamed N, Kamel F, Al-Qahtani A, Madini MA, Hussin A, Kamel NM. Teaching professionalism by Vignettes in Psychiatry for nursing students. Int J Adv Res. 2016;4:625–34.
Codeço A, Dias Coutinho VR, Pereira-Lopes O, Faria‐Almeida R, Santos Resende M. Assessing clinical simulation as a learning tool when training motivation skills in Periodontology—Students’ perceptions.European Journal of Dental Education. 2020Nov; 24(4):644–9. https://doi.org/10.1111/eje.12544
Zafar S, Lai Y, Sexton C, Siddiqi A. Virtual reality as a novel educational tool in pre-clinical paediatric dentistry training: students’ perceptions. Int J Pediatr Dent. 2020;30(6):791–7. https://doi.org/10.1111/ipd.12648 .
Umarji O, McPartlan P, Moeller J, Li Q, Shaffer J, Eccles J. The motivational system of task values and anticipated emotions in daily academic behavior. Motivation and Emotion. 2021 Oct;45(5):599–616. https://doi.org/10.1007/s11031-021-09898-y .
Fajari LE. Student critical thinking skills and learning motivation in elementary students. In Journal of Physics: Conference Series. 2020; 1440(1):12104). IOP Publishing. https://doi.org/10.1088/1742-6596/1440/1/012104
Loyens SM, Rikers RM, Schmidt HG. Relationships between students’ conceptions of constructivist learning and their regulation and processing strategies. Instr Sci. 2008;36(5):445–62. https://doi.org/10.1007/s11251-008-9065-6 .
Our sincere thanks go to all participants of the study.
This research received no funds from the government, the corporate sector, or the non-profit sector.
Authors and affiliations.
Department of Community Nursing, College of Nursing, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
Nora Ghalib AlOtaibi, Amira Alshowkan, Neama Kamel & Nagla Saleh AlSaleh
Lecturer of Psychiatric and Mental Health Nursing, Faculty of nursing, Mansoura University, Mansoura, Egypt
Eman Sameh Abd Elhay
Lecturer of Psychiatric and Mental Health Nursing, Faculty of nursing, Alexandria University, Alexandria, Egypt
Ayman Mohamed El-Ashry
You can also search for this author in PubMed Google Scholar
Amira alshowkan: Conceptualization, preparation, methodology, investigation formal analysis, data curation, writing-original draft & writing-review. Neama Kamel: Conceptualization, methodology, investigation, writing-original draft, writing-review & editing. Eman Sameh Abd Elhay: Methodology, preparation and collecting data of the study, investigation, and data statistical analysis. Nora Ghalib AlOtaibi: Conceptualization, methodology, investigation, writing-original draft, writing-review & editing. Ayman Mohamed El-Ashry: Conceptualization, preparation and collecting data of the study, methodology, investigation & editing. Nagla Saleh AlSaleh: Conceptualization, preparation and collecting data of the study, methodology, investigation & editing. All authors approved the submitted and revised versions and agreed to be accountable for the final version.
Correspondence to Ayman Mohamed El-Ashry .
Ethics approval and consent to participate.
Every method was used in accordance with the relevant rules and regulations of the Declaration of Helsinki (DoH-Oct2008). The research was approved by Imam Abdulrahman Bin Faisal University Ethics Committee, Saudi Arabia ( Institutional Review Board = HAP-05-D-003/4/503/Approved 11/2022 ). An electronic informed written consent was obtained from nursing students who accepted to participate in the study. Students were given details about the anonymous online survey, including what it would entail and ethical considerations.
Consent for publication
The authors declare that there are no conflicts of interest.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Supplementary Material 1
Rights and permissions.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Reprints and Permissions
About this article
Cite this article.
AlOtaibi, N.G., Alshowkan, A., Kamel, N. et al. Assessing perceptions about critical thinking, motivation learning strategies in online psychiatric and mental health nursing education among Egyptian and Saudi undergraduate nursing students. BMC Nurs 22 , 112 (2023). https://doi.org/10.1186/s12912-023-01264-2
Received : 21 January 2023
Accepted : 23 March 2023
Published : 10 April 2023
DOI : https://doi.org/10.1186/s12912-023-01264-2
Share this article
Anyone you share the following link with will be able to read this content:
Sorry, a shareable link is not currently available for this article.
Provided by the Springer Nature SharedIt content-sharing initiative
- Critical thinking
- Motivation learning strategies
- Online psychiatric
- Mental health nursing
What are the 6 Attitudes that Every Nurse Must Possess in Order to Clinically Reason?
- How well do you understand the rationale and reason for nursing care priorities with each patient you care for?
- Do you have a clearly defined outcome that you are working towards with each patient you care for?
This is an essential skill that is foundational to both clinical reasoning as well as making a correct clinical judgment. Everything that nurse does in practice, must also be reflected upon by the nurse and determine if the actions and interventions are effective and working towards the outcome that is needed to advance the plan of care.
Christine Tanner and her work on clinical judgment also identified the importance of reflection. Reflection-in-action as well as reflection-on-action.
Clinical reasoning is strengthened and developed when the nurse is able to reflect on past and current clinical experiences and situations and be intentional to ask WHY you are engaging and choosing specific nursing interventions in the present as well as reflecting afterwards.
Stated another way, reflection is thinking about your thinking and determining what can be learned, affirmed, or done differently to grow and develop as a nurse.
- How well are you able to integrate reflection and learn as a result while you are caring for patients?
The nurse must be eager and ask questions and acquire needed information and knowledge. The origin of curiosity is “cura,” which means to care. Reflection and curiosity are a perfect fit and need to be used together. Nursing is curiosity or care with a purpose.
When the nurse is inquisitive about everything that takes place in the clinical setting including the ways that the patient acts, thinks, and presents, the less judgmental the nurse will be. The greater the level of curiosity, the more compassion the nurse will possess.
- Do you have a strong desire to deeply understand aspects of your patient that you do not understand?
4. Tolerance for ambiguity
This is the ability of the nurse to feel comfortable even when the current situation is unclear and the best outcome is undefined or unknown. Since students are concrete, textbook learners, this aspect of practice can be difficult for them to integrate into their practice.
It is imperative to let students know that the textbook is simply the textbook and clinical situations are rife with ambiguity, moral and ethical conflict, as well as family dynamics that are interrelated and contribute at times to ambiguity and volatility in practice.
- What is your comfort level in the clinical setting when ambiguity is present?
The nurse must possess a certain amount of mojo that is balanced and healthy that believes in yourself, can feel good about your abilities as a nurse though still inexperienced and confident that you have what it takes to be a nurse!
An important aspect of self-confidence is to be aware and know your strengths as well as weaknesses, and be willing to do what is needed to turn those weaknesses into a strength.
- Are you your own worst enemy or do you have a healthy sense of your abilities as a nurse?
6. Professional motivation
The nurse must be committed to the vision, values and mission of the nursing profession that is embodied in the ANA code of ethics. These values must be known, assimilated, and lived out by the nurse.
The nurse must choose to act differently and hold themselves to the highest level of moral and ethical practice. This practically means that the nurse becomes self-monitoring and will self-report if a medication error is made or other deficiency in practice occurs.
By using the attitude and skill of reflection, this same nurse will learn from any error made and be the better as a result.
- Do you consistently hold yourself to the highest standards of ethical conduct and have a strong desire to be the best nurse possible?
How well-established are these essential prerequisite attitudes for nurse thinking present in you as a nurse or your students?
I found the attitude of intent and professional motivation especially helpful and makes it clear that good nursing care and thinking does not just happen but must be intentional and fueled by a desire to be a consummate professional nurse.
These six attitudes would make an excellent post conference topic so consider sharing these attitudes with your students including the reflective questions to help strengthen and develop clinical reasoning in their practice!
What do you think?
Which attitudes are present or which are works in progress with you or your students? What can be done to strengthen these attitudes in clinical practice?
Comment below and let the conversation begin!
Pesut, D.J. & Herman, J. (1999). Clinical reasoning: The art and science of critical & creative thinking. Albany, NY: Delmar Publishers.
Keith Rischer – Ph.D., RN, CCRN, CEN
As a nurse with over 35 years of experience who remained in practice as an educator, I’ve witnessed the gap between how nursing is taught and how it is practiced, and I decided to do something about it! Read more…
The Ultimate Solution to Develop Clinical Judgment Skills
KeithRN’s Think Like a Nurse Membership
Access exclusive active learning resources for faculty and students, including KeithRN Case Studies, making it your go-to resource.
Sign up to receive a free KeithRN NextGen Case Study!
Develop clinical judgment skills with this innovative new case study on asthma to prepare your students for nextgen nclex and practice.
" * " indicates required fields
Why students struggle to transition to real-world clinical practice, recommended for you.
An official website of the United States government
The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
- Account settings
- Browse Titles
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing: Mental Health and Community Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.
Nursing: Mental Health and Community Concepts [Internet].
- About Open RN
Chapter 2 Therapeutic Communication and the Nurse-Client Relationship
2.1. introduction, learning objectives.
- Review basic concepts of client-centered communication
- Outline effective therapeutic communication techniques
- Describe barriers to effective therapeutic communication
- Explore guidelines for effective communication during teletherapy
Nurses engage in compassionate, supportive, professional relationships with their clients as part of the “art of nursing.” [ 1 ] This chapter will review the nurse-client relationship, therapeutic communication, and motivational interviewing. It will also introduce teletherapy and telehealth.
2.2. BASIC CONCEPTS OF COMMUNICATION
Communication standard of professional performance.
The Standard of Professional Performance for Communication established by the American Nurses Association (ANA) is defined as, “The registered nurse communicates effectively in all areas of professional practice.”  See the following box for the competencies associated with the Communication standard.
ANA’s Communication Competencies
The registered nurse:
- Assesses one’s own communication skills and effectiveness.
- Demonstrates cultural humility, professionalism, and respect when communicating.
- Assesses communication ability, health literacy, resources, and preferences of health care consumers to inform the interprofessional team and others.
- Uses language translation resources to ensure effective communication.
- Incorporates appropriate alternative strategies to communicate effectively with health care consumers who have visual, speech, language, or communication difficulties.
- Uses communication styles and methods that demonstrate caring, respect, active listening, authenticity, and trust.
- Conveys accurate information to health care consumers, families, community stakeholders, and members of the interprofessional team.
- Advocates for the health care consumer and their preferences and choices when care processes and decisions do not appear to be in the best interest of the health care consumer.
- Maintains communication with interprofessional team members and others to facilitate safe transitions and continuity in care delivery.
- Confirms with the recipient if the communication was heard and if the recipient understands the message.
- Contributes the nursing perspective in interactions and discussions with the interprofessional team and other stakeholders.
- Promotes safety in the care or practice environment by disclosing and reporting concerns related to potential or actual hazards or deviations from the standard of care.
- Demonstrates continuous improvement of communication skills.
Review basic communication concepts for nurses in the “ Communication ” chapter in Open RN Nursing Fundamentals .
Establishment of the therapeutic nurse-client relationship is vital in nursing care. Nurses engage in compassionate, supportive, professional relationships with their clients as part of the “art of nursing.”  This is especially true in psychiatric care, where the therapeutic relationship is considered to be the foundation of client care and healing.  The nurse-client relationship establishes trust and rapport with a specific purpose; it facilitates therapeutic communication and engages the client in decision-making regarding their plan of care.
Therapeutic nurse-client relationships vary in depth, length, and focus. Brief therapeutic encounters might last only a few minutes and focus on the client’s immediate needs, current feelings, or behaviors. For example, in the emergency department setting, a nurse may therapeutically communicate with a client in crisis who recently experienced a situational trauma. During longer periods of time, such as inpatient care, nurses work with clients in setting short-term goals and outcomes that are documented in the nursing care plan and evaluated regularly. In long-term care settings, such as residential facilities, the therapeutic nurse-client relationship may last several months and include frequent interactions focusing on behavior modification.
Read more about crisis and crisis intervention in the “ Stress, Coping, and Crisis Intervention ” chapter.
Phases of development of a therapeutic relationship.
The nurse-client relationship goes through three phases. A well-known nurse theorist named Hildegard Peplau described these three phases as orientation, working, and termination. 
During the brief orientation phase, clients may realize they need assistance as they adjust to their current status. Simultaneously, nurses introduce themselves and begin to obtain essential information about clients as individuals with unique needs, values, beliefs, and priorities. During this brief phase, trust is established, and rapport begins to develop between the client and the nurse. Nurses ensure privacy when talking with the client and providing care and respect the client’s values, beliefs, and personal boundaries.
A common framework used for introductions during patient care is AIDET, a mnemonic for Acknowledge, Introduce, Duration, Explanation, and Thank You.
- Acknowledge: Greet the patient by the name documented in their medical record. Make eye contact, smile, and acknowledge any family or friends in the room. Ask the patient their preferred way of being addressed (for example, “Mr. Doe,” “Jonathon,” or “Johnny”) and their preferred pronouns (e.g., he/him, she/her, or they/them).
- Introduce: Introduce yourself by your name and role. For example, “I’m John Doe, and I am a nursing student working with your nurse to take care of you today.”
- Duration: Estimate a timeline for how long it will take to complete the task you are doing. For example, “I am here to perform an admission assessment. This should take about 15 minutes.”
- Explanation: Explain step by step what to expect next and answer questions. For example, “I will be putting this blood pressure cuff on your arm and inflating it. It will feel as if it is squeezing your arm for a few moments.”
- Thank You: At the end of the encounter, thank the patient and ask if anything is needed before you leave. In an acute or long-term care setting, ensure the call light is within reach and the patient knows how to use it. If family members are present, thank them for being there to support the patient as appropriate. For example, “Thank you for taking time to talk with me today. Is there anything I can get for you before I leave the room? Here is the call light (Place within reach). Press the red button if you would like to call the nurse.”
The majority of a nurse’s time with a client is in the working phase. During this phase, nurses use active listening and begin by asking the reason the client is seeking care to determine what is important to them. They use assessment findings to develop a nursing plan of care and plan patient education. If a care plan has already been established on admission, nurses use this time to implement interventions targeted to meet short-term outcomes and long-term goals. During the working phase, clients begin to accept nurses as health educators, counselors, and care providers. Nurses use therapeutic communication techniques to facilitate clients’ awareness of their thoughts and feelings and mutually develop goals and an individualized plan of care. Nurses provide reflective and nonjudgmental feedback to clients to help them clarify their thoughts, goals, and coping strategies.  Therapeutic communication techniques used during this phase, including motivational interviewing, are discussed later in this chapter.
The final phase of a nurse-client relationship is the termination phase. This phase typically occurs at the end of a shift or on discharge from care. If the previous working phase has been successful, the client’s needs have been successfully met by collaboration among the client, nurses, and interprofessional health care team members. The nurse should be aware the client may try to return to the working phase to avoid termination of the relationship. During the termination phase, the nurse can encourage the client to reflect on progress they have made and review post-discharge goals. The nurse also makes community referrals for follow-up and continuation of support in meeting goals.
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
- Ross C. A., Goldner E. M. Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: A review of the literature. Journal of Psychiatric and Mental Health Nursing. 2009; 16 (6):558–567. [ PubMed : 19594679 ] [ CrossRef ]
- Hagerty T. A., Samuels W., Norcini-Pala A., Gigliotti E. Peplau’s Theory of Interpersonal Relations: An alternate factor structure for patient experience data? Nursing Science Quarterly. 2018; 30 (2):160–167. [ PMC free article : PMC5831243 ] [ PubMed : 28899257 ] [ CrossRef ]
2.3. THERAPEUTIC COMMUNICATION
Therapeutic communication has roots going back to Florence Nightingale, who insisted on the importance of building trusting relationships with patients. She taught that therapeutic healing resulted from nurses’ presence with patients. [ 1 ] Since then, several professional nursing associations have highlighted therapeutic communication as one of the most vital elements in nursing. Therapeutic communication is a type of professional communication defined as the purposeful, interpersonal, information-transmitting process that leads to client understanding and participation. [ 2 ] Read an example of a nursing student using therapeutic communication in the following box.
Example of Nurse Using Therapeutic Listening
Ms. Z. is a nursing student (as simulated in Figure 2.1 ) [ 3 ] who enjoys interacting with patients. When she goes to patients’ rooms, she greets them and introduces herself and her role in a calm tone. She kindly asks patients about their problems and notices their reactions. She provides information and answers their questions. Patients perceive that she wants to help them. She treats patients professionally by respecting boundaries and listening to them in a nonjudgmental manner. She addresses communication barriers and respects patients’ cultural beliefs. She notices patients’ health literacy and ensures they understand her messages and patient education. As a result, patients trust her and feel as if she cares about them, so they feel comfortable sharing their health care needs with her. [ 4 ]
Nursing Student Using Therapeutic Communication
Therapeutic communication is different from social interaction. Social interaction does not have a goal or purpose and includes casual sharing of information, whereas therapeutic communication has a goal or purpose for the conversation. An example of a nursing goal before using therapeutic communication is, “The client will share feelings or concerns about their treatment plan by the end of the conversation.”
Therapeutic communication includes active listening, professional touch, and a variety of therapeutic communication techniques.
Listening is an important part of communication. There are three main types of listening, including competitive, passive, and active listening. Competitive listening occurs when we are mostly focused on sharing our own point of view instead of listening to someone else. Passive listening occurs when we are not interested in listening to the other person, and we assume we understand what the person is communicating correctly without verifying their message. During active listening , we communicate both verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with them. For example, an active listening technique is to restate what the person said and then verify our understanding is correct. This feedback process is the major difference between passive listening and active listening. [ 5 ]
Nonverbal communication is an important component of active listening. SOLER is a mnemonic for establishing good nonverbal communication with clients. SOLER stands for the following [ 6 ]:
- S: S itting and squarely facing the client
- O: Using o pen posture (i.e., avoid crossing arms)
- L: L eaning towards the client to indicate interest in listening
- E: Maintaining good e ye contact
- R: Maintaining a r elaxed posture
Professional touch is a powerful way to communicate caring and empathy if done respectfully while also being aware of the client’s preferences, cultural beliefs, and personal boundaries. Nurses use professional touch when assessing, expressing concern, or comforting patients. For example, simply holding a patient’s hand during a painful procedure can effectively provide comfort.
For individuals with a history of trauma, touch can be negatively perceived, so it is important to ask permission before touching. Inform the person before engaging in medical procedures requiring touch such as, “I need to hold down your arm so I can draw blood.”
Nurses should avoid using touch with individuals who are becoming agitated or experiencing a manic or psychotic episode because it can cause escalation. It is also helpful to maintain a larger interpersonal distance when interacting with an individual who is experiencing paranoia or psychosis.
Therapeutic Communication Techniques
There are a variety of therapeutic techniques that nurses use to engage clients in verbalizing emotions, establishing goals, and discussing coping strategies. See Table 2.3a for definitions of various therapeutic communication techniques discussed in the American Nurse , the official journal of the American Nurses Association.
Therapeutic Communication Techniques 
Nurses must be aware of potential barriers to communication and avoid nontherapeutic responses. Nonverbal communication such as looking at one’s watch, crossing arms across one’s chest, or not actively listening may be perceived as barriers to communication. Nontherapeutic verbal responses often block the client’s communication of feelings or ideas. See Table 2.3b for a description of nontherapeutic responses to avoid.
Nontherapeutic Responses ,
See the following box for a summary of tips for using therapeutic communication and avoiding common barriers to therapeutic communication.
Tips for Effective Therapeutic Communication
- Establish a goal for the conversation.
- Be self-aware of one’s nonverbal messages.
- Observe the client’s nonverbal behaviors and actions as ‘cues’ for assessments and planning interventions.
- Avoid self-disclosure of personal information and use professional boundaries. (Review boundary setting in the “ Boundaries ” section of Chapter 1.)
- Be patient-centered and actively listen to what the client is expressing (e.g., provide empathy, not sympathy; show respect; gain the client’s trust; and accept the person as who they are as an individual).
- Be sensitive to the values, cultural beliefs, attitudes, practices, and problem-solving strategies of the client.
- Effectively use therapeutic communication techniques.
- Recognize themes in a conversation (e.g., Is there a theme emerging of poor self-esteem, guilt, shame, loneliness, helplessness, hopelessness, or suicidal thoughts?).
Common Barriers to Therapeutic Communication
- Using a tone of voice that is distant, condescending, or disapproving.
- Using medical jargon or too many technical terms.
- Asking yes/no questions instead of open-ended questions.
- Continually asking “why,” causing the client to become defensive or feel challenged by your questions.
- Using too many probing questions, causing the client to feel you are interrogating them, resulting in defensiveness or refusal to talk with the nurse.
- Lacking awareness of one’s biases, fears, feelings, or insecurities.
- Causing sensory overload in the client with a high emotional level of the content.
- Giving advice.
- Blurring the nurse-client relationship boundaries (e.g., assuming control of the conversation, disclosing personal information, practicing outside one’s scope of practice).
Recognizing and Addressing Escalation
When communicating therapeutically with a client, it is important to recognize if the client is escalating with increased agitation and becoming a danger to themselves, staff, or other patients. When escalation occurs, providing safety becomes the nurse’s top priority, and the focus is no longer on therapeutic communication. Read more information in the “ Crisis and Crisis Intervention ” section of the “Stress, Coping, and Crisis Intervention” chapter.
Recall the discussion from Chapter 1 on how cultural values and beliefs can impact a client’s mental health in many ways. Every culture has a different perspective on mental health. For many cultures, there is stigma surrounding mental health. Mental health challenges may be considered a weakness and something to hide, which can make it harder for those struggling to talk openly and ask for help. Culture can also influence how people describe and feel about their symptoms. It can affect whether someone chooses to recognize and talk openly about physical symptoms, emotional symptoms, or both. Cultural factors can determine how much support someone gets from their family and community when it comes to mental health. [ 10 ]
Nurses can help clients understand the role culture plays in their mental health by encouraging therapeutic communication about their symptoms and treatment. For example, a nurse should ask, “What do you think is wrong? How would you treat your symptoms?”
Read more about providing culturally responsive care in the “ Diverse Clients ” chapter of Open RN Nursing Fundamentals .
2.4. motivational interviewing.
Patient education and health promotion are core nursing interventions. Motivational interviewing (MI) is a communication skill used to elicit and emphasize a client’s personal motivation for modifying behavior to promote health. MI has been effectively used for several health issues such as smoking cessation, diabetes, substance use disorders, and adherence to a treatment plan. [ 1 ]
The spirit of motivational interviewing is a collaborative partnership between nurses and clients, focused on patient-centered care, autonomy, and personal responsibility. It is a technique that explores a client’s motivation, confidence, and roadblocks to change. During motivational interviewing, nurses pose questions, actively listen to client responses, and focus on where the client is now with a current health behavior and where they want to be in the future. [ 2 ]
Motivational interviewing uses these principles [ 3 ]:
- Express empathy. Use reflective listening to convey acceptance and a nonjudgmental attitude. Rephrase client comments to convey active listening and let clients know they are being heard.
- Highlight discrepancies. Help clients become aware of the gap between their current behaviors and their values and goals. Present objective information that highlights the consequences of continuing their current behaviors to motivate them to change their behavior.
- Adjust to resistance. Adjust to a client’s resistance and do not argue. The client may demonstrate resistance by avoiding eye contact, becoming defensive, interrupting you, or seeming distracted by looking at their watch or cell phone. Arguing can place the client on the defensive and in a position of arguing against the change. Focus on validating the client’s feelings.
- Understand motivations. Uncover a client’s personal reasons for making behavioral changes and build on them.
- Support self-efficacy. Encourage the client’s optimistic belief in the prospect of change and encourage them to commit to positive behavioral changes. Ask clients to elaborate on past successes to build self-confidence and support self-efficacy.
- Resist the reflex to provide advice. Avoid imposing your own perspective and advice.
When implementing motivational interviewing, it is important to assess the client’s readiness for change. Motivational interviewing is especially useful for clients in the contemplation stage who are feeling ambivalent about making change. Recall these five stages of behavioral change [ 4 ]:
- Precontemplation: Not considering change.
- Contemplation: Ambivalent about making change.
- Preparation: Taking steps toward implementing change.
- Action: Actively involved in the change process.
- Maintenance: Sustaining the target behavior.
Identify clients who are ambivalent about making a behavioral change or following a treatment plan by listening for the phrase, “Yes, but.” The “but” holds the key for opening the conversation about ambivalence. For example, a client may state, “I want to take my medication, but I hate gaining weight.” The content in the sentence after the “but” reveals the client’s personal roadblock to making a change and should be taken into consideration when planning outcomes and interventions. [ 5 ]
See the following box for an example of a nurse using motivational interviewing with a client.
Example of Motivational Interviewing [ 6 ]
Mr. L. had been in treatment for bipolar I disorder with medication management and supportive therapy for many years. He had a history of alcohol dependence but was in full recovery. Mr. L. was admitted to the intensive care unit with a toxic lithium level. He had been seen in the emergency room the preceding evening and was noted to have a very high blood alcohol level. The next day the nurse asked the client about his alcohol use using motivational interviewing.
Client: I am so sick of everyone always blaming everything on my drinking!
Nurse (Using reflective listening): You seem pretty angry about the perception that you were hospitalized because you had been drinking.
Client: You better believe it! I am a man! I can have a few drinks if I want to!
Nurse: (Expressing empathy and acceptance): You want to be respected even when you are drinking.
Client: I have had some trouble in the past with drinking, but that is not now. I can quit if I want to! Compared to what I used to drink, this is nothing.
Nurse (Rolling with resistance): So you see yourself as having had drinking problems in the past, but the drinking you’ve done recently is not harmful for you.
Client: Well, I guess I did end up in the hospital.
Nurse (Using open-ended questioning): Tell me more about what happened.
Client: I was pretty angry after an argument with my girlfriend, and I decided to buy a bottle of whiskey.
Nurse (Exploring): And then?
Client: Well, I meant to have a couple of shots, but I ended up drinking the whole fifth. I really don’t remember what happened next. They said I nearly died.
Nurse (Summarizing): So after many years of not drinking, you decided to have a couple of drinks after the argument with your girlfriend, but unintentionally drank enough to have a blackout and nearly die.
Client: I guess that does sound like a problem…but I don’t want anyone else telling me whether or not I can drink!
Nurse (Emphasizing autonomy): Tell me how the choice to drink or not continues to support or oppose your health goals.
View the following supplementary YouTube videos about motivational interviewing:
Introduction to Motivational Interviewing [ 7 ]
Motivational Interviewing – Good Example – Alan Lyme [ 8 ]
Complete Western Region Public Health Training Center’s Motivational Interviewing course and receive a certificate of completion.
2.5. teletherapy and telehealth.
Telehealth is the use of digital technologies to deliver medical care, health education, and public health services by remotely connecting multiple users in separate locations. Nurses must be aware of potential barriers affecting client use of telehealth (such as lack of Internet access or lack of support for individuals learning new technologies), as well as state and federal policies regarding telehealth and their nursing license across state lines.
Read more about telehealth licensing requirements and interstate compacts at the Telehealth.hss.gov webpage .
Teletherapy is mental health counseling over the phone or online with videoconferencing. COVID-19 has led to reduced access to medical and mental health care, so delivering behavioral health care via telehealth is one way to address this issue. When using teletherapy, nurses should treat clients as if they are sitting across from them and focus on eye contact and empathetic expressions to build a connection, just during a face-to-face encounter. [ 1 ]
Group therapy can be accomplished via telehealth. Connecting clients through telehealth creates a group dynamic that can build community, reduce feelings of isolation, and offer new perspectives. Group therapy via telehealth can create a sense of belonging and build a trusted support system.
Here are a few guidelines for group therapy telehealth sessions [ 2 ]:
- Prescreen group members: Group members may have various needs, experiences, or personalities. It is helpful to screen each potential client to ensure every member can benefit from group therapy and that their needs match the goals of the group.
- Require completion of online consent forms: Group telehealth sessions involve multiple people and are conducted outside of a controlled setting like an office. Client consent forms should be required and available online. The consent forms should outline any associated risks, benefits, and limits to confidentiality.
- Develop group guidelines: Make clear ground rules covering what is acceptable and what is not acceptable. Some common ground rules include requiring all participants to have their camera on, attend from a room where they can be alone during the session, and use the digital “raise hand” feature (or raise their hand) when they want to speak. Prohibiting recording of the session is a common ground rule to protect confidentiality. Address logistical topics like how many missed sessions are allowed and how to contact the group leader(s).
- Select your settings and technology: Choose the telehealth video platform that best suits your needs for encryption and privacy, user controls, and more. Go through all of the settings ahead of time to select the options that provide the highest level of privacy. Think about what will help you and the group communicate effectively such as screen sharing options or a virtual whiteboard.
- Be engaging: When you are on screen instead of in person, it is even more important to be conscious of the group dynamic and take steps to keep group members interested, energized, and engaged. Start with introductions and greetings using first names only for privacy. Make eye contact with group members by looking into the camera and use body language and hand gestures to help express your ideas. Build in moments for clients to interact and contribute to the conversation, such as breakout rooms or paired discussions.
2.6. LEARNING ACTIVITIES
Communicating both verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with them.
A communication skill used to elicit and emphasize a client’s personal motivation for modifying behavior to promote health.
A relationship that establishes trust and rapport with a specific purpose of facilitating therapeutic communication and engaging the client in decision-making regarding their plan of care.
A mnemonic for effective nonverbal communication that stands for the following [ 1 ]:
- S: Sit and squarely face the client
- O: Open posture
- L: Lean towards the client to indicate interest in listening
- E: Eye contact
The use of digital technologies to deliver medical care, health education, and public health services by remotely connecting multiple users in separate locations.
Mental health counseling over the phone or online with videoconferencing tools.
A type of professional communication defined as the purposeful, interpersonal, information-transmitting process that leads to client understanding and participation. [ 2 ]
Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .
- Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing: Mental Health and Community Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 2 Therapeutic Communication and the Nurse-Client Relationship.
- PDF version of this title (53M)
In this Page
- BASIC CONCEPTS OF COMMUNICATION
- THERAPEUTIC COMMUNICATION
- MOTIVATIONAL INTERVIEWING
- TELETHERAPY AND TELEHEALTH
- LEARNING ACTIVITIES
Other titles in this collection
- Open RN OER Textbooks
Related Items in Bookshelf
- All Textbooks
- Bulk download content from FTP
- PMC PubMed Central citations
- PubMed Links to PubMed
- Chapter 2 Therapeutic Communication and the Nurse-Client Relationship - Nursing:... Chapter 2 Therapeutic Communication and the Nurse-Client Relationship - Nursing: Mental Health and Community Concepts
Your browsing activity is empty.
Activity recording is turned off.
Turn recording back on
Connect with NLM
National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894
Web Policies FOIA HHS Vulnerability Disclosure
Help Accessibility Careers