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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

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

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

What Is Critical Thinking in Nursing?

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

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

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

How Is Critical Thinking Important for Nurses? 

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

Elements of Critical Thinking in Nursing

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

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

How to Develop and Apply Critical-Thinking Skills in Nursing

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

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

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

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

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The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

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

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

Jenna Liphart Rhoads, Ph.D., RN

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

Nicholas McGowan, BSN, RN, CCRN

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

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

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

What is Critical Thinking in Nursing?

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

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

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

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Critical thinking in nursing clinical practice, education and research: From attitudes to virtue

Affiliations.

• 1 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, Consolidated Research Group Quantitative Psychology (2017-SGR-269), University of Barcelona, Barcelona, Spain.
• 2 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, Consolidated Research Group on Gender, Identity and Diversity (2017-SGR-1091), University of Barcelona, Barcelona, Spain.
• 3 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, University of Barcelona, Barcelona, Spain.
• 4 Multidisciplinary Nursing Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Hospital, Barcelona, Spain.
• PMID: 33029860
• DOI: 10.1111/nup.12332

Critical thinking is a complex, dynamic process formed by attitudes and strategic skills, with the aim of achieving a specific goal or objective. The attitudes, including the critical thinking attitudes, constitute an important part of the idea of good care, of the good professional. It could be said that they become a virtue of the nursing profession. In this context, the ethics of virtue is a theoretical framework that becomes essential for analyse the critical thinking concept in nursing care and nursing science. Because the ethics of virtue consider how cultivating virtues are necessary to understand and justify the decisions and guide the actions. Based on selective analysis of the descriptive and empirical literature that addresses conceptual review of critical thinking, we conducted an analysis of this topic in the settings of clinical practice, training and research from the virtue ethical framework. Following JBI critical appraisal checklist for text and opinion papers, we argue the need for critical thinking as an essential element for true excellence in care and that it should be encouraged among professionals. The importance of developing critical thinking skills in education is well substantiated; however, greater efforts are required to implement educational strategies directed at developing critical thinking in students and professionals undergoing training, along with measures that demonstrate their success. Lastly, we show that critical thinking constitutes a fundamental component in the research process, and can improve research competencies in nursing. We conclude that future research and actions must go further in the search for new evidence and open new horizons, to ensure a positive effect on clinical practice, patient health, student education and the growth of nursing science.

Keywords: critical thinking; critical thinking attitudes; nurse education; nursing care; nursing research.

© 2020 John Wiley & Sons Ltd.

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Harnessing the power of critical thinking can be the key to becoming a successful and competent nurse. 

Developing and refining your critical thinking skills is crucial as you embark on your nursing journey. By doing so, you’ll enhance your ability to provide high-quality care, advance your professional growth, and contribute to the ever-evolving nursing field.

What is critical thinking in nursing?

Critical thinking is an essential cognitive process that enables nurses to analyze, evaluate, and synthesize information to make informed decisions. In the context of nursing, it involves observing, interpreting, and responding to patient needs effectively. 

Critical thinking allows nurses to go beyond memorized facts and apply logical reasoning to address patient problems holistically.

As a nurse, you’ll encounter multifaceted healthcare scenarios, each presenting its unique challenges. Critical thinking enables you to approach these situations systematically, evaluate the available data, identify relevant factors, and understand the patient’s condition comprehensively.

By employing critical thinking skills, you can differentiate between urgent and non-urgent issues, prioritize care, anticipate potential complications, and adapt your interventions accordingly. This analytical approach helps minimize errors, promote patient safety, and achieve positive patient outcomes.

Why is critical thinking important in nursing?

Critical thinking serves as the backbone of nursing practice. You’ll encounter various uncertainties, changing conditions, and ethical dilemmas as a nurse. Developing critical thinking abilities empowers you to navigate these challenges confidently and provide optimal patient care.

In nursing, critical thinking is crucial for the following reasons:

• Enhanced Clinical Judgment: Critical thinking enables assessing complex situations, analyzing available information, and drawing logical conclusions. It enhances your clinical judgment, allowing you to make informed decisions based on the best available evidence and expert consensus.
• Effective Problem Solving: Nursing involves encountering problems and finding effective solutions. Critical thinking equips you with the tools to identify underlying issues, explore alternative options, and implement interventions that address the root cause of the problem.
• Patient Advocacy: Critical thinking empowers you to advocate for your patients’ needs. By actively engaging in critical inquiry, you can challenge assumptions, question policies, and promote patient-centered care.
• Adapting to Changing Environments: Healthcare is constantly evolving, with new research findings, technologies, and treatments emerging regularly. Developing critical thinking skills helps you adapt to these changes, ensuring you stay updated and deliver evidence-based care.

Examples of Critical Thinking in Nursing

Let’s dive into some real-life examples that highlight how critical thinking plays a crucial role in nursing practice:

• Prioritization: Imagine working in an emergency department where multiple patients arrive simultaneously with varying degrees of severity. Utilizing critical thinking, you can assess each patient’s condition, prioritize care based on the urgency of their needs, and allocate resources effectively.
• Medication Administration: When administering medication, critical thinking prompts you to cross-check the prescribed dose, assess potential drug interactions or allergies, and evaluate the patient’s response to the medication. This proactive approach ensures patient safety and minimizes medication errors.
• Ethical Dilemmas: Critical thinking helps you navigate complex ethical dilemmas by analyzing the values at stake, considering legal and ethical principles, and collaborating with the healthcare team to make decisions that align with the patient’s best interests.

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Critical Thinking in Nursing

• First Online: 02 January 2023

Cite this chapter

• Şefika Dilek Güven 3  

Part of the book series: Integrated Science ((IS,volume 12))

1276 Accesses

Critical thinking is an integral part of nursing, especially in terms of professionalization and independent clinical decision-making. It is necessary to think critically to provide adequate, creative, and effective nursing care when making the right decisions for practices and care in the clinical setting and solving various ethical issues encountered. Nurses should develop their critical thinking skills so that they can analyze the problems of the current century, keep up with new developments and changes, cope with nursing problems they encounter, identify more complex patient care needs, provide more systematic care, give the most appropriate patient care in line with the education they have received, and make clinical decisions. The present chapter briefly examines critical thinking, how it relates to nursing, and which skills nurses need to develop as critical thinkers.

Graphical Abstract/Art Performance

Critical thinking in nursing.

This painting shows a nurse and how she is thinking critically. On the right side are the stages of critical thinking and on the left side, there are challenges that a nurse might face. The entire background is also painted in several colors to represent a kind of intellectual puzzle. It is made using colored pencils and markers.

(Adapted with permission from the Association of Science and Art (ASA), Universal Scientific Education and Research Network (USERN); Painting by Mahshad Naserpour).

Unless the individuals of a nation thinkers, the masses can be drawn in any direction. Mustafa Kemal Atatürk

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Nevşehir Hacı Bektaş Veli University, Semra ve Vefa Küçük, Faculty of Health Sciences, Nursing Department, 2000 Evler Mah. Damat İbrahim Paşa Yerleşkesi, Nevşehir, Turkey

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Güven, Ş.D. (2023). Critical Thinking in Nursing. In: Rezaei, N. (eds) Brain, Decision Making and Mental Health. Integrated Science, vol 12. Springer, Cham. https://doi.org/10.1007/978-3-031-15959-6_10

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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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Why Critical Thinking Is Important in Nursing

Most nursing professionals have natural nurturing abilities, a desire to give others support, and an appreciation for science and anatomy. Successful nurses also possess a skill that is often overlooked: they can think critically.

A critical thinker will identify the problem, determine the best solution, and choose the most effective method. Critical thinkers evaluate the execution of a plan to see if it was effective and if it could have been done better. 

The ability to think critically has multiple applications in your life, as you can see. But Why is critical thinking important in nursing? Learn why and how you can improve this skill by reading on.

Why Are Critical Thinking Skills in Nursing Important?

Critical thinking is an essential skill for nursing students to have. It’s not something that it can teach in a classroom, and it must be developed over time through experience and practice. 

Critical thinking is the process of applying logic and reason to make decisions or solve problems. The ability to think critically will help you make better decisions on your own and collaborate with others when solving problems – both are essential skills for nurses.

Nursing has always been a profession that relies on critical thinking. Nurses are constantly faced with new situations and problems, which they need to think critically about to solve. 

Critical thinking is essential for nurses because it helps them make decisions based on the available information and their past experiences and knowledge of the field. It also allows nurses to plan before making any changes to be most effective as possible.

It is an essential skill for nurses to have to provide the best care possible. Critical thinkers can comprehend a problem and think about how they can solve it, rather than reactively or automatically.

Critical thinking is a crucial skill for doctors, nurses, and other health care providers.

How can you develop your critical thinking skills?

As you know, learning doesn’t end when you graduate from nursing school. You must continue to grow as a professional and develop your critical thinking skills.

Critical thinkers are better problem solvers than others in the same situation because they examine all the facts before coming up with solutions. They can also take many different perspectives into account when solving problems.

It’s easy for people to come to conclusions too quickly, but those who think critically will avoid this trap by first looking at every possible angle.

When faced with difficult decisions, these nurses won’t just rely on their gut feelings or what seems right according to society’s norms; instead, they’ll analyze all available information carefully until they develop the best solution.

Critical thinking is also crucial because it helps nurses avoid making mistakes in their work by providing them with a way to examine each situation and identify any potential risks or problems that may arise from subsequent actions before they take place.

It’s not enough for you to have empathy if your compassion isn’t backed up by critical thought and understanding of how certain decisions might affect others in various circumstances, so keep learning ways to become more thoughtful about the world around you.

The skills involved in being a good nurse are many and varied, but one thing all nurses need, regardless of what specialty they choose, is critical solid thinking abilities.

Reasons Critical Thinking In Nursing Is Important

Nurses’ experiences often include making life-altering decisions, establishing authority in stressful situations, and helping patients and their loved ones cope with some of the most stressful and emotional times of their lives.  Critical thinking is an essential aspect of nursing.

Following are the reasons:

• Nurses’ critical thinking has a significant impact on patient care 
• Recognizing changes in patient status is essential 
• It’s essential to an honest and open exchange of ideas 
• It enables you to ensure patient safety 
• Nurses can find quick fixes with it 
• Improvements can be made through critical thinking 
• It Contributes to Rational Decision Making

Further critical thinking is essential to nursing because nurses can establish authority in a stressful situation, such as issuing orders or administering care when needed.

This can be difficult because it may require balancing medical expertise with empathy and compassion towards patients’ feelings, leading them to question your judgment at some point in time.

Another reason this skill set is crucial involves making decisions that will have life-changing effects on a patient’s health and well-being.

These are often irreversible choices that only you know how much weight they carry within the context of each situation, so you need to make sure all factors are carefully considered before deciding what action must be taken next without hesitation.

Skills that Critical Thinkers Need

When it comes to critical thinking, some skills are more important than others. Using a framework known as the Nursing Process, some of these skills are applied to patient care. The most important skills are:

Interpretation: Understanding and explaining a specific event or piece of information.

Analysis: Studying data based on subjective and objective information to determine the best course of action.

Evaluation: Here, you assess the information you received. Is the information accurate, reliable, and credible? The ability to determine if outcomes have been fully achieved requires this skill as well.

The nurse can then use clinical reasoning to determine what the problem is based on those three skills. 

The decisions need to be based on sound reasoning:

Provide a clear, concise explanation of your conclusions. Nurses should provide a rationale for their answers.

Self-regulation – You need to be aware of your thought processes. As a result, you must reflect on the process that led to your conclusion. In this process, you should self-correct as necessary. Keep an eye out for bias and incorrect assumptions.

Critical Thinking Pitfalls

It can fall by the wayside when it’s not seen as necessary or when there are more pressing issues.

• Critical thinking is important in nursing because it can fall by the wayside when it’s not seen as an essential or more pressing issue.
• It can be difficult to think critically about complex, ambiguous situations with a shortage of information and time in healthcare settings.
• If we don’t use critical thinking skills, problems might go undetected or unresolved, leading to further complications down the road.

Sometimes nurses can’t differentiate between a less acute clinical problem and one that needs immediate attention. When a large amount of complex data must be processed in a time-critical manner, errors can also occur.

Conclusion:

Nurses cannot overstate the importance of critical thinking. The clinical presentations of patients are diverse. To provide safe, high-quality care, nurses must make rational clinical decisions and solve problems. Nurses need critical thinking skills to handle increasingly complex cases.

• Why Is Research Important in Nursing?
• Why Is the Nursing Process Important?
• Why Compassion is Important in Nursing

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The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice. Nurses’ ability to recognize and respond to signs of patient deterioration in a timely manner plays a pivotal role in patient outcomes (Purling & King 2012). Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events (Tomlinson, 2015). The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement. Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010). At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction.

The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. 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 judgements and decisions are reached in complex healthcare environments.

As lifelong learners, nurses are constantly accumulating more knowledge, expertise, and experience, and it’s a rare nurse indeed who chooses to not apply his or her mind towards the goal of constant learning and professional growth. Institute of Medicine (IOM) report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice. American Nurses Association (ANA), Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice (p.26)

Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier

The future of nursing: Leading change, advancing health, (2010). https://campaignforaction.org/resource/future-nursing-iom-report

Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today. 30(6), 515-520.

NMC (2010) New Standards for Pre-Registration Nursing. London: Nursing and Midwifery Council.

Purling A. & King L. (2012). A literature review: graduate nurses’ preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23–24), 3451–3465

Thompson, C., Aitken, l., Doran, D., Dowing, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50 (12), 1720 - 1726 Tomlinson, J. (2015). Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Medical Education, 15(103)

Competing interests: No competing interests

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Factors associated with the critical thinking ability of professional nurses: A cross‐sectional study

Tuan van nguyen.

1 Faculty of Nursing and Medical Technology, Can Tho University of Medicine and Pharmacy, Can Tho Vietnam

2 School of Nursing, College of Medicine, Chang Gung University, Taoyuan Taiwan

Hsueh‐Erh Liu

3 Department of Rheumatology, Chang Gung Memorial Hospital, Linkou Taiwan

4 Department of Nursing, College of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan

Associated Data

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

To measure the level of critical thinking among Vietnamese professional nurses and to identify the related factors.

A cross‐sectional design was used.

The total sample included 420 professional nurses. Data were collected from July to September 2019 in three public hospitals located in Southwestern Vietnam. The level of critical thinking was measured using the Vietnamese version of the Nursing Critical Thinking in Clinical Practice Questionnaire. The data were analysed using the independent Student's t tests, ANOVA, Pearson's correlation and regression analysis.

Most of the participants had a low (48.3%) or moderate (45.5%) level of critical thinking. Age, gender, ethnicity, education level, health condition, duration of working as a nurse, duration of working in the current hospital, having heard the term “critical thinking” and work position had an impact on the critical thinking ability. Work position and gender explained 11% of the total variance in critical thinking ability.

1. INTRODUCTION

Critical thinking is defined as the cognitive process of reasoning that involves trying to minimize errors and to maximize positive outcomes while attempting to make a decision during patient care (Zuriguel‐Pérez et al.,  2015 ). The importance of critical thinking in nursing practice has been identified in the literature (Chang et al.,  2011 ; Ludin,  2018 ; Mahmoud & Mohamed,  2017 ; Yurdanur,  2016 ; Zuriguel‐Pérez et al.,  2015 ). The current nursing environment has become more complex and demanding, especially regarding the acuity and safety of patients and the rapid turnover rate of hospitalization. If professional nurses want to provide high‐quality care, critical thinking is required (Berkow et al.,  2011 ; Brunt,  2005 ; Fero et al.,  2009 ; Zuriguel‐Pérez et al.,  2015 ). Nurses are often the first‐line professionals to observe and provide direct care for patients. Therefore, critical thinking is a necessary skill for them to be able to analyse clinical situations in order to make fast and correct decisions (Lee et al.,  2017 ). More importantly, critical thinking can also improve patient outcomes by preventing habitual thinking that may lead to incorrect medication or procedures (Fesler‐Birch,  2005 ). The critical thinking ability of nurses can have an impact on the patient's safety, and it is a priority in educational programs for healthcare providers (Berkow et al.,  2011 ; Buerhaus et al.,  2006 ). We can identify those with poor critical thinking and provide in‐service education. Although critical thinking has been shown that is influenced by the experience and knowledge acquired during clinical practice (Zuriguel‐Pérez et al.,  2015 ), other personal information needs to be considered to clarifying. Therefore, it is essential to measure the levels of critical thinking and to identify the work‐related and personal‐related factors that influence the critical thinking of nurses.

2. BACKGROUND

The literature has identified that there is a relationship between leadership and positive patient outcomes, such as fewer medication errors and nosocomial infections, lower patient mortality and higher patient satisfaction (Van Dyk et al.,  2016 ; Wong,  2015 ). Alongside leadership, critical thinking is an important factor that supports the management. They can apply critical thinking skills in decision‐making and problem‐solving, and they can develop strategies that help staff nurses to improve their critical thinking ability (Van Dyk et al.,  2016 ; Wong,  2015 ; Zuriguel‐Pérez et al., 2018 ). Thus, the ability to think critically is necessary for nurses because it will help them to effectively make decisions and to solve problems in practice.

Although the importance of critical thinking in nursing practice has been identified, a limited number of studies have been conducted in this population. Particularly, few hospitals have evaluated the critical thinking skills of nurses before employment or during the clinical competency evaluation (Lang et al.,  2013 ). By reviewing 90 articles to assess the current state of the scientific knowledge regarding critical thinking in nursing, Zuriguel‐Pérez et al., ( 2015 ) found that only 16 studies used working nurses as participants. Furthermore, Zuriguel‐Pérez et al., ( 2018 ) reported that few studies have explored the critical thinking ability of nurse managers (NMs). Moreover, several studies have identified that working nurses have a low (Lang et al.,  2013 ; Yurdanur,  2016 ) or moderate level of critical thinking (Chang et al.,  2011 ; Lang et al.,  2013 ; Zuriguel‐Pérez et al., 2018 ). To the researchers’ knowledge, no studies have investigated this issue in Vietnam.

In order to improve the quality and safety of patient care, various types of professional nurses have been established, such as Registered Nurses (RNs), NMs and administrative assistants (AAs). RNs provide direct care to the patients, NMs are responsible for forwarding management and delivering expert clinical care for patients, and AAs are an integral part of maintaining the quality of patient care. The AAs perform administrative tasks (e.g. filing, taking meeting minutes and distributing them and undertaking regular reports) that help NMs to spend more time assisting staff nurses and taking care of patients (Locke et al.,  2011 ). Therefore, RNs, NMs and AAs need to cooperate to help patients to regain their health.

In Vietnam, professional nurses work in three different positions, which are NMs, general nurses (GNs) and AAs (Ministry of Health,  1997 ). Specifically, NMs are recognized as head nurses in Western countries, and their responsibilities are in charge of organizing and implementing comprehensive patient care and conduct a variety of administrative work (e.g. planning and assigning work to nurses, planning the acquisition of tools and consumables, checking care sheets, recording daily labour). GNs are similar to RNs in Western countries, and they provide direct and comprehensive care to patients. AAs perform administrative tasks (e.g. keeping records about the hospitalized and discharged patients, preserving medical records, managing daily medications). They also participate in patients care if necessary (Ministry of Health,  1997 , 2011 ). Although the roles of these three types of professional nurses are different, their final goal is the same to provide holistic care for patients. With the cooperation and effort of these three types of professional nurses, patients can recover. Therefore, more surveys are needed that examine these participants’ level of critical thinking and the associated work‐related factors.

Previous studies have also found that several personal‐related factors are associated with the nurses' critical thinking ability, which are age, gender, ethnicity, education qualification, working experience and shift work (Chang et al.,  2011 ; Feng et al.,  2010 ; Howenstein et al.,  1996 ; Lang et al.,  2013 ; Ludin,  2018 ; Mahmoud & Mohamed,  2017 ; Ryan & Tatum,  2012 ; Wangensteen et al.,  2010 ; Yildirim et al.,  2012 ; Yurdanur,  2016 ; Zuriguel‐Pérez et al., 2018 ). However, the relationships between the critical thinking ability and these variables are inconsistent. For example, age and critical thinking have been found to be positively correlated (Chang et al.,  2011 ; Ludin,  2018 ; Zuriguel‐Pérez et al., 2018 ), negatively correlated (Howenstein et al.,  1996 ) and not related (Lang et al.,  2013 ; Mahmoud & Mohamed,  2017 ; Yurdanur,  2016 ). Gender and critical thinking have been reported with a statistically significant relationship (Liu et al.,  2019 ; Ludin,  2018 ) and no relationship (Mahmoud & Mohamed,  2017 ; Wangensteen et al.,  2010 ). Level of education and critical thinking have been found in a positive association (Chang et al.,  2011 ; Ludin,  2018 ) and not association (Lang et al.,  2013 ; Mahmoud & Mohamed,  2017 ). Year of experiences and critical thinking have been shown to be positively correlated (Chang et al.,  2011 ; Ludin,  2018 ), negatively correlated (Howenstein et al.,  1996 ) and not related (Lang et al.,  2013 ; Mahmoud & Mohamed,  2017 ). Those inconsistent findings indicated the relationships between the personal‐characteristics and the critical thinking ability of professional nurses need further exploration. Therefore, this study aimed to examine the level of critical thinking of professional nurses and to explore the work‐related and personal‐related factors. This is the first study to investigate this issue in Vietnam. The results of the current study will make a significant contribution to the literature because it will provide thorough descriptions of the critical thinking of professional nurses and its associated factors. Furthermore, the findings may be used as a baseline for nurse managers and nurse educators to propose further strategies to improve this ability in professional nurses.

3.1. Research design

A cross‐sectional design was used. The Strengthening the Reporting of Observational Studies in Epidemiology guidelines were applied in this report (Von Elm et al.,  2014 ).

3.2. Setting and sampling

Data collection was carried out from July to September 2019 in three representative and major public hospitals located in the Southwestern region of Vietnam. These hospitals have the same organizational structure, role of treating, operation of professional nursing and provide similar quality of health care to people around that area. The total numbers of professional in these three hospitals nurses were around 1,200. Besides, our study has two steps. The first step was to translate the English version of the Nursing Critical Thinking in Clinical Practice Questionnaire (N‐CT‐4 Practice) into the Vietnamese version. In that step, we used data as a pilot study to estimate the sample size in the second step, which was reported here. Sample size calculation was done by the formula: n  = 1.96 2  × p × (1‐p)/0.05 2 , where p  = .46 came from the poor level of critical thinking among nurses in the first step and 0.05 indicated the acceptable margin of error (5.0%); 382 participants were required by this formula. An additional 10% of participants were done to adjust for potential failures such as withdrawals or missing data (Suresh & Chandrashekara,  2012 ). Therefore, in total, 420 participants were required for this study. Convenience sampling was conducted to recruit the sample. The inclusion criteria were the nurses' employed full‐time employment in the study hospitals. Participants who participated in step 1 or being absent during the data collection such as sick leave or delivering a baby were excluded. Participants were grouped in each hospital and received an envelope with all questionnaires. Then, researchers explained the research's purpose, benefits and risks to the potential participants and the procedure for ensuring confidentiality, and the voluntary nature of the participation. The informed consent form was signed immediately after they agreed to participate in this study. Then, the participants were required to complete the questionnaires in 20 to 30 min and to return them to the data collector.

3.3. Data assessment

3.3.1. sample characteristics.

This instrument collected data about the personal information and occupational variables. The personal information included age, gender, marital status, ethnicity, religion, education level and self‐rated health conditions. The occupational variables were the duration of working as a nurse, the duration of working in the current hospital, the duration of working in the specific position, having heard the term “critical thinking” or not, previous exposure to critical thinking training or education or not, and type of work position.

3.3.2. Vietnamese version of the Nursing Critical Thinking in Clinical Practice Questionnaire ((N‐CT‐4 Practice (V‐v))

The N‐CT‐4 Practice (V‐v) was used to measure the critical thinking ability of the professional nurses. The original instrument (N‐CT‐4 Practice) was established and classified based on the four dimensions of the 4‐circle critical thinking model of Alfaro‐LeFevre (Zuriguel‐Pérez et al., 2017 ). These four dimensions were personal; intellectual and cognitive; interpersonal and self‐management; and technical dimensions. The personal dimension has 39 items to assess the individual pattern of intellectual behaviours; the intellectual and cognitive dimension has 44 items to assesses the knowledge of activity comprehension connected to the nursing process and decision‐making. For the interpersonal and self‐management dimension, it has 20 items to analyse interpersonal abilities that allow for therapeutic communication with patients and health teams and to gain information that is associated with the patient in the clinical environment. The final one, the technical dimension, has 6 items to is concerned with knowledge and expertise in the procedures that are part of the discipline of nursing. This scale has 109 items that are rated using a four‐point Likert response format (1 = never or almost never, 2 = occasionally, 3 = often, and 4 = always or almost always), for example: “I recognize my own emotions.” (item 1); “I have the scientific knowledge required to carry out my professional practice.” (item 40); “I adapt information to the needs and capacities of the patient.” (item 84); “I possess skills in the use of information and communication technologies needed to produce optimal professional results.” (item 105). The total score is obtained from the sum of the 109 items. The scores range from 109–436, and they are categorized into a low level (score <329), moderate level (score between 329–395) and high level (score >395). The overall Cronbach's alpha was 0.96, and the intraclass correlation coefficient (ICC) was 0.77 (Zuriguel‐Pérez et al., 2017).

The N‐CT‐4 Practice (V‐v) was translated, and its psychometric properties were tested with 545 Vietnamese nurses. The results showed that the N‐CT‐4 Practice (V‐v) has acceptable reliability (Cronbach's alpha) and validity (content and construct validity). Particularly, the overall Cronbach's alpha was 0.98, with that of the four dimensions ranging from 0.86–0.97. The ICC was 0.81 over two weeks. The item content validity index was 1.0. Moreover, the goodness‐of‐fit indexes in a confirmatory factor analysis showed acceptable values, which were χ 2 / df  = 2.87, root mean square error of approximation (RMSEA) = 0.059, standardized root mean square residual (SRMR) = 0.063, comparative fit index (CFI) = 0.73 and Tucker Lewis index (TLI) = 0.72 (T. V. Nguyen & Liu,  2021 ). Therefore, the N‐CT‐4 Practice (V‐v) can be used to measure the critical thinking ability of Vietnamese professional nurses.

3.4. Ethical considerations

This study conformed with the ethical principles of the Declaration of Helsinki (Helsinki Declaration,  2013 ), and it was granted research ethics committee approval by the ethical review board of the first author's institution.

3.5. Data analysis

The data were analysed using SPSS for Windows version 23.0 (IBM Corp.), and both descriptive and inferential statistics were calculated. The level of significance for all analyses was set at < 0.05. First, descriptive statistics were employed to summarize the collected data. The continuous variables were described using the mean and standard deviation ( SD ), and the frequency and percentage (%) were used for the categorical variables. Next, independent Student's t tests, analysis of variance (with Scheffe's post hoc comparison) and Pearson's correlation analysis were conducted to explore the association between the critical thinking ability and the personal and occupational factors. Then, a multiple regression analysis using the stepwise method was performed to identify the predictors of critical thinking ability (Pallant,  2010 ).

4.1. Characteristics of the participants

A total of 420 participants completed the questionnaires; the characteristics of overall participants and subjects in each group are listed in Table  1 . Three groups of subjects were included, which were NMs (24.8%), GNs (49.8%) and AAs (25.4%), respectively. Regarding the personal variables, almost all participants were Vietnamese (96.7%), no religion (73.1%) and had good health condition (60%). Meanwhile, the comparison among each group showed that age ( F  = 9.89, p  < .001), gender (χ 2  = 6.48, p  < .05), marital status (χ 2  = 6.77, p  < .05) and education level (χ 2  = 147.38, p  < .001) had reached the statistical significance. Further analysis showed that the age of NMs was significantly older than subjects in both the GN and AA group, AA group had a higher ratio of that in the GN group, and the AA group had a higher ratio of married one than the GN group. For educational levels, subjects in the NM group had a higher ratio of bachelor and master degree, whereas the other two groups had a high ratio of diploma and associate degree.

Characteristics of the participants ( n  = 420)

Abbreviations: AA, Administrator assistant; CT , Critical thinking; GN, General nurse; NM, Nurses manager ; SD , standard deviation.

Chi‐square and one‐way ANOVA test; significant at * p  < .05; ** p  < .01; *** p  < .001.

Regarding work‐related factors, the characters of all participants and subjects in each group are also listed in Table  1 . The comparison of professional experience, such as duration of working as a nurse, duration of working in the current hospital, duration of working in this specific position and heard the terminology of "critical thinking" showed a significant statistical difference among the three groups ( p  < .001). They showed that NMs had a longer duration of working as a nurse (mean = 12.30, SD  = 7.12) and duration of working in the current hospital (mean = 11.6, SD  = 7.02) than the other two groups; GNs had the longest duration of working in the specific position (mean = 7.41, SD  = 6.21). More subjects in the NM group heard the terminology of "critical thinking" than subjects in the other two groups. However, none of the subjects had been exposed to critical thinking training or education. Furthermore, there was a positive correlation among age, the duration of working as a nurse, the duration of working in the current hospital and duration of working in a specific position ( r  = .78–.975, p  < .01).

4.2. Level of the critical thinking of the professional nurses

The mean of the total scores of the N‐CT‐4 Practice (V‐v) for all participants was 333.86 ± 40.22 (with the average score/item = 3.06 ± 0.37), the median score was 331 (interquartile range [IQR] = 311–359), and it ranged from 204–436, which indicates that they generally had a moderate level of critical thinking. Meanwhile, most of the participants reported a low (48.3%) or moderate (45.5%) level of critical thinking. Only 6.2% of the participants had a high level of critical thinking. Regarding the four dimensions of the N‐CT‐4 Practice (V‐v), the average sum score was 119.52 ± 14.19 (with the average score/item = 3.06 ± 0.36) in the personal dimension, 136.38 ± 17.62 (with the average score/item = 3.10 ± 0.40) in the intellectual and cognitive dimension, 68.71 ± 12.65 (with the average score/item = 3.44 ± 0.63) in the interpersonal and self‐management dimension and 18.09 ± 3.01 (with the average score/item = 3.01 ± 0.50) in the technical dimension.

4.3. Work‐related and personal‐related factors associated with critical thinking ability

There were statistically significant associations between the critical thinking ability and some work‐related factors, such as work position ( F  = 23.30, p  < .001), duration of working as a nurse ( r  = 0.15, p  < .01), duration of working in the current hospital ( r  = 0.13, p  < .05) and having heard the term "critical thinking" ( t  = −2.48, p  < .05; Table  2 ). The findings indicated that NMs had higher scores than GNs and AAs. Moreover, nurses who had worked for a longer duration as a nurse or worked longer in the current hospital had a higher critical thinking ability. Meanwhile, those who had not heard the term "critical thinking" had lower scores than participants who had heard this term.

Association between the participants’ characteristics and the critical thinking ability ( n  = 420)

The bolded values indicate the level of statistical significance (with p < .05; p < .01; or p < .001) between the independent and dependent variables.

Abbreviations: SD , standard deviation.

There were statistically significant associations between the critical thinking ability and some personal‐related factors, such as age ( r  = 0.12, p  < .05), gender ( t  = 2.32, p  < .05), ethnicity ( t  = 1.97, p  < .05), education level ( F  = 7.45, p  < .01) and health condition ( F  = 3.14, p  < .05; Table  2 ). The findings indicated that the older nurses reported a higher critical thinking ability, and male nurses had a higher score than female ones. Vietnamese participants had higher scores than participants with other ethnicities. Participants with a bachelor's/graduate degree level of education had higher scores than participants with a diploma and associate degree level of education. Those with very good health had a higher score than participants who rated their health as fair/bad/very bad.

All of the statistically significant variables identified in the univariate analysis were selected as independent variables to determine the predictors of critical thinking ability. For the regression analysis, the categorical variables were first coded as dummy variables. The factors of having never heard of “critical thinking,” being an NM being male, being Vietnamese, having a diploma degree and being in very good health were selected as the standard factors. The results of the stepwise multiple regression method showed that there were only two predictors, namely the variables of work position and gender. Working as an AA or GN or being female can predict the critical thinking ability, and they accounted for 11% of the total variance ( F  = 17.12, p  < .001). This indicates that the AAs and GNs had a lower level of critical thinking than the NMs. Besides, when compared with male nurses, the female nurses exhibited a lower level of critical thinking (Table  3 ).

Predictors of the critical thinking ability ( n  = 420)

5. DISCUSSION

This study showed that the critical thinking ability of most professional nurses was at a low or moderate level. This finding is consistent with previous studies (Chang et al.,  2011 ; Lang et al.,  2013 ; Zuriguel‐Pérez et al., 2018 ). Using the same tool, Zuriguel‐Pérez et al. ( 2018 ) found that the median score of the N‐CT‐4 Practice was 363 (IQR = 340–386) for clinical nurses in Spain. Our study found a slightly lower median score (331; IQR = 311–359) but it was still in a moderate level (range of score: 329–395). Although critical thinking is a relatively new issue in Vietnamese professional nurses, it is not a brand new concept. Certain elements have been included in the nursing curriculum and clinical practice (e.g. the nursing process, problem‐based learning, evidence‐based practice). Therefore, up to 66.7% of participants had never heard the term "critical thinking," but 45.5% still reported a moderate level when measured using the N‐CT‐4 Practice (V‐v).

In Vietnam, clinical professional nurses are categorized into NMs, GNs and AAs with different job descriptions. Critical thinking ability has been identified as an important component for the high quality of care around the world, except in Vietnam. In order to identify this ability, we collected data from 3 hospitals in one region and grouped these data for analysis. Based on the comparison among NMs, GNs and AAs, it was found that NMs had a higher level of critical thinking than GNs and AAs. This can be explained by the fact that NMs have a higher age, work experience and high educational qualification than the other two groups. This result partially supports the finding that NMs report a slightly higher level of critical thinking than RNs (Zuriguel‐Pérez et al., 2018 ). Critical thinking is a necessary skill for effective and efficient management. Evidently, at present, NMs with a high level of critical thinking create positive practice environments that can help the staff nurses to deliver high quality and safe patient care (Zori et al.,  2010 ). Therefore, all healthcare personnel needs to learn and apply critical thinking in order to conduct their work effectively and efficiently.

For clinical nurses, continuous in‐service education is very important to update their knowledge and skill of care. Literature found various factors associated with curriculum design and learning of critical thinking ability. Therefore, grouping subjects in the present study together in order to identify the related factors could help the development of further in‐service education of critical thinking ability effectively and efficiently. In this study, a statistically significant positive correlation was found between the critical thinking ability and age, the duration of working as a nurse and the duration of working in the current hospital. These findings are consistent with previous studies. For example, older nurses have a higher level of critical thinking than younger ones (Chang et al.,  2011 ; Chen et al.,  2019 ; Feng et al.,  2010 ; Ludin,  2018 ; Wangensteen et al.,  2010 ; Yurdanur,  2016 ; Zuriguel‐Pérez et al., 2018 ), and nurses with more experience report a better critical thinking ability than those with less experience (Chang et al.,  2011 ; Chen et al.,  2019 ; Feng et al.,  2010 ; Ludin,  2018 ). Older and experienced nurses are more mature in their way of thinking (Chen et al.,  2019 ; Ludin,  2018 ). Because there were statistically significant positive correlations among age, the duration of working as a nurse and the duration of working in the current hospital. This indicates that older nurses have a longer duration of working as a nurse or working in the current hospital so they have better critical thinking. However, the correlation between these factors and critical thinking in the current study is small; further explorations are suggested.

This study showed that there is a significant association between critical thinking ability and gender and ethnicity, which is also supported by the literature. Ludin ( 2018 ) found that female nurses reported a lower critical thinking ability than male nurses. Traditionally, females have generally had fewer opportunities to receive education and more difficulty asserting their rights during decision‐making than males in Vietnam (L. T. Nguyen et al.,  2017 ). Even today, the phenomenon of gender inequality still exists in certain areas in Vietnam. This traditional burden and the limited opportunities to practice in a clinical care setting might lower the levels of the female participants’ critical thinking. Ethnicity has a similar impact, as found in the present study. For example, it has been reported that Caucasian and Hispanic/Latino participants have a significantly higher critical thinking ability than African American participants (Lang et al.,  2013 ) and that Malaysian and Indian participants report different levels of critical thinking; nevertheless, only 0.9% of the participants were Indian (Ludin,  2018 ). However, in the present study, as almost all of the participants were Vietnamese (96.7%), the skewed distribution of the ethnicity might limit the generalizability of the results. In future studies, an equal distribution of ethnicity is strongly recommended.

This study also confirmed that those who had a bachelor's/graduate degree had a higher level of critical thinking than those who had a diploma or associate degree, even though the former had never heard the term "critical thinking." A vast amount of studies has found that education has a positive impact on the level of critical thinking (Chang et al.,  2011 ; Gloudemans et al.,  2013 ; Ludin,  2018 ; Yildirim et al.,  2012 ; Zuriguel‐Pérez et al., 2018 ). Meanwhile, this study found that participants who had heard the term "critical thinking" displayed a higher level of critical thinking than those who had not heard this term. Education might be the major reason for this variation. In the present study, only 40.7% of participants had a bachelor's/graduate degree. In order to promote their levels of critical thinking, it is necessary to arrange for them, to encourage them, to attend advanced education or to provide further content in the in‐service education.

In this study, participants with very good health had a higher level of critical thinking than participants who self‐rated their health as fair/bad/very bad. Health status does have an impact on work productivity, job performance, quality of care and extra learning (Letvak et al.,  2011 ). Thus, poor health limits their learning and critical thinking ability. This ability is an important predictor of real‐life outcomes (e.g. interpersonal, work, financial, health and education) (Butler et al.,  2017 ). Therefore, the causal effects between health and critical thinking ability need further exploration.

In the current study, only the female gender and the type of work position as an AA or GN were identified as predictors, and they explained only 11% of the total variance of critical thinking ability in the regression model. The uneven distribution of gender and work position might be the reason for the low variance. Even though the male was significantly less than the female, NM was fewer than GN and AA. More factors need to be included in further studies.

The limitations of this study include that it used a convenience sample from only three public hospitals located in the Southwestern part of Vietnam. This sample does not represent all professional nurses in Vietnam. The N‐CT‐4 Practice is the instrument with good psychometric properties specific for clinical practice and translated into English (Zuriguel‐Pérez et al., 2017), Persian (FallahNezhad & Ziaeirad,  2018 ) and Turkish (Urhan & Seren, 2019 ). Different points of the Likert response format were selected by tools to measure critical thinking ability. For example, the N‐CT‐4 Practice selected a four‐point Likert response and it was rated in frequency, such as 1 = never or almost never and 4 = always or almost always. However, a seven‐point Likert scale for the Critical Thinking Disposition Assessment (CTDA) was selected and rated in levels of agreement, such as 1 for very strongly disagree and 7 for very strongly agree (Cui et al.,  2021 ). Which response format can be more reprinting the characters of critical thinking ability? Further investigation is strongly suggested. Besides, the N‐CT‐4 Practice (V‐v) questionnaire has too many items that may lead to the boredom of the participants to answer and thus affect the accuracy of the results. Moreover, the collapsing of three distinctly separate groups of nurses into one group for most of the analyses lead to not showing differences in critical thinking and influencing factors among the three groups. These factors all limit the generalization of the present results. Based on these limitations, it is suggested that the use of nationwide systematic sampling and an international comparison are strongly suggested in further studies. Regarding the critical thinking questionnaire, it would be better to use the revised versions with fewer questions. Therefore, developmental and psychometric properties are suggested to shorten this questionnaire.

6. CONCLUSIONS

The results demonstrate that most of the professional nurses had a low or moderate critical thinking ability. Certain personal and occupational variables were significantly associated with the level of critical thinking. Being male or working as an NM were statistically significant predictors of critical thinking ability, and they explained only 11% of the total variance.

The findings of this study indicate that it is necessary to develop strategies to improve the critical thinking ability of professional nurses. The critical thinking ability has been confirmed to be an essential factor for high‐quality health care that focuses on the quality of patient care and patient safety. Besides, providing more opportunities to pursue advanced degrees or enhancing the provision of in‐service education in hospitals that involves classroom teaching or web‐based learning is strongly recommended for this specific group of nurses. Consequently, the quality of patient care could be improved.

CONFLICT OF INTEREST

The authors declare that they have no competing interests.

ACKNOWLEDGEMENTS

The authors would like to thank the expert panel, translators, research assistants, the hospitals and all of the clinical nurses who participated in this study. We are indebted to the study participants and would like to dedicate the research findings to improving the critical thinking ability of Vietnamese professional nurses in the future. No specific grant was received from funding agencies in the public, commercial, or not‐for‐profit sectors.

Van Nguyen T, Liu H‐E. Factors associated with the critical thinking ability of professional nurses: A cross‐sectional study . Nurs Open . 2021; 8 :1970–1980. 10.1002/nop2.875 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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Why Critical Thinking Skills in Nursing Matter (And What You Can Do to Develop Them)

By Hannah Meinke on 07/05/2021

The nursing profession tends to attract those who have natural nurturing abilities, a desire to help others, and a knack for science or anatomy. But there is another important skill that successful nurses share, and it's often overlooked: the ability to think critically.

Identifying a problem, determining the best solution and choosing the most effective method to solve the program are all parts of the critical thinking process. After executing the plan, critical thinkers reflect on the situation to figure out if it was effective and if it could have been done better. As you can see, critical thinking is a transferable skill that can be leveraged in several facets of your life.

But why is it so important for nurses to use? We spoke with several experts to learn why critical thinking skills in nursing are so crucial to the field, the patients and the success of a nurse. Keep reading to learn why and to see how you can improve this skill.

Why are critical thinking skills in nursing important?

You learn all sorts of practical skills in nursing school, like flawlessly dressing a wound, taking vitals like a pro or starting an IV without flinching. But without the ability to think clearly and make rational decisions, those skills alone won’t get you very far—you need to think critically as well.

“Nurses are faced with decision-making situations in patient care, and each decision they make impacts patient outcomes. Nursing critical thinking skills drive the decision-making process and impact the quality of care provided,” says Georgia Vest, DNP, RN and senior dean of nursing at the Rasmussen University School of Nursing.

For example, nurses often have to make triage decisions in the emergency room. With an overflow of patients and limited staff, they must evaluate which patients should be treated first. While they rely on their training to measure vital signs and level of consciousness, they must use critical thinking to analyze the consequences of delaying treatment in each case.

No matter which department they work in, nurses use critical thinking in their everyday routines. When you’re faced with decisions that could ultimately mean life or death, the ability to analyze a situation and come to a solution separates the good nurses from the great ones.

How are critical thinking skills acquired in nursing school?

Nursing school offers a multitude of material to master and upholds high expectations for your performance. But in order to learn in a way that will actually equip you to become an excellent nurse, you have to go beyond just memorizing terms. You need to apply an analytical mindset to understanding course material.

One way for students to begin implementing critical thinking is by applying the nursing process to their line of thought, according to Vest. The process includes five steps: assessment, diagnosis, outcomes/planning, implementation and evaluation.

“One of the fundamental principles for developing critical thinking is the nursing process,” Vest says. “It needs to be a lived experience in the learning environment.”

Nursing students often find that there are multiple correct solutions to a problem. The key to nursing is to select the “the most correct” solution—one that will be the most efficient and best fit for that particular situation. Using the nursing process, students can narrow down their options to select the best one.

When answering questions in class or on exams, challenge yourself to go beyond simply selecting an answer. Start to think about why that answer is correct and what the possible consequences might be. Simply memorizing the material won’t translate well into a real-life nursing setting.

How can you develop your critical thinking skills as a nurse?

As you know, learning doesn’t stop with graduation from nursing school. Good nurses continue to soak up knowledge and continually improve throughout their careers. Likewise, they can continue to build their critical thinking skills in the workplace with each shift.

“To improve your critical thinking, pick the brains of the experienced nurses around you to help you get the mindset,” suggests Eileen Sollars, RN ADN, AAS. Understanding how a seasoned nurse came to a conclusion will provide you with insights you may not have considered and help you develop your own approach.

The chain of command can also help nurses develop critical thinking skills in the workplace.

“Another aid in the development of critical thinking I cannot stress enough is the utilization of the chain of command,” Vest says. “In the chain of command, the nurse always reports up to the nurse manager and down to the patient care aide. Peers and fellow healthcare professionals are not in the chain of command. Clear understanding and proper utilization of the chain of command is essential in the workplace.”

How are critical thinking skills applied in nursing?

“Nurses use critical thinking in every single shift,” Sollars says. “Critical thinking in nursing is a paramount skill necessary in the care of your patients. Nowadays there is more emphasis on machines and technical aspects of nursing, but critical thinking plays an important role. You need it to understand and anticipate changes in your patient's condition.”

As a nurse, you will inevitably encounter a situation in which there are multiple solutions or treatments, and you'll be tasked with determining the solution that will provide the best possible outcome for your patient. You must be able to quickly and confidently assess situations and make the best care decision in each unique scenario. It is in situations like these that your critical thinking skills will direct your decision-making.

Do critical thinking skills matter more for nursing leadership and management positions?

While critical thinking skills are essential at every level of nursing, leadership and management positions require a new level of this ability.

When it comes to managing other nurses, working with hospital administration, and dealing with budgets, schedules or policies, critical thinking can make the difference between a smooth-running or struggling department. At the leadership level, nurses need to see the big picture and understand how each part works together.

A nurse manager , for example, might have to deal with being short-staffed. This could require coaching nurses on how to prioritize their workload, organize their tasks and rely on strategies to keep from burning out. A lead nurse with strong critical thinking skills knows how to fully understand the problem and all its implications.

• How will patient care be affected by having fewer staff?
• What kind of strain will be on the nurses?

Their solutions will take into account all their resources and possible roadblocks.

• What work can be delegated to nursing aids?
• Are there any nurses willing to come in on their day off?
• Are nurses from other departments available to provide coverage?

They’ll weigh the pros and cons of each solution and choose those with the greatest potential.

• Will calling in an off-duty nurse contribute to burnout?
• Was this situation a one-off occurrence or something that could require an additional hire in the long term?

Finally, they will look back on the issue and evaluate what worked and what didn’t. With critical thinking skills like this, a lead nurse can affect their entire staff, patient population and department for the better.

Beyond thinking

You’re now well aware of the importance of critical thinking skills in nursing. Even if you already use critical thinking skills every day, you can still work toward strengthening that skill. The more you practice it, the better you will become and the more naturally it will come to you.

If you’re interested in critical thinking because you’d like to move up in your current nursing job, consider how a Bachelor of Science in Nursing (BSN) could help you develop the necessary leadership skills.

EDITOR’S NOTE: This article was originally published in July 2012. It has since been updated to include information relevant to 2021.

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Hannah Meinke

Posted in General Nursing

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How to CRITICALLY THINK in Nursing School (Your COMPLETE Step-By-Step Guide)

Clinical , Med Surg

In this video, I’m walking you through the step-by-step process for how to critically think in nursing school.

I always found it crazy that when you get to nursing school, everyone throws around this phrase “critical thinking,” and they all expect you to know how to do it. But no one tells you what it even means!

So I’m going to walk you through how to critically think, step-by-step, so that you can FINALLY understand it and start doing it in nursing school.

HERE’S A BREAKDOWN OF WHAT WE’LL TALK ABOUT:

Planning ahead (1:22)

Connecting the dots (3:02)

Critical Thinking Model (4:50) D: Definition/Description (5:19) R: Reason/Rationale (5:55) C: Connection (6:22)

Cardiac Example (6:43) D: Definition/Description (6:55) R: Reason/Rationale (7:22) C: Connection (8:42)

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The Nursing Process and Critical Thinking (Step by Step)

VIDEO TRANSCRIPT

In this video, I’m walking you through the step-by-step process for how to critically think in nursing school. I always found it crazy that when you get to nursing school, everyone throws around this phrase “critical thinking,” and they all expect you to know how to do it. But no one tells you what it even means! So I’m going to walk you through how to critically think, step-by-step, so that you can FINALLY understand it and start doing it. So hit that subscribe button and click the notification bell and let’s dive in.

So here’s the BEST news about critical thinking in nursing school: there’s really only 2 main parts to it,

• Planning ahead
• Connecting the dots between all the things you’re learning

That’s it. Doesn’t sound so bad, right?

But the problem is, actually being ABLE to plan ahead AND connect the dots. That is not an easy task. Thankfully, I have a step-by-step process that I’m going to walk you through to show you exactly how to connect the dots and critically think in nursing school. We’ll get to that in a minute. I also have a free critical thinking cheat sheet that walks you through this as well. The link is in the description below, so be sure to get it after watching this video, because it will REALLY help you as you study for your classes.

First, let’s talk about what it actually MEANS to plan ahead and connect the dots, and then we’ll dive into the nitty gritty on how to do it.

Planning ahead means, pretty much like it sounds, you’re always planning the next thing. You’re always thinking about your next move as a nurse. So if you’re going into a patient’s room,

• What are you going to do?
• What supplies do you need?
• Do they need water or an extra gown?
• Is their meal tray ready?
• What are you going to do when you’re in the room?
• Are you going to do an assessment and give meds?
• Flush their IV?
• Check their drains?

You should always have your game plan laid out BEFORE you walk into a patients room.

I had an instructor in nursing school who was absolutely brilliant, I totally loved her, she was the best. She had this rule that you had to do AT LEAST 3 THINGS every time you walked into a patients room. You had to batch your tasks and have a plan BEFORE you went in.

And throughout the clinical day, batching our tasks like this really added up so a LOT of time saved. So instead of going back and fourth, in and out of the room to grab random supplies or things, we always had a game plan going in, and knew what tasks we were going to do in the room. And it had to be AT LEAST 3 . And trust me, she would catch us and ask right before we walked into the patients room, so we always had to be prepared.

So that is planning ahead. You always need to be one-step ahead and know what you’re going to do next.

Thankfully, that part of critical thinking is pretty easy and straightforward.

Connecting the dots, however, is really where the fun starts to happen.

Connecting the dots in nursing school means that you’re comparing and contrasting all of the topics and concepts you’re learning about. You’re putting all the puzzle pieces together, both during lecture class, skills lab, and clinical.

So you understand the disease process of what’s going on with your patient, and you understand how that disease process is causing the signs and symptoms their showing, you know what to assess for, and you know what nursing interventions you expect to do.

This isn’t just memorizing a list of signs and symptoms and assessments, though. Critical thinking means that you’re able to compare and contrast it with other disorders, and put 2 and 2 together.

Don’t worry, I’m going to walk you through an example in a minute, so hang tight. This is ALL going to come together for you!

Before we get there, though, I want to give a shout out to Keona for our YouTube comment of the week, which says,

“This has helped me so much with understand. I need things to be broken down like this, I get it and don’t feel overwhelmed. That textbook can be intimidating! Thank you so much!”

Oh my, I TOTALLY agree. Those textbooks are filled with so much info, it can be super hard to know what to focus on and study. I’m so glad our videos have helped you out, friend! Thanks so much for being here!

And keep your comments coming. We read and respond to every one, and they make me so happy! Thank you so much for all of your support, you’re the BEST !

Now, as promised, let’s dive into exactly HOW to critically think.

I’m going to walk you through the CRITICAL THINKING MODEL , which is a model I created to walk you through exactly HOW to critically think, step-by-step.

Using this CRITICAL THINKING MODEL is going to be the difference between getting an A on an exam, and getting a C. You absolutely MUST know how to critically think to be successful in nursing school, pass your exams, and be a rock star at clinical.

So let’s walk through it and I’ll show you exactly how to do it:

The first step is the D, which stands for definition or description.

This is the very high level part, but we have to start here before we can move onto the other steps. Because if you don’t understand the basics, you won’t be able to understand the deeper level stuff.

So this means you’ll write out what it is, what you need to know about it, or what the description is of it.

And don’t worry, I’m going to put all this to an example here in a minute, so stay with me. It will all come together for you.

So the first step is the D, what’s the definition or description of the topic you’re learning about?

Now the next step is the R, which stands for reason or rationale.

This is the WHY behind the topic. You’ll write out WHY it happens and WHY it matters. This is the reasoning behind it. And most often, this step will be related to the pathophysiology. So if you’re studying a particular disorder and are writing out WHY it happens, this is where you’ll dive into the pathophysiology of what’s happening with the disorder.

Now, the next step is the C, which stands for connection.

This is really where your critical thinking skills will shine! You’ll connect the topic to everything else you’re learning about in nursing school. This is the HOW : how does this topic connect to everything else? This is where it really all starts to come together.

Okay, so now that we’ve gone over what it looks like, let’s put it to an example.

Let’s take a really complex example, like the cardiac system, and I’ll show you how this DRC CRITICAL THINKING MODEL works.

So the first step is the D: definition or description.

So the description of the cardiac system is that it pumps blood through the body, right? It contains the heart, the blood vessels, and the blood. And when it all works together, the heart pumps the blood into the blood vessels, to the organs, and then the blood comes back to the heart to be circulated again. That’s really the cardiac system in a nutshell, right?

So let’s move onto the deeper level, the R, which stands for reasoning or rationale.

So WHY does this matter? WHY is the cardiac system important? What’s the point?

So here we could write out what it’s purpose is and what it does, so WHY does it matter. Well, the blood in the cardiac system is rich with nutrients and oxygen, which are 2 things the organs need to function. Without those nutrients and the oxygen, the organs would fail, right?

The blood also takes AWAY deoxygenated blood and waste products from the organs. So as the organs and body tissues function throughout the day, they create waste products like carbon dioxide and lactic acid. It’s the bloods job to take these waste products and take them to where they need to go, so they can be removed from the body.

If the blood didn’t do it’s job, those waste products could build up to toxic levels in the body and cause major issues, like METABOLIC ACIDOSIS .

And no worries, if you need a refresher on the pathway of blood flow through the heart and how it all works, you can check THIS video out right here.

So that’s the R part of the DRC CRITICAL THINKING MODEL for the cardiac system: it transports nutrients and oxygen to the body tissues, and removes toxic waste products that the tissues don’t need.

Now, let’s move into the really good part, the C, which stands for connection.

How does the cardiac system CONNECT with everything else you’re learning in nursing school?

This is where the fun really begins!

The cardiac system really affects the entire body, but let’s focus on 2 main areas that it impacts:

• The kidneys

So in nursing school, you’ll probably study the respiratory system along with the cardiac system, and you might even study the renal system and kidneys along with it to, so that’s why I want to connect all 3 of those together for you. I’m basically going to give you all the answers here.

So let’s walk through it:

The cardiac system sends blood to all the other organs and tissues in the body, including the lungs and the kidneys.

So if the heart is pumping fine and the blood is circulating properly, the lungs and kidneys are happy campers and they can do their job just fine.

BUT , if the heart starts to fail, or the blood isn’t able to circulate properly, then that’s where we start to see problems.

If the blood isn’t able to get pumped out of the heart and move FORWARD to the body, then it is going to stagnate and stay in the heart, and back up in the system. And where’s the first place it’s going to back up into? The LUNGS ! If the left ventricle can’t pump blood to the body, it’s going to back up into the LUNGS !

Now, this will lead to a whole bunch of problems. What do you think will happen to the lungs when they have extra blood and fluid in them? Well, they’ll get filled with that fluid, right? So when you listen with your stethoscope, you will probably hear crackles, which are caused by all that fluid build up. Your patient may also have trouble breathing, since their lungs aren’t able to do all the gas exchange they need to because they have that layer of fluid in the lungs.

Now on the cardiac side, if blood isn’t going to the rest of the body, including the kidneys, what would you expect to see?

I’ll give you a few seconds to think about it, I know you can do it!

Okay, so if the heart isn’t able to pump blood to the rest of the body, including the kidneys, what would you expect to see? The first thing that came to my mind was a decreased urine output. If the kidneys aren’t getting enough blood, they aren’t going to be able to do their job and make urine, right? So they will have a decreased urine output.

On top of that, if the heart isn’t pumping blood to the body, you’ll probably notice that it’s harder to feel the patients pulses in their wrists or feet. If the blood isn’t pumping there as much, their pulses will be decreased. Their hands and feet might also be colder and pale since there’s not as much blood circulating to warm them up.

So you see how all of these things connect together? This is exactly what you’ll walk through during step number 3 of the DRC CRITICAL THINKING MODEL : connect the dots with everything else that you’re learning.

Really challenge yourself here. I don’t want you to stay high-level and call it good. No, I want you to dig deep and really try to put the concepts together.

If you’re a NursingSOS Member, be sure to log-into your dashboard and find the course that goes along with what you’re studying in class and watch those videos if you need help with it. I’ll walk you through the critical thinking for all of it, so it will make this process a whole lot easier for you!

Now in the next video, I’m going to tell you the TOP HABITS of highly successful nursing students. So if you want to succeed in nursing school, make sure you’re doing these things, they are super important!

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• Open access
• Published: 23 August 2024

Think-aloud approach combined with case-based learning in nursing teaching round for new nurses in cancer hospital

• Rui Zhao 1 ,
• TingTing Ding 2 ,
• JinPing Meng 2 ,
• Miao Lei 2 &
• Huili Ma 2  

BMC Medical Education volume  24 , Article number:  916 ( 2024 ) Cite this article

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The transition from nursing students to working as new nurses can be a challenging process. This study aimed to assess the efficacy of a pedagogical approach amalgamating the think-aloud approach and case-based learning in the instructional rounds for new nurses.

Utilizing convenience sampling, new nurses were selected between 2020 and 2021 in China cancer hospital. A total of 98 participants agreed to participate, with 50 enrolled in 2020 as the control group and 48 in 2021 as the observation group. Across a span of weeks 1, 3, 5, 7, 9, and 11, each clinical department conducted six teaching rounds. The observation group engaged in teaching rounds combining the think-aloud approach with case-based learning, whereas the control group solely utilized case-based learning. Disparities in case analysis scores and critical thinking ability between the two groups were scrutinized, alongside an analysis of learning strategies and the observation group feedback.

The observation group exhibited superior case analysis scores (91.92 ± 6.33) and overall critical thinking ability scores (308.39 ± 35.88) in comparison to the control group, which scored (85.27 ± 5.39) and (275.11 ± 31.32) respectively, reflecting statistically significant variances ( t  = 1.868 ~ 6.361, P  < 0.05). Predominant learning strategies employed in the observation group ranged from cognitive to meta-cognitive, followed by psychosocial strategies. During interviews focused on nurses’ feedback on the learning process, themes emerged surrounding the enhancement of learning proficiency, invigoration of learning enthusiasm, and bolstering psychological well-being.

The combination of think-aloud approach and case-based learning in nursing teaching rounds greatly improves the efficiency of training and the critical thinking acuity of new nurses. Concurrently, it facilitated an evaluation of learning strategies, thereby offering valuable insights for the nursing teaching rounds of new nurse.

Peer Review reports

By the year 2020, China boasted a staggering registration of approximately 4.45 million nurses [ 1 ], a figure that has sparked projections suggesting a necessity for 8.18 nurses per 1,000 individuals by the year 2030 [ 2 ]. This surge indicates a forthcoming influx of new nurses into clinical settings. New nurses training is an essential component of hospital nurse training programs, aiding new nurses in addressing challenges during the transition from nursing students to clinical nurse roles [ 3 ]. China’s National Health and Wellness Commission has issued the Training Syllabus for Newly Entered Nurses as a guiding document for in-service education. However, there is currently no unified training system or standard. The training content of most hospitals includes theoretical training and skill training, and there exists a single training method, which cannot motivate the enthusiasm of nurses for training, and the training effect is not satisfactory [ 4 ]. Notably, the incidence of adverse nursing events among those with less than two years of experience stands at 61.4% [ 5 , 6 ].

Teaching rounds stand out as a cornerstone for fostering nursing practical education, was deemed one of the most efficacious methods for both learning and instructing in the nursing domain [ 7 ]. Serving as a vital component of nurses’ clinical practice, these rounds offer a platform to seamlessly blend theoretical knowledge with hands-on practice, thereby nurturing the quality of nursing care and refining interpersonal competencies among trainees [ 8 ].Ward rounds, intricate and multifaceted processes, demands a fusion of medical expertise and non-technical proficiency [ 9 ]. Medical education has leveraged ward-round teaching to augment students’ prowess in patient assessment, management, and nontechnical skills [ 10 ]. In nursing practice education, teaching ward rounds play an important role in elevating the standards of nursing students and practitioners, ultimately upholding the quality of nursing services [ 11 ].

Case-based learning (CBL), the most common method of ward rounds during ward rotations, is a student-centered, case-based approach to teaching [ 12 ]. Medical knowledge is applied to clinical cases, allowing students to apply clinical reasoning and decision-making at all stages of the clinical case management process [ 13 ]. However, some studies have found that students’ participation is uneven during CBL implementation, which is not conducive to their knowledge acquisition and clinical reasoning ability [ 14 ]. Therefore, clinical instructors should actively improve their teaching methods to enhance the effectiveness of training.

Think-aloud (TA) approach as a teaching method suitable for individuals and groups, also recognized as the “oral report method” or “thinking aloud,” entails articulating thought processes verbally [ 15 ], which finds utility among educators in medical and nursing training settings to enhance students’ knowledge acquisition and clinical reasoning ability [ 16 ]. Applying the TA approach to the “Geriatric Nursing” case discussion class for undergraduate nursing students has demonstrated significant improvements in training performance, clinical reasoning, and critical thinking skills [ 17 ]. By verbalizing and elucidating their thoughts, students can discern and structure pertinent information, thereby making decisions geared towards resolving clinical dilemmas [ 18 ]. As an effective teaching approach, TA posits that cognition operates like an ancient city of information processing, where language serves as a window into the cognitive process. By verbalizing their thoughts, students continuously process and refine their thinking independently, thereby enhancing their clinical reasoning and critical thinking skills. This approach not only fosters independent thinking but also enhances students’ active participation and engagement.

Cancer as one of the most traumatic diseases, imposes significant physical, psychological, and social burdens on patients throughout the treatment process [ 19 ].

Nurse as the primary caregivers of cancer patients, assume multiple roles including assessment, decision-making, treatment, care, and education throughout the diagnostic and treatment process. This multifaceted responsibility implies higher requirements for the clinical practice skills of nurses in oncology hospitals.However, the application of TA approach combined with CBL in nursing teaching rounds for new nurses has not been thoroughly explored.

Therefore, this study incorporates these two methods into the nursing training program for new nurses in oncology hospitals, aiming to assess the efficacy of a pedagogical approach amalgamating the TA approach and CBL in the instructional rounds for new nurses. This integration of pedagogical methods is intended to elevate the clinical practice competencies of new nurses and to address critical challenges in key areas of nursing education and training.

Participants

Convenience sampling was used to select new nurses from Henan Cancer Hospital between 2020 and 2021. As a 3 A specialized cancer institution, Henan Cancer Hospital not only boasts a national key specialty nursing status but also serves as a pivotal educational hub for national nursing science, accommodating over 3,000 beds and employing nearly 1,800 skilled nurses. The study included new nurses and those with less than two months of experience in clinical nursing roles. Participants who resigned or were absent from their positions for over a month during the study period were excluded. Ethical guidelines were strictly adhered to, with all participants providing informed consent subsequent to a comprehensive elucidation of the study’s objectives and design, facilitated by ethics approval number 2020-KY-0092. The participants were classified into observation and control group based on their year of employment, with the control group comprising 50 nurses recruited in 2020 and the observation group consisting of 48 nurses enrolled in 2021. As per the training schedule for new nurses, six departments were designated for the teaching rounds: neck and thyroid surgery, bone and soft tissue surgery, thoracic surgery, general surgery, breast surgery, and hepatobiliary surgery.

Training design

Aligned with the training program for new nurses, both groups curated typical cases within their respective rotating specialties for the teaching rounds, with a specific focus on head-neck and thyroid surgeries, exemplifying diseases like thyroid tumours, laryngeal tumours, oral and maxillofacial tumours for head-neck thyroid surgery, and oesophageal and lung cancers for thoracic surgery. Commencing in the second month following the nurses’ induction, each rotation department organized six nursing teaching rounds in weeks 1, 3, 5, 7, 9, and 11.

Control group

This group embraced the cbl.

First, pre-teaching preparation encompassed enlightening the nurses in the control group about the definition, utility, and nuances of the case teaching method. Clinical nursing instructors handpicked illustrative cases tailored to the diseases prevalent in the specialized rotations, demystified the purpose and methodologies employed during rounds to new nurses, and elucidated clinical intricacies in tandem with case data.

Second, during teaching rounds, lasting 60–70 min, the patient’s primary concerns were documented within the wards, followed by a comprehensive physical assessment. Subsequent deliberations ensued within office settings, deliberating on the chief clinical complaints, physical findings, and diagnostic outcomes, culminating in nurse evaluations, tailored diagnoses, the formulation of precise nursing strategies, and the articulation of nursing objectives. The session concluded with the new nurses presenting their findings to the group.

Finally, post-teaching round summaries lasted 5–10 min, wherein clinical teaching personnel encapsulated key revelations, navigated challenges encountered, dissected pinpointed issues, and proposed enhancements.

Observation group

This group combined TA approach and CBL.The observation group differed from the control group in several key aspects. It was based on the observation group using CBL with the addition of the TA approach. The TA approach includes theoretical knowledge training, “three step” thinking path training, and think-aloud method case reporting, which are steps not included in the control group.

First, establishment of a teaching round research group comprising 11 members, spearheaded by the deputy director of the nursing department overseeing nursing instruction, six nursing teaching leaders, and four clinical nursing educators—all holding supervisory nurse titles or higher with over 5 years of oncology specialty teaching experience. The research team leader, deputizing the nursing department, was entrusted with formulating the intervention plan, ensuring quality control, and supervising implementation.

Second, based on the initial draft of the intervention design developed from the literature review, the intervention was refined through consultations with experts in nursing, education, and psychology. culminating in a pilot trial encompassing three new nurses to streamline operational details like seating arrangements during bedside rounds and optimal positioning of video equipment during presentations, eventually leading to the finalization of a comprehensive intervention scheme for nursing rounds incorporating the TA approach.

Third, theoretical knowledge training and"three step” thinking path training were conducted for new nurses. The theoretical knowledge training totaled 3 times. The “three step” thinking path training was initially modeled by the trainers using case studies, followed by the students presenting and reporting the process, with trainers providing face-to-face guidance.

Finally, typical cases were selected, and the new nurses were informed in advance to prepare their knowledge related to these cases. The personnel were then organized into small groups. This was followed by bedside rounds, case reports using TA approach, and discussions and summaries after the nursing rounds. The detailed procedures and case presentations for the educational observation group are provided in Table  1 .

Basic demographic and baseline information of the new nurses, including gender, age, education level, case analysis scores, and critical thinking ability scores, were collected one week prior to the commencement of the nursing teaching rounds. To evaluate the effectiveness of the nursing teaching rounds, both groups of nurses were assessed for case analysis scores and critical thinking ability scores one week post-training. Additionally, to assess the learning strategies of the new nurses, the observation group provided feedback and evaluated the learning strategies of the new nurses following the nursing teaching rounds.

Scores of case analysis

Assessment outcomes of case analysis were meticulously orchestrated by the team, incorporating a structured case analysis assessment test featuring aptly challenging cases mirroring the rotation specialties, distinctly apart from those explored in nursing teaching rounds. Conducted in a closed-book format, the assessment necessitated nurses to address key components—nursing assessment, diagnosis, plan, implementation, and evaluation—based on case particulars. Each facet carried a weight of 20 points, accumulating to a maximum score of 100 points. The Scale-level Content Validity Index (S-CVI/AVe) of the paper was 0.804. Pre-and post-nursing teaching round case analyses were independently evaluated, supervised by educational leaders within each subspecialty. An impartial, non-research team instructor evaluated responses in congruence with confirmed solutions.

Critical thinking ability

Evaluation of critical thinking abilities bore precedence prior to and after the teaching rounds, leveraging the Chinese version of the Critical Thinking Ability Scale revised by Peng in 2004 [ 20 ]. This evaluation encompassed seven dimensions—truth-seeking, open-mindedness, analytical prowess, systematic thinking, self-assurance, curiosity, and cognitive maturation—featuring 70 items. Employing a 6-point Likert scale, scores spanned from 70 to 420, with responses gauging levels of agreement ranging from “strongly agree” to “strongly disagree,” whereby negative items commanded scores from 1 to 6, and positive items from 6 to 1. The scale demarcated negative, indeterminate, positive, and robust critical thinking tendencies based on total score brackets [ 21 ]. Noteworthy reliability encountered through Cronbach’s α coefficient was 0.802, with dimensions fluctuating within the range of 0.653 to 0.865.

Learning strategy

The analysis of learning strategies includes four steps: transcription of video materials, evaluation of data reliability and validity, inclusion of qualified data, and classification and frequency statistics of strategies. In this study, the above steps were meticulously reviewed, evaluated, and statistically analyzed by two clinical teachers to ensure the accuracy of the results.Subsequent analysis by the research team delved into the application of learning strategies, categorizing them into meta-cognitive, cognitive, and social-emotional paradigmss [ 22 ]. The strategy distribution encapsulated the strategic landscape exhibited in specific cognitive behaviors, encompassing the types and utilization frequencies of distinct strategiess [ 23 ]. The assessment of the reliability and validity of learning strategy data utilized a logical rather than a statistical approach, including 11 evaluation criteria [ 18 ]. Reliability indicators included ensuring that the data were not collected under inspiration or guidance and that the data were not fabricated by the subjects to suit or cope with the tester. Validity checks included the tester’s experience with audible thought data collection, the representativeness of the selected sample, technical and psychological training for subjects, a suitable testing environment, clear and reliable video quality, cumulative silence in videotaped material not exceeding 10% of the total test time, and strict adherence to transcription norms. Shared indicators for reliability and validity included data from subjects with good cooperative attitudes and no unforeseen conditions (e.g., psychological or health issues) affecting subjects and testers before and during the test. The reliability and validity analysis of the strategic data in this study was completed by two researchers over two rounds: initially, each researcher assessed separately, followed by a joint assessment, and data were included in the analysis only after reaching mutual agreement.

Learning feedback

Elicitation of learning feedback within the observation group transpired through individual interviews, soliciting new nurses’ perspectives and suggestions concerning the teaching rounds model. The interview framework was informed by existing literature and insights from nursing education experts [ 24 , 25 ], refined through a preliminary trial involving two participant nurses. The guide encompassed nuanced queries probing the novices’ sentiments post-teaching experience, their perceived learning gains, recommendations for enhancing teaching rounds, and a reflective assessment of encountered challenges and resolution pathways. Each interview spanned 15–20 min and participants were transparently briefed that recordings would be preserved anonymously, with a mandate allowing them to cease participation at their discretion. The overarching goal and logistics of the interview were communicated before initiation, with the qualitative sample size dictated by data saturation. Iterative queries post-interview were posed to elicit comprehensive feedback, the cease of interviews transpired upon attaining saturation, with transcripts transcribed into textual data. Noteworthy, feedback themes from nursing rounds underwent analysis encompassing the Colaizzi method underpinned by thematic analysis framework.

Statistical analyses

Data input was meticulously cataloged using an Excel spreadsheet, subjected to dual verification to guarantee precision, with analyses conducted through SPSS 21.0 software. Descriptive statistics incorporating mean and standard deviation statistics encapsulated age, case analysis scores, and critical thinking ability scores, whereas gender, educational background, sole child status, and learning strategies were articulated through frequency and percentage statistics. Age, case analysis scores, and critical thinking ability scores among nurses in the two groups underwent comparison via T-tests, whereas educational background, sole-child status, and gender patterns were scrutinized throughχ 2 tests. Statistical significance was stipulated at P  < 0.05.

Baseline data

The mean ages of the nurses in the control and observation group were 23.46 ± 1.33 and 23.73 ± 1.29, respectively. The mean case analysis results for the control and observation group were 83.15 ± 3.76 and 84.24 ± 3.95, respectively. Notably, there were no statistically significant disparities in baseline data between the two cohorts of new nurses, as delineated in Table  2 .

The mean case analysis scores of new nurses in the control group (90.33 ± 6.17) lagged behind those in the observation group (95.49 ± 6.62), with a statistically significant difference observed ( t  = 3.988, P  < 0.001).

Subsequent to the teaching rounds, discernible discrepancies in critical thinking prowess emerged between the observation and control groups, save for the cognitive maturity dimension, where distinctions were statistically significant ( P  < 0.05), depicted in Table  3 .

Learning strategies analysis

A corpus of 98 videos was amassed for meticulous scrutiny. Post-examination for reliability and validity, 90 written transcriptions met the stringent inclusion criteria, while eight entries were extirpated; three owing to prolonged periods of reporter silence exceeding 10% of the total video duration, and five due to noncompliant transcription standards. These revelations are detailed in Table  4 .

Feedback of the new nurses on the nursing rounds using TA approach

A dozen nurses underwent individual interviews, eliciting feedback spanning diverse themes inclusive of honing independent cogitation and swift responsiveness, refining verbal dexterity and logical ratiocination, stimulating a vested interest in learning among peers, instilling personal confidence, nurturing proactive learning propositions, pre-round preparations, and bolstering psychological acumen. The transcription of video materials served as a conduit for identifying knowledge lacunae and delineating precise learning objectives, thereby enriching the study’s efficacy.

The integration of the TA approach into teaching rounds for new nurses has proven instrumental in improving their clinical reasoning skills. Clinical reasoning, a multifaceted cognitive process encompassing the collection, analysis, evaluation, and prioritization of patient information, underwent a marked enhancement through this pedagogical intervention [ 26 ]. Findings underscored a significant disparity in case analysis scores, showcasing a superior clinical reasoning adeptness in the observation group compared to the control group, substantiating the method’s efficacy in fortifying nurses’ prompt and precise decision-making in intricate clinical scenarios, This is consistent with previous research findings [ 27 ]. The incorporation of TA not only empowered new nurses through three-step thinking path training but also fostered their engagement in autonomous thinking during case reporting, thereby galvanizing comprehensive learning experiences intertwined with modern educational techniques, optimizing the fusion of passive and active learning methodologies, and elevating learning efficiency. The interactive dialogue sessions post case reports further catalyzed a collaborative learning environment, fostering mutual knowledge exchange and concept application, thereby bolstering new nurses’ reflective learning practices and augmenting their clinical reasoning proficiency.

Furthermore, the implementation of the TA approach within nursing rounds evidenced a profound impact on enhancing critical thinking abilities among new nurses. Manifested through the amplification of cognitive faculties such as thinking, application, analysis, synthesis, and evaluation within varied scenarios [ 28 , 29 , 30 ], this approach fueled a transformative surge in individual and cumulative critical thinking scores in the observation group post-rounds, eclipsing those in the control group. Noteworthy dimensions like truth-seeking, open-mindedness, self-assurance, and curiosity exhibited substantive improvements among observation group nurses, accentuating the TA approach’s role in stimulating inquisitiveness and nurturing self-assurance. Augmented analytical and systematization competencies were also noted among the observation group, elucidating the tangible benefits derived from three-step thinking path training, independent case reporting utilizing TA approach, and immersive simulation exercises. These results mirror existing literature emphasizing TA approach’ s positive impact on clinical and critical reasoning abilities among nursing cohorts, substantiating the efficacy of this pedagogical approach in nurturing critical thinking skills within new nurses [ 32 , 33 ].

Moreover, the utilization of the TA approach in teaching rounds for new nurses heralded transformative benefits in adjusting training strategies within cancer hospitals. An in-depth analysis of learning strategies employed by the observation group during case reporting sessions unveiled an informative landscape of meta-cognitive, cognitive, and social/emotional strategies utilization rates. While cognitive strategies were prevalent, meta-cognitive strategies exhibited a noticeable gap, emphasizing the pivotal role of nurturing meta-cognitive aptitude in enhancing learning norms and overall educational quality [ 34 ]. Alarmingly low usage rates of social/emotional strategies signaled the imperative need for bolstering nurses’ psychological and team-oriented competencies. Clinical nursing leaders are urged to curate collaborative learning opportunities, foster psychological resilience, energize teamwork dynamics, and prioritize meta-cognitive training within the nursing curricula to foster holistic nursing skills development. The amalgamation of video-recorded case reports into written materials emerged as a valuable tool for educators and students alike, facilitating a nuanced comprehension of individual knowledge levels, thereby enabling tailored teaching and learning strategies for optimal pedagogical outcomes.

Limitations

There are some limitations to this study, in particular the lack of post-training follow-up assessment due to the rotation of new nurses every three months, which hindered long-term efficacy assessments. However, periodic quarterly evaluations serve as a robust mechanism to continually appraise clinical knowledge and practice quality among new nurses. Furthermore, the singular focus on a solitary cancer hospital could limit the study’s generalizability, warranting a multicenter, large-scale, long-term evaluation to comprehensively assess the TA approach’s industry-wide impact.

Conclusions

The integration of the TA approach has been correlated with enhanced clinical competencies among nurses, reflecting an intrinsic alignment with the dynamic demands of nursing practices within cancer hospital settings.

Data availability

The datasets used and analysed during the current study were available from the Correspondence author on reasonable request.

Abbreviations

Think-Aloud

Case-Based Learning

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Acknowledgements

We would like to thank all participants for their extraordinary patience in successfully completing the course. We would like to express our gratitude to the six nursing teaching team leaders for their specialized guidance.

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Nursing Department, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, 450008, PR China

Head and Neck Thyroid Surgery Department, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou,450008, PR China

TingTing Ding, JinPing Meng, Miao Lei & Huili Ma

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Contributions

RZ: wrote, reviewing and editing the main manuscript tex, methodology, data curation. TTD, JPM, ML, HLM : prepared Tables  1 , 2 , 3 and 4 , data collection. All authors reviewed the manuscript. All authors have approved the final article to be published.

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Correspondence to Rui Zhao .

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The study was reviewed and approved by the Ethics Committee of Henan Cancer Hospital.The project was also designed in accordance with the Declaration of Helsinki (beneficence, nonmaleficence, autonomy and justice). In our study, informed consent was obtained from all subjects. We guaranteed all the participants the confidentiality of their private information and their right to withdraw from the study at any stage.

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Zhao, R., Ding, T., Meng, J. et al. Think-aloud approach combined with case-based learning in nursing teaching round for new nurses in cancer hospital. BMC Med Educ 24 , 916 (2024). https://doi.org/10.1186/s12909-024-05891-4

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Received : 17 June 2024

Accepted : 12 August 2024

Published : 23 August 2024

DOI : https://doi.org/10.1186/s12909-024-05891-4

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Our kids are missing out on critical thinking

If we are to navigate the complex challenges of the 21st century, our understanding of and ability to teach critical thinking demands urgent attention

By Associate Professor Martin Davies , University of Melbourne

Published 28 August 2024

Critical thinking is more essential today than ever. The world faces numerous challenges that warrant urgent critical reflection – from climate change and wealth inequality to ongoing conflicts and resource shortages.

These crises are compounded by a growing crisis of confidence, marked by the spread of 'fake news ' and the erosion of trust in traditional institutions. The  January 6 US Capitol attack , exemplifies this breakdown, as does the deepening political polarisation in its aftermath.

There has been a hardening of views on both sides of the political spectrum since then.

The recent attempted assassination of former President Trump by a lone-wolf activist is not unusual in U.S. history.

However, the extent of political polarisation now seems to be framed by hostility and partisanship, the likes of which have not been seen since the civil rights era – or perhaps even earlier, the civil war of the mid-19th century.

People are increasingly unwilling to accept the status quo or the platitudes that politicians regularly serve up . Along with this, the rise of AI and technologies like ChatGPT has intensified scepticism about what we read, hear or see.

A recent Australasian Society for Computers in Learning in Tertiary Education (ASCILITE) presentation highlighted that, in this tech-dominated world, critical thinking is crucial for academic integrity.

They noted a troubling trend: learners are focusing more on 'How can I get this done?' rather than asking, 'Is this ethical?'.

Politics & Society

How disinformation is undermining our cities

Social media platforms like Facebook, X, and TikTok allow anyone to share information without filters for accuracy, leading to the widespread issue of “ truth decay ” – the idea that facts and critical analysis now play an ever-diminishing role in public life.

The media, too, has become susceptible to misinformation, often prioritising sensationalism over facts. Rather than serving as guardians of truth, they sometimes propagate falsehoods , making the need for critical thinking all the more urgent.

Paradoxically, while critical thinking is in decline, it is in high demand among an odd assortment of stakeholders – businesses, universities, governments, and venture capitalists.

According to the World Economic Forum's Future of Jobs report (2023-2027), "analytical thinking" – a synonym for ‘critical thinking’ – is the most sought-after skill across various industries worldwide.

In a survey of 803 companies employing 11.3 million workers across 27 industry clusters, critical thinking was considered more crucial than technological literacy, AI, talent management, leadership, multilingualism and even cybersecurity.

A 2017 report by the Australian government highlighted that the importance of critical thinking in job ads rose by 158 per cent, surpassing problem-solving, teamwork, communication skills and financial literacy.

It will apparently consume 3.8 billion more work hours by 2030.

Critical thinking certainly appears to be a skill ‘on the rise’ and central to employment in the new economy.

However, despite its importance, we don’t really know what critical thinking is . It is not even clear that critical thinking is principally, and just a “skill .”

Reports, institutions, and funding bodies might well be dedicated to a 'skill on the rise,'  but they might also be quite misinformed about the very thing they purport to foster in the population.

Tech savvy teaching of critical thinking

In the US, critical thinking has become an industry, with papers written on its application in fields as diverse as engineering and the military . Disturbingly however, many students show no significant improvement in critical thinking abilities after completing a college degree.

A recent OECD study involving 120,000 students from six countries found that one-fifth of students performed at the lowest level in critical thinking, with half performing at the two lowest levels.

A US study noted that 45 per cent of college students showed no significant gains in critical thinking, complex reasoning, or writing skills over their four-year degree.

Since the inception of the modern university in Bologna in 1088, critical thinking has been a desirable – arguably the most desirable– 'graduate attribute'.

But universities' claims that they teach critical thinking have been  under scrutiny for decades . Some employers argue that graduates no longer demonstrate the critical thinking skills they expect .

Some employers want to move away from a reliance on academic qualifications, preferring instead to 'train on the job'. Is declining critical thinking in the academy to blame?

Moreover, faculty members often demonstrate ignorance about the intellectual traits – known as ' dispositions ' – that are essential to critical thinking.

They are also unable to outline the differences between critical thinking and creative thinking, problem-solving or decision-making.

This raises doubts about their ability to teach it effectively .

Blind faith in Australia’s education ‘system’ is failing our kids

Socrates, through Plato’s dialogues, can perhaps lay claim to being one of the earliest exponents of what we now call 'critical thinking'.

By maintaining his ignorance, Socrates asked probing questions that undermined staunchly held views on subjects like 'truth', 'beauty' or 'justice'.

By questioning and dismantling the assumptions of others, Socrates exemplified critical thinking in its purest form: the re-evaluation of certainties and the testing of claims against stronger arguments.

Today, modern universities continue to emphasise the importance of critical thinking in promotional materials and course descriptions. However, as we have seen, the reality often falls short of the rhetoric.

Critical thinking is not well understood by those who are supposed to be teaching it  and the broader context in which it is situated is not fully grasped by its advocates.

This situation is unlikely to be resolved soon, but it highlights the need for further research into critical thinking, not only in students but in the wider public.

           A promising – albeit woefully underused – technique is computer-aided argument mapping.  This is a way to explicitly and concisely represent reasoning by building diagrams that map out the logical structure of an argument.

Evidence suggests that it leads to significant gains  on independent critical thinking assessment tests.

The importance of critical thinking has never been greater, yet our understanding of it has never been so limited. This creates a perfect storm – a situation where the need for critical thinking is rising, but our capacity to foster it is in serious question.

It’s a scandalous situation, demanding urgent attention if we are to navigate the complex challenges of the 21st century. 

Associate Professor Martin Davies was co-editor, with Professor Ronald Barnett, of the Palgrave Handbook of Critical Thinking in Higher Education (Palgrave, 2015).

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Associate Professor Martin Davies

Principal Fellow in Higher Education, Melbourne Graduate School of Education, University of Melbourne

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