critical thinking development in nursing

ANA Nursing Resources Hub

Search Resources Hub

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.

Images sourced from Getty Images

Related Resources

Item(s) added to cart

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?

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

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save.

• Get 10 units per month
• Download Article/Chapter or eBook
• 1 Unit = 1 Article or 1 Chapter
• Cancel anytime
• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Available as EPUB and PDF
• Compact, lightweight edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info
• Durable hardcover edition

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

Thinking Critically About the Quality of Critical Thinking Definitions and Measures

Criticality in Osteopathic Medicine: Exploring the Relationship between Critical Thinking and Clinical Reasoning

A guide to critical thinking: implications for dental education

Bilgiç Ş, Kurtuluş Tosun Z (2016) Birinci ve son sınıf hemşirelik öğrencilerinde eleştirel düşünme ve etkileyen faktörler. Sağlık Bilimleri ve Meslekleri Dergisi 3(1):39–47

Article   Google Scholar  

Kantek F, Yıldırım N (2019) The effects of nursing education on critical thinking of students: a meta-analysis. Florence Nightingale Hemşirelik Dergisi 27(1):17–25

Ennis R (1996) Critical thinking dispositions: their nature and assessability. Informal Logic 18(2):165–182

Riddell T (2007) Critical assumptions: thinking critically about critical thinking. J Nurs Educ 46(3):121–126

Cüceloğlu D (2001) İyi düşün doğru karar ver. Remzi Kitabevi, pp 242–284

Google Scholar  

Kurnaz A (2019) Eleştirel düşünme öğretimi etkinlikleri Planlama-Uygulama ve Değerlendirme. Eğitim yayın evi, p 27

Doğanay A, Ünal F (2006) Eleştirel düşünmenin öğretimi. In: İçerik Türlerine Dayalı Öğretim. Ankara Nobel Yayınevi, pp 209–261

Scheffer B-K, Rubenfeld M-G (2000) A consensus statement on critical thinking in nursing. J Nurs Educ 39(8):352–359

Article   CAS   Google Scholar  

Rubenfeld M-G, Scheffer B (2014) Critical thinking tactics for nurses. Jones & Bartlett Publishers, pp 5–6, 7, 19–20

Gobet F (2005) Chunking models of expertise: implications for education. Appl Cogn Psychol 19:183–204

Ay F-A (2008) Mesleki temel kavramlar. In: Temel hemşirelik: Kavramlar, ilkeler, uygulamalar. İstanbul Medikal Yayıncılık, pp 205–220

Birol L (2010) Hemşirelik bakımında sistematik yaklaşım. In: Hemşirelik süreci. Berke Ofset Matbaacılık, pp 35–45

Twibell R, Ryan M, Hermiz M (2005) Faculty perceptions of critical thinking in student clinical experiences. J Nurs Educ 44(2):71–79

The Importance of Critical Thinking in Nursing. 19 November 2018 by Carson-Newman University Online. https://onlinenursing.cn.edu/news/value-critical-thinking-nursing

Suzanne C, Smeltzer Brenda G, Bare Janice L, Cheever HK (2010) Definition of critical thinking, critical thinking process. Medical surgical nursing. Lippincott, Williams & Wilkins, pp 27–28

Profetto-McGrath J (2003) The relationship of critical thinking skills and critical thinking dispositions of baccalaureate nursing students. J Adv Nurs 43(6):569–577

Elaine S, Mary C (2002) Critical thinking in nursing education: literature review. Int J Nurs Pract 8(2):89–98

Brunt B-A (2005) Critical thinking in nursing: an integrated review. J Continuing Educ Nurs 36(2):60–67

Carter L-M, Rukholm E (2008) A study of critical thinking, teacher–student interaction, and discipline-specific writing in an online educational setting for registered nurses. J Continuing Educ Nurs 39(3):133–138

Daly W-M (2001) The development of an alternative method in the assessment of critical thinking as an outcome of nursing education. J Adv Nurs 36(1):120–130

Edwards S-L (2007) Critical thinking: a two-phase framework. Nurse Educ Pract 7(5):303–314

Rogal S-M, Young J (2008) Exploring critical thinking in critical care nursing education: a pilot study. J Continuing Educ Nurs 39(1):28–33

Worrell J-A, Profetto-McGrath J (2007) Critical thinking as an outcome of context-based learning among post RN students: a literature review. Nurse Educ Today 27(5):420–426

Morrall P, Goodman B (2013) Critical thinking, nurse education and universities: some thoughts on current issues and implications for nursing practice. Nurse Educ Today 33(9):935–937

Raymond-Seniuk C, Profetto-McGrath J (2011) Can one learn to think critically?—a philosophical exploration. Open Nurs J 5:45–51

Download references

Author information

Authors and affiliations.

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

Şefika Dilek Güven

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Şefika Dilek Güven .

Editor information

Editors and affiliations.

Universal Scientific Education and Research Network (USERN), Stockholm, Sweden

Nima Rezaei

Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

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

Download citation

DOI : https://doi.org/10.1007/978-3-031-15959-6_10

Published : 02 January 2023

Publisher Name : Springer, Cham

Print ISBN : 978-3-031-15958-9

Online ISBN : 978-3-031-15959-6

eBook Packages : Behavioral Science and Psychology Behavioral Science and Psychology (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

• Visit Nurse.com on Facebook
• Visit Nurse.com on YouTube
• Visit Nurse.com on Instagram
• Visit Nurse.com on LinkedIn

Nurse.com by Relias . © Relias LLC 2024. All Rights Reserved.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Critical thinking: the development of an essential skill for nursing students

Affiliations.

• 1 Nursing Department, Technological Educational Institute of Thessaly, Greece.
• 2 Nursing Department, Technological Educational Institute of Crete, Greece.
• 3 State Mental Hospital of Attica "Daphne", Greece.
• 4 Nursing Department, Alexander Technological Educational Institute of Thessaloniki, Greece.
• PMID: 25395733
• PMCID: PMC4216424
• DOI: 10.5455/aim.2014.22.283-286

Critical thinking is defined as the mental process of actively and skillfully perception, analysis, synthesis and evaluation of collected information through observation, experience and communication that leads to a decision for action. In nursing education there is frequent reference to critical thinking and to the significance that it has in daily clinical nursing practice. Nursing clinical instructors know that students face difficulties in making decisions related to clinical practice. The main critical thinking skills in which nursing students should be exercised during their studies are critical analysis, introductory and concluding justification, valid conclusion, distinguish of facts and opinions, evaluation the credibility of information sources, clarification of concepts and recognition of conditions. Specific behaviors are essentials for enhancing critical thinking. Nursing students in order to learn and apply critical thinking should develop independence of thought, fairness, perspicacity in personal and social level, humility, spiritual courage, integrity, perseverance, self-confidence, interest for research and curiosity. Critical thinking is an essential process for the safe, efficient and skillful nursing practice. The nursing education programs should adopt attitudes that promote critical thinking and mobilize the skills of critical reasoning.

Keywords: clinical nurse education; clinical nursing practice; critical thinking; nursing education.

PubMed Disclaimer

Conflict of interest statement

CONFLICT OF INTEREST: NONE DECLARED.

Similar articles

• Critical thinking in clinical nurse education: application of Paul's model of critical thinking. Andrea Sullivan E. Andrea Sullivan E. Nurse Educ Pract. 2012 Nov;12(6):322-7. doi: 10.1016/j.nepr.2012.03.005. Epub 2012 Apr 22. Nurse Educ Pract. 2012. PMID: 22525831
• Student and educator experiences of maternal-child simulation-based learning: a systematic review of qualitative evidence protocol. MacKinnon K, Marcellus L, Rivers J, Gordon C, Ryan M, Butcher D. MacKinnon K, et al. JBI Database System Rev Implement Rep. 2015 Jan;13(1):14-26. doi: 10.11124/jbisrir-2015-1694. JBI Database System Rev Implement Rep. 2015. PMID: 26447004
• Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: self-regulated learning theory. Kuiper RA, Pesut DJ. Kuiper RA, et al. J Adv Nurs. 2004 Feb;45(4):381-91. doi: 10.1046/j.1365-2648.2003.02921.x. J Adv Nurs. 2004. PMID: 14756832 Review.
• An information communication technology based approach for the acquisition of critical thinking skills. Pucer P, Trobec I, Žvanut B. Pucer P, et al. Nurse Educ Today. 2014 Jun;34(6):964-70. doi: 10.1016/j.nedt.2014.01.011. Epub 2014 Feb 14. Nurse Educ Today. 2014. PMID: 24581890
• Teaching critical reflection skills for advanced mental health nursing practice: a deconstructive-reconstructive approach. Crowe MT, O'Malley J. Crowe MT, et al. J Adv Nurs. 2006 Oct;56(1):79-87. doi: 10.1111/j.1365-2648.2006.03982.x. J Adv Nurs. 2006. PMID: 16972921 Review.
• Think-aloud approach combined with case-based learning in nursing teaching round for new nurses in cancer hospital. Zhao R, Ding T, Meng J, Lei M, Ma H. Zhao R, et al. BMC Med Educ. 2024 Aug 23;24(1):916. doi: 10.1186/s12909-024-05891-4. BMC Med Educ. 2024. PMID: 39180035 Free PMC article.
• Effectiveness of an Evidence-Based Practice Education Program for Undergraduate Nursing Students: A Systematic Review and Meta-Analysis. Jeong D, Park C, Sugimoto K, Jeon M, Kim D, Eun Y. Jeong D, et al. Int J Environ Res Public Health. 2024 May 16;21(5):637. doi: 10.3390/ijerph21050637. Int J Environ Res Public Health. 2024. PMID: 38791851 Free PMC article. Review.
• The effect of "typical case discussion and scenario simulation" on the critical thinking of midwifery students: Evidence from China. Wang Y, Peng Y, Huang Y. Wang Y, et al. BMC Med Educ. 2024 Mar 26;24(1):340. doi: 10.1186/s12909-024-05127-5. BMC Med Educ. 2024. PMID: 38532375 Free PMC article.
• Higher Vocational Nursing Students' Clinical Core Competence in China: A Cross-Sectional Study. Wang S, Huang S, Yan L. Wang S, et al. SAGE Open Nurs. 2024 Mar 1;10:23779608241233147. doi: 10.1177/23779608241233147. eCollection 2024 Jan-Dec. SAGE Open Nurs. 2024. PMID: 38435341 Free PMC article.
• Delayed amyotrophic lateral sclerosis diagnosis with subtle cardiac manifestations: Was anchoring bias contributory? Cherin N, Patel S, Jukic M. Cherin N, et al. Clin Case Rep. 2024 Feb 20;12(2):e8544. doi: 10.1002/ccr3.8544. eCollection 2024 Feb. Clin Case Rep. 2024. PMID: 38385052 Free PMC article.
• Scriven M, Paul R. (n.d.). Defining critical thinking. Retrieved February 23 2013, from //www.critical-thinking.org/University/univclass/Defining.Html .
• Scheffer BK, Rubenfeld MG. A consensus statement on critical thinking in nursing. Journal of Nursing Education. 2000;39:352–359. - PubMed
• Papathanasiou I, Kotrotsiou S, Bletsa V. Nursing documentation and recording systems of nursing care. Health Science Journal. 2007;1(4)
• Facione P. Millbrae, CA: California Academic Press; 1990. Critical thinking:A statement of expert consensus for purpose of educational assessment and instruction.
• Facione P. Milbrae CA: California Academic Press; 1998. Critical Thinking:What it is and why it counts.

Related information

Linkout - more resources, full text sources.

• Europe PubMed Central
• PubMed Central

Other Literature Sources

• scite Smart Citations
• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

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.

Comments are closed.

Medical & Legal Disclaimer

All the contents on this site are for entertainment, informational, educational, and example purposes ONLY. These contents are not intended to be used as a substitute for professional medical advice or practice guidelines. However, we aim to publish precise and current information. By using any content on this website, you agree never to hold us legally liable for damages, harm, loss, or misinformation. Read the  privacy policy  and  terms and conditions.

Privacy Policy

Terms & Conditions

© 2024 nurseship.com. All rights reserved.

We use cookies on our website to support technical features that enhance your user experience, and to help us improve our website. By continuing to use this website, you accept our privacy policy .

• Student Login
• Call Us: 888-549-6755
• 888-559-6763
• Search site Search our site Search Now Close
• Request Info

Skip to Content (Press Enter)

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.

• Share on Facebook
• Share on Twitter
• Share on Pinterest
• Share on LinkedIn

Request More Information

Talk with an admissions advisor today.

Fill out the form to receive information about:

• Program Details and Applying for Classes
• Financial Aid (for those who qualify)
• Customized Support Services
• Detailed Program Plans

There are some errors in the form. Please correct the errors and submit again.

Please enter your first name.

Please enter your last name.

There is an error in email. Make sure your answer has:

• An "@" symbol
• A suffix such as ".com", ".edu", etc.

There is an error in phone number. Make sure your answer has:

• 10 digits with no dashes or spaces
• No country code (e.g. "1" for USA)

There is an error in ZIP code. Make sure your answer has only 5 digits.

We offer tuition savings for many employers—see if yours is one of them.

Please enter Corporate Employer.

Can’t find your employer? Select "Other Employer Not In List" or "Not Employed".

Please choose a School of study.

Please choose a program.

Please choose a degree.

The program you have selected is not available in your ZIP code. Please select another program or contact an Admissions Advisor (877.530.9600) for help.

The program you have selected requires a nursing license. Please select another program or contact an Admissions Advisor (877.530.9600) for help.

Rasmussen University is not enrolling students in your state at this time.

By selecting "Submit," I authorize Rasmussen University to contact me by email, phone or text message at the number provided. There is no obligation to enroll. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

About the author

Hannah Meinke

Posted in General Nursing

• nursing education

Related Content

Brianna Flavin | 05.07.2024

Brianna Flavin | 03.19.2024

Robbie Gould | 11.14.2023

Noelle Hartt | 11.09.2023

This piece of ad content was created by Rasmussen University to support its educational programs. Rasmussen University may not prepare students for all positions featured within this content. Please visit www.rasmussen.edu/degrees for a list of programs offered. External links provided on rasmussen.edu are for reference only. Rasmussen University does not guarantee, approve, control, or specifically endorse the information or products available on websites linked to, and is not endorsed by website owners, authors and/or organizations referenced. Rasmussen University is accredited by the Higher Learning Commission, an institutional accreditation agency recognized by the U.S. Department of Education.

• - Google Chrome

Intended for healthcare professionals

• My email alerts
• BMA member login
• Username * Password * Forgot your log in details? Need to activate BMA Member Log In Log in via OpenAthens Log in via your institution

Search form

• Advanced search
• Search responses
• Search blogs
• News & Views
• Margaret McCartney:...

Nurses are critical thinkers

Rapid response to:

Margaret McCartney: Nurses must be allowed to exercise professional judgment

• Related content
• Article metrics
• Rapid responses

Rapid Response:

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

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.10(8); 2023 Aug
• PMC10333820

Curriculum framework to facilitate critical thinking skills of undergraduate nursing students: A cooperative inquiry approach

Christian makafui boso.

1 Department of Nursing and Midwifery, Faculty of Medicine & Health Sciences, Stellenbosch University, Cape Town South Africa

2 School of Nursing and Midwifery, College of Health and Allied Sciences, University of Cape Coast, Cape Coast Ghana

Anita S. van der Merwe

Janet gross.

3 Peace Corps Liberia, Mother Patern College of Health Sciences, Stella Maris Polytechnic, Monrovia Liberia

Associated Data

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

Critical thinking (CT) is vital in assisting nurses to function efficiently in the ever‐changing health care environment. A CT‐based curriculum framework provides the impetus necessary to drive the acquisition of CT skills of students. Yet, there is no known CT‐based framework contextualized to developing countries where seniority tradition is a norm. Therefore, the aim of this study was to develop a CT‐based curriculum framework to facilitate the development of CT skills of nursing students in developing countries.

Cooperative inquiry.

Using purposive sampling, 11 participants comprising students, educators and preceptors developed a CT‐based curriculum framework.

Findings were organized into a framework illustrating interconnected concepts required to foster CT skills of nursing students. These concepts include authentic student–facilitator partnership, a facilitator that makes a difference; a learner that is free to question and encouraged to reflect; a conducive and participatory learning environment; curriculum renewal processes and contextual realities.

1. INTRODUCTION

Nurses in today's volatile and complex health care environment need to be able to critically appraise information when giving care (Dozier et al.,  2021 ; Whiteman et al.,  2021 ). Nursing regulatory bodies worldwide such as the Nursing and Midwifery Council of Ghana ( 2015 ) and the South African Nursing Council ( 2014 ) recognize critical thinking (CT) as crucial for nurses. These bodies require that nursing curricula promote CT skills of students (Dozier et al.,  2021 ; Gholami et al.,  2016 ). The rationale is that individuals with CT skills are potentially able to make good clinical judgements (Dozier et al.,  2021 ; Gholami et al.,  2016 ) which may lead to good patient outcomes (Ward‐Smith,  2020 ).

Critical thinking‐based curricula adopt learning outcomes, instructional methods and assessment approaches that are grounded on the principles of CT. Such CT‐based curricula create a participatory and democratic learning environment for students. Students will be empowered if they are allowed to take risks, encouraged to make inputs, permitted to share their opinions and if their mistakes are rectified with dignity (Raymond et al.,  2017 ). Thus, as consistent with Billings & Halstead ( 2005 ) view, a curriculum should aim at enhancing active learning and the student–faculty interaction (as cited in Billings & Halstead,  2005 ). Learning environments where divergent views are suppressed (Raymond et al.,  2017 ), and the educator is seen as the authority of information (Boso & Gross,  2015 ) do not promote CT in students.

A considerable number of reforms in higher education have stressed the need to facilitate CT skills of students (Butler,  2012 ). CT courses have been introduced in different academic disciplines such as nursing, law, sociology, psychology and philosophy. Despite the attention CT has received, there remains doubt whether graduates are being prepared to think critically (Butler,  2012 ). At the heart of this challenge is the fact that the concept of CT has not been incorporated into the teaching methods of many educators (Billings & Halstead,  2005 ). For example, educators construct questions that are mostly at the lower level of thinking (Amoako‐Sakyi & Amonoo‐Kuofi,  2015 ). This suggests that educational institutions may be failing in their quest to develop CT skills of students (Dunne,  2015 ).

In many developing countries, nursing schools encounter challenges that may further compound the challenge of assisting students to engage in CT skills. For example, in Ghana, challenges such as limited resources in nursing schools (Talley,  2006 ) have been reported. Specifically, a lack of qualified educators (Bell et al.,  2013 ), infrastructural and logistical constraints (Talley,  2006 ), inappropriate instructional methods and large class sizes (Wilmot et al.,  2013 ) are some of the challenges affecting nursing education. Also, as indicated in the authors' previous articles (Boso et al.,  2020 , 2021c ), sociocultural norms uphold the seniority tradition. Traditionally, seniority is valued in most global societies. The aged are viewed as the source of knowledge, power and authority, thus seniority is a dominant cultural norm (Chen & Chung,  2002 ). For example, an individual is not expected to disagree or question an authority figure in public even if the authority figure appears to be wrong (Donkor & Andrews,  2011 ). The seniority tradition has been noted as a challenge to facilitating the CT skills of students (Chan,  2013 ; Raymond et al.,  2017 ). Meanwhile, the complexity of fostering CT skills of students has often been underestimated leading to diverse conceptualizations of CT (Dwyer et al.,  2014 ). Diverse conceptualizations could impede the development of CT skills of students.

Notwithstanding these challenges, a CT‐based curriculum framework could provide the needed impetus to foster the development of CT skills of students. A curriculum framework could provide ‘a means of conceptualizing and organizing the knowledge, skills, values, and beliefs critical to the delivery of a coherent curriculum that facilitates the achievement of the desired curriculum outcomes’ (Billings & Halstead,  2005 , p. 167). More importantly, a CT‐based framework provides a participatory and effective learning environment for both the learner and the educator (Dozier et al.,  2021 ; Duron et al.,  2006 ) even in societies where the seniority tradition is strongly adhered to. Yet, these authors could not identify a known curriculum framework to drive the facilitation of CT skills in the context of developing countries where the seniority tradition is a norm.

2. AIM OF THE STUDY

The aim of this study was to develop a CT‐based curriculum framework to facilitate the development of CT skills of nursing students in developing countries.

3. BACKGROUND

This study was underpinned by an eclectic model derived from Dwyer et al.'s ( 2014 ) and Duron et al.'s ( 2006 ) frameworks of CT development (see Figure  1 ). This eclectic model addressed four interconnected concepts relating to the exploration of experiences of students and educators towards CT skills facilitation namely CT, memory, comprehension (Dwyer et al.,  2014 ) and instructional activities (Duron et al.,  2006 ). These concepts are further explicated.

Eclectic model of critical thinking development adopted from Duron et al.'s ( 2006 ) and Dwyer et al.'s ( 2014 ) models of CT. Permission to adapt was obtained.

3.1. Critical thinking

There is no agreement about the definition of CT (Raymond et al.,  2018 ) and its relationship with memory and comprehension (Dwyer et al.,  2014 ). According to Davies and Barnett ( 2015 ), there are three main approaches to CT, namely, ‘skills‐and‐judgement’, ‘skills‐plus‐propensity’ and ‘skills‐plus‐disposition‐actions’ perspectives. The skills‐and‐judgement perspective of CT views CT as the possession of a set of characteristic skills. The skills‐plus‐propensity perspective highlights both skills and dispositions aspects of CT. While the ‘skills‐plus‐disposition‐actions’ view, also known as criticality, sees CT beyond skills and disposition to include actions/activism. The skills‐plus‐propensity view on which this study is based recognizes that activism is an outcome of CT and not necessarily an aspect of CT. Thus, Facione's ( 1990 ) definition accepted for the purposes of this study illustrates skills‐plus‐propensity perspective of CT: ‘…purposeful, self‐regulatory judgment which results in interpretation, analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment is based…’ (Facione,  1990 , p. 5).

Though Facione's definition has been criticized for being long‐winded and difficult to implement (Davies & Barnett,  2015 ), its use for CT assessment in nursing education is evident (Raymond et al.,  2017 ). Dwyer et al.'s ( 2014 ) model incorporate both reflective judgement (skills) and self‐regulatory functions of metacognition (disposition) as requirements for CT consistent with Facione's ( 1990 ) definition. Self‐regulation refers to the individual's ability, willingness and perceived need to think critically when solving problems.

3.2. Memory

Critical thinking skills are dependent on what information one can remember (Dwyer et al.,  2014 ). Information is either stored in short‐ or long‐term memory. Dwyer et al. ( 2014 ) assert that through deliberate attention or perception processes, information is stored as short‐term memory (working memory). This short‐term memory includes two sub‐systems—phonological loop and visuospatial sketchpad; a central executive (attention focussing process that relates to long‐term memory) and episodic buffer (storage centre that integrates new information from working memory with existing memory from long‐term memory) (Baddeley,  2010 ). Through manipulation, information in short‐term memory may be encoded as long‐term memory. Long‐term memory is stored as schemas (categorization of knowledge based on how it will be used).

3.3. Comprehension

Meaningfully organizing information into schemas for future retrieval requires understanding or comprehension (Dwyer et al.,  2014 ). Comprehension encompasses the ability to translate or interpret information based on previous learning (Huitt,  2011 ). Long‐term memory and comprehension are fundamental processes for CT application (Dwyer et al.,  2014 ).

3.4. Instructional activities

Duron et al. ( 2006 ) designed a 5‐step model to provide a practical impetus in the acquisition of CT skills. This model focuses on steps that educators should take to foster the CT skills of students. The 5‐step framework requires that educators first determine learning objectives. The educator should identify the behaviours that the students should exhibit by the time they exit a course. The objectives should correspond to the higher order of Bloom's taxonomy. Secondly, the importance of teaching through questioning is underlined. The educator should design appropriate questions and questioning techniques to encourage discussion. The questions should vary and be concise to generate student participation. Particularly, divergent questions encourage CT. Thirdly, practice before assessing is considered important – inclusive of learning experiences that encourage active and experiential learning. Fourthly, the educator should continuously review, refine and improve instructional activities for CT skills. These include strategies such as evaluating students' participation through teaching, diary and journaling. Lastly, educators need to provide feedback and assessment of learning. Thoughtful, purposeful and timely feedback should be provided to students on their performance.

It is the contention of these authors that a CT‐based curriculum framework should address factors that either impede or enhance the students' abilities to memorize information (attention/perception processing), comprehend, reflectively make judgement (ability to analyse, evaluate and create) and engage in self‐regulation functions (disposition towards CT). Pursuant to this view, these authors observed classroom instructional practices (Boso et al.,  2020 ), explored the experiences of students and educators (Boso et al.,  2021c ) and assessed the CT disposition of students (Boso et al.,  2021b ). These studies revealed a number of issues that informed the development of a CT‐based curriculum framework. For example, challenges such as seniority tradition, large class size; negative attitude, lack of commitment and inappropriate assessment styles/methods of educators; background and culture, learning practices, lack of comprehension of the participant, distractive behaviour of students (Boso et al.,  2020 , 2021c ) were identified. Though students had a confident disposition towards reasoning, they did not have a mindset of truth‐seeking (Boso et al.,  2021b ). Lack of involvement of students in curriculum reviews and continuous professional development programs on CT for faculty were also identified as challenges in developing CT skills of students (Boso et al.,  2021c ). Also, educators' examination questions about a higher order of thinking constituted <6% (Boso et al.,  2021a ).

4.1. Research design

This article is the concluding part of a larger project (see Boso et al.,  2020 , 2021a , 2021b , 2021c ) that sought to develop a CT‐based curriculum framework. The study used participatory action research (PAR), specifically, cooperative inquiry (CI) as an overarching research design to develop a CT‐based curriculum framework. CI is one of the approaches embedded in PAR (Mash,  2014 ; Mash & Meulenberg‐Buskens,  2001 ) and is used interchangeable with PAR in this article. PAR inter alia assists in problem solving (Hart & Bond, 1995 ; Mash,  2014 ), promotes organizational improvement (Hart & Bond, 1995), bridges the theory–practice gap (Mash,  2014 ; Rolfe, 1996 ) and allows users to be involved (Beresford, 2006 ).

4.2. Study setting, population and sampling

The study was conducted in the nursing school of an accredited publicly funded university in Ghana. There were approximately 527 nursing students and 16 full‐time faculty members. Like many educational institutions in developing countries, the school had challenges such as a lack of sufficient qualified faculty, and infrastructural and logistical constraints that may militate against assisting students to acquire CT skills. For example, class sizes could range from 50 to 150 students.

The study participants included students who had been enrolled in the degree nursing program for at least a year, nurse educators with current full‐time appointments with at least a year of teaching experience, preceptors and coordinators of CT‐based medical programs. It is believed that these participants had been associated with the nursing educational system long enough to provide rich data on their experiences and expertise. Furthermore, using diverse stakeholders in the study aided in providing balanced perspectives.

Twelve participants comprised 3 educators (with 1 being a coordinator of a CT‐based medical program), 2 preceptors, 6 students and the researcher himself were part of the cooperative inquiry group (CIG). Pertinent to the tenets of cooperative inquiry, these CIG were to collaboratively engage to develop a CT‐based curriculum framework. To select students for the CIG, presentations on the purpose and nature of the study were made in their respective classrooms. A list of those who agreed to participate in the study was compiled based on the different educational levels. Individuals were randomly selected and contacted through email or telephone. Similarly, a list of preceptors was obtained. In the Ghanaian context, preceptors are clinical nurses who instruct students during clinical placement. They were contacted and those who were willing to participate were ranked based on their educational level and experience. Two preceptors with Master's degrees in nursing were selected to participate in the study as their clinical experience and educational background provided the necessary expertise towards developing the CT‐based curriculum framework. Two educators were randomly selected while the coordinator of the CT‐based medical program (also an educator) was purposively invited through email and/or telephone. The CIG was engaged throughout the entire research process to identify ideas, observe, and reflect on results to develop a framework to foster CT skills of students. Seven steps of the research process evolved till the aim of the study was met. Different data sets—qualitative and quantitative—were gathered and analysed, culminating in the development of the framework.

4.3. Summary of research process

In this study, O'Leary's cycle of action research as described by Koshy et al. ( 2011 ) was adopted. The process alternates from observation, reflection and planning to action. Seven steps from observation to action were followed during the entire research project (see Figure  2 ). The cooperative inquiry group members were engaged throughout the seven steps of the research process. In total, three workshop meetings were held.

Summary of research process.

4.3.1. Step 1

Data were collected on the instructional practices/activities of the selected school from September 2017 to March 2018. These data sets were to aid the CIG in understanding current practices and to provide the baseline data for the development of the framework. Factors that either inhibited or enhanced perception/attention processing and comprehension of information and reflective judgement (analysing, evaluating and creating) according to Dwyer et al.'s ( 2014 ) were identified. Prior to data collection, the participants were exposed to the research methodology and methods at a training workshop held in September 2017. Nine participants—the first author (initiating researcher), two preceptors, one educator and five students—were able to attend this session. The first author introduced the CIG members to the Nominal Group Technique (NGT). The NGT is considered one of the most frequently used formal consensus building techniques (Harvey & Holmes, 2012 ). The NGT includes five stages, namely: (1) introduction and explanation, (2) silent generation of ideas, (3) sharing ideas—round robin, (4) group discussion/clarifying and (5) voting and ranking. Measures to ensure the rigour of inquiry were discussed and agreed upon. Two educators who were unable to attend the session were met individually and the purpose and methods of the study were discussed with them.

4.3.2. Step 2

The analysed data from step 1 were presented to the CIG members at a second meeting held in March 2018. Nine participants—three educators, two preceptors, three students and the first author—were present at this meeting. The CIG deliberated on the results obtained through group discussions facilitated by the first author. Upon reflection, CIG agreed that the data provided enough basis for a draft framework to be considered. Vital issues about instructional practices had been elicited.

4.3.3. Step 3

Following the reflection on the data, the CIG through the Nominal Group Technique (NGT) facilitated by the first author designed a draft framework. Three questions were formulated for the NGT session, namely, (a) What concept(s) should be included in the framework that will facilitate CT skills of nursing students? (b) How should these elements/components/concepts/variables be related? and (c) What should the structure of the framework be?

At the first stage of introduction and explanation of the NGT, purpose of the study, NGT procedure and the three questions for the NGT procedure were reiterated to provide all members with the same point of reference. At the second stage of the NGT, members were allocated 5 minutes to generate ideas for the framework. Seventy‐six concepts were generated. These concepts were collated at the third stage of the NGT process. The fourth stage saw the concepts discussed, their meanings sought and consolidated. Through consensus, some concepts or synonyms were removed, leaving a total of 45 concepts. For example, the concept learner replaced and/or represented similar concepts such as student and nursing students. Likewise, facilitators replaced educators and/or lecturers. The 45 concepts were further consolidated (categorized) into nine. These included learner (and associated characteristics), educator/facilitator (and associated characteristics), teaching methods/style, learning environment, institutional support, assessment, technology, review system and curriculum. At the final stage, the CIG members voted to rank the concepts in order of importance. Learner, facilitator, teaching methods, learning environment and assessment were the five most ranked concepts. The first author was tasked to develop the draft framework with the concepts and relationships for the CIG members to review individually and for subsequent evaluation by students and educators for its applicability. Accordingly, the draft framework was designed by the first author together with one of the CIG members and subsequently distributed to all CIG members for input.

The draft framework suggested that the teaching‐learning process needed to be a caring professional relationship between the learner and the facilitator. This relationship should be the heart of the curriculum. The draft framework included six concepts/components which included: (a) caring professional relationship; (b) facilitator; (c) learner; (d) learning environment; (e) outcome setting, system review and advocacy and (f) contextual dynamics.

4.3.4. Step 4

The draft framework was made available to six educators and eight students in the selected school to review/comment on its applicability. The following questions accompanied the draft framework: How applicable is this framework in facilitating CT skills of students? What do you believe are the strength(s)/weakness(es) of this framework? What concept(s) do you believe should be removed and/or added to the framework to make it more applicable? Three educators and six students evaluated the draft framework. Given that these groups of participants are part of the nursing school, their views about the applicability of the framework were important to consider when implementing the framework in a real‐life situation.

4.3.5. Step 5

The students' and educators' comments and critiques about the draft framework were carefully analysed thematically by the first author. The draft framework was evaluated as applicable by all participants (3 applicable, 6 very applicable). The reasons for their choices included that the framework was simple, realistic, comprehensive (essential factors included), improved relationships for easier communication, made the facilitator a role model, made the learner an active participant and the learner's view was encouraged. Considering the strengths of the framework, the evaluators thought the framework was well structured, bridged gaps in the learner–facilitator relationship, comprehensively covered most factors of education, and covered current trends, and legal/regulatory issues.

The following were seen as the weaknesses of the draft framework by the evaluators: (a) difficulty to elicit commitment from all; (b) challenges associated with the hard environment; (c) possibility of being misused by students; (d) possible failure of the authentic student–facilitator partnership; (e) perceived difficulty to explain complex concepts/processes such as outcome setting, advocacy, system review and (f) possible lack of CT skills of learners and facilitators. They also thought concepts like culture, time, students' involvement, external motivation and career counselling should be included in the framework.

4.3.6. Step 6

The results of the evaluation of the draft framework were presented to the CIG at a workshop facilitated by the first author in May 2018. The comments and critiques of the framework were reflected on by the CIG for possible revision. Eight participants—two preceptors, five students and the first author were present at this 5‐h workshop. The CIG members considered the weaknesses identified during the evaluation as rather systemic challenges in the selected school and not of the framework. In their view, a framework should represent the ideal. Also, the CIG members thought culture, time and students' involvement were already captured.

4.3.7. Step 7

A revised framework was designed to reflect the views of the evaluators of the draft framework. Some concepts/processes were fine‐tuned, and others were further explicated by the members (see Results section for more details). For example, the caring professional relationship was altered to authentic student–facilitator partnership. Likewise, more extended phrases were used to provide further explication to the facilitator, learner and learning environment. Through NGT, ownership was suggested and added to the definition of authentic student–facilitator partnership. The CIG held the assertion that ownership will enhance responsible learner and educator behaviour. The final framework is presented in the Results section.

The results from the cooperative inquiry were organized into a framework illustrating interconnected concepts required to foster CT skills of nursing students in developing countries. The framework proposes six key interconnected thematic priorities (see Figure  3 ) to drive the development of CT of students. The concepts/themes included in the final framework were (a) authentic student–facilitator partnership, (b) a facilitator that makes a difference, (c) a learner that is free to question and encouraged to reflect, (d) a conducive and participatory learning environment, (e) curriculum renewal processes and (f) contextual realities. These six concepts are important components that should drive a curriculum based on CT principles. The concepts which emanated from the CIG discussions are described below.

Critical thinking‐based curriculum for undergraduate nursing program.

5.1. Authentic student–facilitator partnership

The authors of this study suggest that the central focus of the teaching–learning process should be authentic partnership between the learner and the facilitator (Raymond et al.,  2018 ). This view is motivated by the evidence of dysfunctional learner–facilitator relationships coupled with heightened students' perceptions of mistrust, lack of support, lack of emotional connectedness and lack of democratic practices informed by cultural realities identified (Boso et al.,  2020 , 2021c ). These authors define authentic student–facilitator partnership as a supportive, empathetic, learner‐directed, mutually respectful, accountable and democratic learning relationship which focuses on assisting a learner to engage in meaningful learning experiences toward the development of CT skills.

It is suggested that the educator takes responsibility for the optimum functioning of this partnership (Billings & Halstead,  2005 ; Mangena & Chabeli,  2005 ; Raymond et al.,  2017 ). However, both the student and the facilitator (Raymond et al.,  2018 ) should feel a sense of ownership of the teaching and learning process. The findings of this study suggest that factors relating to both students and facilitators could either facilitate or inhibit the fostering of CT skills acquisition. Consequently, both the student and the facilitator should be committed to setting up appropriate boundaries to govern this partnership. These boundaries should include adherence to educational justice—creating equal opportunities, fair evaluation, fair criticism and non‐discrimination on the basis of gender, race or religious status (Boozaripour et al.,  2018 ). Adherence to boundaries is likely to enhance the perception of trust and ownership.

5.2. A facilitator that makes a difference

We see the facilitator as the leader, role model, mentor and guardian of the student for a purposeful learning experience towards CT skills acquisition. It was evident in this study that the facilitator's approach to classroom management and general attitude towards students and cultural realities influenced how students engaged in the teaching and learning process (Boso et al.,  2020 , 2021c ). Cultural competence in healthcare is a global standard; thus, the facilitator should be aware of the influence of cultural tendencies (Chan,  2013 ; Donkor & Andrews,  2011 ) on the student–facilitator partnership. The facilitator should become a role model in terms of how he/she collaborates and communicates (Raymond et al.,  2018 ) as well as his/her punctuality to class. These general effective teaching tenets are required to set the tone for the reflective engagement of students towards the acquisition of CT skills. For example, a lack of punctuality will limit the amount of instructional time required for students to think critically. Also, the facilitator should demonstrate CT tenets in his/her teaching.

Furthermore, the facilitator needs to demonstrate scholarly attributes and experience in teaching, clinical skills, and theoretical nursing knowledge; be student‐centred, empathetic, supportive; and enthusiastic about the nursing profession and teaching (Billings & Halstead,  2005 ; Mangena & Chabeli,  2005 ; Raymond et al.,  2018 ). The facilitator needs to connect with the learner on an emotional level (Raymond et al.,  2018 ). It is proposed that the facilitator should use tools such as CT‐oriented learning outcomes/objectives, appropriate assessment for CT and active learning teaching approaches/methods. In addition, teaching and assessment methods should vary and should be driven by appropriate questioning techniques (Duron et al.,  2006 ; Raymond et al.,  2018 ). These questioning techniques should predominantly target higher‐order of thinking to help students to engage in appropriate thinking moments (Duron et al.,  2006 ).

5.3. A learner that is free to question and encouraged to reflect

The learner is the inquirer/discoverer of knowledge guided by the facilitator in an educational program. It was noted in this study that students were influenced by the Ghanaian cultural realities (Boso et al.,  2020 , 2021c ) that did not allow them to question authority (Donkor & Andrews,  2011 ) and the type of assessment/teaching methods to which they are exposed. These authors posit that to assist in fostering CT skills of learners, the students should not see themselves as a receptacle in which content/information is dumped, but rather as rational individuals who can decide for themselves regarding truth. Therefore, students should adopt CT‐oriented learning practices that ensure a reflective view of content/information for self‐determination and lifelong learning. This encourages facilitators to share their CT with students (Raymond et al.,  2018 ). In addition, they should be encouraged to be self‐motivated and self‐directed.

Strategies needed to promote CT skills in students should include the use of CT‐oriented learning outcomes/objectives, appropriate assessment for CT and active learning teaching methods. Additionally, teaching and assessment methods should vary and should be driven by appropriate questioning techniques (Duron et al.,  2006 ; Raymond et al.,  2018 ) which should target higher order of thinking to help students to engage in appropriate thinking moments (Duron et al.,  2006 ).

5.4. Conducive and participatory learning environment

The authentic student–facilitator partnership between the learner and the facilitator occurs in a conducive learning environment that promotes CT (Mangena & Chabeli,  2005 ; Raymond et al.,  2018 ). This environment has two components: hard and soft. The hard environment involves a library, learning space and technology. Appropriate use of technology should be employed in the teaching–learning process. This study showed that students were engaged in distractive use of social media and technology in the classroom (Boso et al.,  2020 ). Guidelines for the use of technology/social media should be available to help learners and facilitators derive maximum benefits from these tools. Also, institutional support is required for the provision of appropriate technology, learning space, appropriate class size and library resources for a meaningful learning experience (Raymond et al.,  2017 , 2018 ).

The soft environment involves the intangible safe, empathetic and democratic atmosphere created to encourage the learner to share his/her views freely. This conducive atmosphere should permeate the entire school environment. This helps to establish emotional connectedness between the students and other role players in the educational environment (Raymond & Profetto‐McGrath, 2005 ; Raymond et al.,  2017 , 2018 ). It was noted in this study that students did not feel adequately supported, and were not regularly engaged in curriculum reviews and other matters that directly affect their learning (Boso et al.,  2021c ). Consequently, we propose the establishment of a system of support (including financial aid) for students and practical avenues for students' engagements based on a consultative process involving students and other role players. Additionally, school managers should provide support to facilitators through staff development programs on CT. Assisting faculty development in the area of CT instructional methods will help educators to infuse CT tenets in their own courses (Mangena & Chabeli,  2005 ; Raymond et al.,  2017 , 2018 ). Measures such as assigning facilitators with teaching assistants should be adopted to give facilitators more time to engage in CT instructional practices (Shell,  2001 ). Facilitators in this study expressed the concern of inadequate time to engage students, partially due to the absence of teaching assistants.

5.5. Curriculum renewal processes

We propose that renewal processes should be adopted for a CT‐oriented curriculum as a whole and of parts as deemed necessary and considering local, national and international trends. The aim of these processes should be to encourage continuous feedback and review that will lead to curriculum improvement (Duron et al.,  2006 ). Students and other role players should be engaged in the curriculum renewal processes. In reviewing the curriculum, contemporary CT assessment theory and practices should be used. Furthermore, the renewal process should adhere to the standards of curriculum review processes. Also, the relevance of courses should be continuously examined to ensure that they attract students' engagement towards CT skills. Consistent with CT activism tenets (Davies & Barnett,  2015 ), advocacy should be encouraged to effect changes that may be occasioned by observations from the curriculum review. Particularly, educators should be encouraged to engage in advocacy to effect changes that may be necessary to assist students to acquire CT skills.

5.6. Contextual realities

A curriculum does not exist in a vacuum. It should be designed and operated in a specific context (Billings & Halstead,  2005 ). The learning process and the extent to which one can address CT skills are influenced by contextual realities. These contextual realities include the program of study, the global/national trends and policies and legal/regulatory framework. For example, as an undergraduate nursing program, CT is highly recommended as a competency (World Health Organization,  2009 ). It is therefore suggested that CT should be taught as a course and teaching methods that support CT be infused into all courses of the program. Global and national trends and policies need to be considered. For example, international development goals, disease patterns and burdens, employer expectations and needs, international best practices and standards, and availability of health facilities and clinical staff for clinicaleducation should guide the curriculum. Additionally, legal/regulatory bodies' requirements need to be adhered to. In the Ghanaian under graduate nursing context, the requirements of the Ghana Tertiary Education Commission (formerly of the National Accreditation Board), the Nursing and Midwifery Council of Ghana and the university in which the program is undertaken would be essential to consider.

6. ETHICAL CONSIDERATIONS

Research Ethics Committee approveal was obtained from the Health Research Ethics Committee of Stellenbosch University (Ref. No. FS17/05/106) and the university in which the study was conducted (name withheld to ensure the anonymity of participants). Written permission was sought from the dean of the selected school. All participants including students, nurse educators and preceptors provided informed consent. Given that this was a PAR, the owner of the authorship and the findings were made explicitly clear to the participants as suggested by Mash ( 2014 ). The names and the contributions of participants were kept confidential and the group was supported by the researcher throughout the study.

7. LIMITATION OF THE STUDY

The quality of a PAR is dependent on how the initiating researcher can unmask and diffuse power differentials. The power relational challenges inherent in many studies may be perpetuated (Scotland, 2012). Given that a hierarchical situation and power inequalities could arise because of the involvement of students, the students' representation was increased to form half of the cooperative inquiry group. Also, training of the cooperative inquiry group was carried out to address coercion, collaboration and partnership. The Nominal Group Technique was adopted for decision‐making to ensure that no one's view was disproportionately rated above others. In addition, the absence of one or two members at different times may have influenced the flow and consistency of ideas generated.

8. CONCLUSION

Conducting a study with the purpose of developing a framework of CT development is appropriate for different reasons. Consistent with the context of this study where the seniority tradition exists which may negatively influence the student–faculty relationship, this curriculum framework emphasized the importance of authentic interaction between students and the faculty in facilitating the CT skills of students. The recommended framework derived may suggest a wider implication for nursing schools and universities to provide CT‐based continuous professional development programs for their nurse faculty. Additionally, the study findings may have implications for monitoring and evaluation activities with the view of improving standard setting and teaching–learning experiences of students.

Based on this study, it is envisaged that nurse educators, who play a pivotal role in nursing education, will find reasons to refine their instructional practices. Also, further research focussing on different contexts of CT in Ghana may be useful. Most importantly, this framework may provide direction for how a curriculum can be predicated on CT, thereby removing arbitrariness.

AUTHOR CONTRIBUTIONS

All the authors made substantial contributions to the manuscript. CMB, ASVDM and JG conceived and designed the study. CMB collected data, analysed and drafted the manuscript. ASVDM and JG supervised the study and made critical revisions to the paper.

FUNDING INFORMATION

No external funding.

CONFLICT OF INTEREST STATEMENT

We do not have any conflict of interest to report.

ACKNOWLEDGEMENTS

We wish to acknowledge Victor Angbah for assisting in data collection. We also express our gratitude to the study participants. Furthermore, we express our profound gratitude to the authority and staff of the educational institution used for this study.

Boso, C. M. , van der Merwe, A. S. , & Gross, J. (2023). Curriculum framework to facilitate critical thinking skills of undergraduate nursing students: A cooperative inquiry approach . Nursing Open , 10 , 5129–5138. 10.1002/nop2.1748 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

DATA AVAILABILITY STATEMENT

• Amoako‐Sakyi, D. , & Amonoo‐Kuofi, H. (2015). Problem‐based learning in resource‐poor settings: Lessons from a medical school in Ghana . BMC Medical Education , 15 , 221–229. 10.1186/s12909-015-0501-4 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Baddeley, A. (2010). Working memory . Current Biology , 20 ( 4 ), R136–R140. [ PubMed ] [ Google Scholar ]
• Bell, S. A. , Rominski, S. , Bam, V. , Donkor, E. , & Lori, J. (2013). Analysis of nursing education in Ghana: Priorities for scaling‐up the nursing workforce . Nursing and Health Sciences , 15 ( 2 ), 244–249. 10.1111/nhs.12026 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Beresford, P. (2006). Making the connections with direct experience: From the Western Front to user‐controlled research . Educational Action Research , 14 ( 2 ), 161–169. 10.1080/09650790600717987 [ CrossRef ] [ Google Scholar ]
• Billings, D. M. , & Halstead, J. A. (2005). Teaching in nursing: A guide for faculty (2nd ed.). Elsevier Inc. [ Google Scholar ]
• Boozaripour, M. , Abbaszadeh, A. , Shahriari, M. , & Borhani, F. (2018). Ethical values in nurse education perceived by students and educators . Nursing Ethics , 25 ( 2 ), 253–263. 10.1177/0969733017707009 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Boso, C. M. , & Gross, J. J. (2015). Nurse educators' perceptions of critical thinking in developing countries: Ghana as a case study . Advances in Medical Education and Practice , 6 , 555–560. 10.2147/AMEP.S88942 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Boso, C. M. , van der Merwe, A. S. , & Gross, J. (2020). Critical thinking skills of nursing students: Observations of classroom instructional activities . Nursing Open , 7 ( 2 ), 581–588. 10.1002/nop2.426 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Boso, C. M. , van der Merwe, A. S. , & Gross, J. (2021a). Analysis of examination questions to determine cognitive level of critical thinking skills required (Manuscript in preparation) .
• Boso, C. M. , van der Merwe, A. S. , & Gross, J. (2021b). Critical thinking disposition of nursing students: A quantitative investigation . Nurse Education in Practice Education in Practice , 55 , 103167. 10.1016/j.nepr.2021.103167 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Boso, C. M. , van der Merwe, A. S. , & Gross, J. (2021c). Students' and educators' experiences with instructional activities towards critical thinking skills acquisition in a nursing school . International Journal of Africa Nursing Sciences , 14 , 100293. 10.1016/j.ijans.2021.100293 [ CrossRef ] [ Google Scholar ]
• Butler, H. A. (2012). Halpern critical thinking assessment predicts real world outcomes of critical thinking . Applied Cognitive Psychology , 26 , 721–729. 10.1002/acp.2851 [ CrossRef ] [ Google Scholar ]
• Chan, Z. C. Y. (2013). A systematic review of critical thinking in nursing education . Nurse Education Today , 33 ( 3 ), 236–240. 10.1016/j.nedt.2013.01.007 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Chen, G.‐M. , & Chung, J. (2002). Seniority and superiority: A case analysis of decision making in a Taiwanese religious group . Intercultural Communication Studies , 11 ( 1 ), 41–56. [ Google Scholar ]
• Davies, M. , & Barnett, R. (2015). The palgrave handbook of critical thinking in higher education (1st ed.). Palgrave Macmillan. [ Google Scholar ]
• Donkor, N. T. , & Andrews, L. D. (2011). Ethics, culture and nursing practice in Ghana . International Nursing Review , 58 ( 1 ), 109–114. 10.1111/j.1466-7657.2010.00852.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Dozier, A. L. , Gilbert, B. G. , Hughes, V. W. , Mathis, D. P. , & Jenkins, L. J. (2021). The use of active learning strategies during the COVID‐19 pandemic to promote critical thinking . The ABNF Journal , 32 ( 1 ), 12–16. [ Google Scholar ]
• Dunne, G. (2015). Beyond critical thinking to critical being: Criticality in higher education and life . International Journal of Educational Research , 71 , 86–99. 10.1016/j.ijer.2015.03.003 [ CrossRef ] [ Google Scholar ]
• Duron, R. , Limbach, B. , & Waugh, W. (2006). Critical thinking framework for any discipline . Interrnational Journal of Teaching and Learning in Higher Education , 17 ( 2 ), 160–166. [ Google Scholar ]
• Dwyer, C. P. , Hogan, M. J. , & Stewart, I. (2014). An integrated critical thinking framework for the 21st century . Thinking Skills and Creativity , 12 , 43–52. 10.1016/j.tsc.2013.12.004 [ CrossRef ] [ Google Scholar ]
• Facione, P. A. (1990). Critical thinking: A statement of consensus for purposes of educational assessment and instruction . California Academic Press. [ Google Scholar ]
• Gholami, M. , Moghadam, P. K. , Mohammadipoor, F. , Tarahi, M. J. , Sak, M. , Toulabi, T. , & Pour, A. H. H. (2016). Comparing the effects of problem‐based learning and the traditional lecture method on critical thinking skills and metacognitive awareness in nursing students in a critical care nursing course . Nurse Education Today , 45 , 16–21. 10.1016/j.nedt.2016.06.007 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hart, E. , & Bond, M. (1995). Action research for health and social care . Open University Press. [ Google Scholar ]
• Harvey, N. , & Holmes, C. (2012). Nominal group technique (NGT): An effective method of obtaining group consensus . International Journal of Nursing Practice , 18 ( 2 ), 188–194. 10.1111/j.1440-172X.2012.02017.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Huitt, W. (2011). Bloom et al.'s taxonomy of the cognitive domain. Educational psychology interactive . Valdosta State University. http://www.edpsycinteractive.org/topics/cognition/bloom.html [pdf]. [ Google Scholar ]
• Koshy, E. , Valsa, K. , & Waterman, H. (2011). Action research in healthcare . SAGE Publications Ltd. [ Google Scholar ]
• Mangena, A. , & Chabeli, M. M. (2005). Strategies to overcome obstacles in the facilitation of critical thinking in nursing education . Nurse Education Today , 25 ( 4 ), 291–298. 10.1016/j.nedt.2005.01.012 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mash, B. (2014). African primary care research: Participatory action research . African Journal of Primary Health Care and Family Medicaine , 6 ( 1 ), 42–46. 10.4102/phcfm.v6i1.585 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mash, B. , & Meulenberg‐Buskens, I. (2001). “Holding it lightly”: The co‐operative inquiry group: A method for developing educational materials . Medical Education , 35 , 1108–1114. [ PubMed ] [ Google Scholar ]
• Nursing and Midwifery Council of Ghana . (2015). Curriculum for the registered general nursing (RGN) program: Based on the semester course unit system . Nursing and Midwifery Council of Ghana. [ Google Scholar ]
• Raymond, C. L. , & Profetto‐McGrath, J. (2005). Nurse educators’ critical thinking: Reflection and measurement . Nurse Education in Practice , 5 , 209–217. 10.1016/j.nepr.2004.10.004 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Raymond, C. , Profetto‐McGrath, J. , Myrick, F. , & Strean, W. B. (2017). An integrative review of the concealed connection: Nurse educators' critical thinking . Journal of Nursing Education , 56 ( 11 ), 648–654. 10.3928/01484834-20171020-03 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Raymond, C. , Profetto‐McGrath, J. , Myrick, F. , & Strean, W. B. (2018). Balancing the seen and unseen: Nurse educator as role model for critical thinking . Nurse Education in Practice , 31 , 41–47. 10.1016/j.nepr.2018.04.010 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rolfe, G. (1996). Going to extremes: Action research, grounded practice and the theory‐practice gap in nursing . Journal of Advanced Nursing , 24 ( 6 ), 1315–1320. 10.1111/j.1365-2648.1996.tb01040.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Shell, R. (2001). Perceived barriers to teaching for critical thinking by nursing faculty . Nursing and Health Care Perspectives , 22 ( 6 ), 286–291. [ PubMed ] [ Google Scholar ]
• South African Nursing Council . (2014). Competencies for a nurse educator . South African Nursing Council. [ Google Scholar ]
• Talley, B. (2006). Nurses and nursing education in Ghana: Creating collaborative opportunities . International Nursing Review , 53 ( 1 ), 47–51. 10.1111/j.1466-7657.2006.00431.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ward‐Smith, P. (2020). The nurse as a critical thinking expert . Urologic Nursing , 40 ( 1 ), 5. 10.7257/1053-816X.2020.40.1.5 [ CrossRef ] [ Google Scholar ]
• Whiteman, K. , Yaglowski, J. , & Stephens, K. (2021). Quality improvement: Critical thinking tools for quality improvement projects . Critical Care Nurse , 41 ( 2 ), e1–e9. 10.4037/con2021914 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wilmot, E. M. , Kumfo, J. , Danso‐Mensah, D. , & Antwi‐Danso, S. (2013). An Investigation into the factors that contribute to nurse/midwife trainees' poor performance in the final licencing examination in Ghana .
• World Health Organization . (2009). Nursing and midwifery human resources for health: Global standards for the initial education of professional nurses and midwives . World Health Organization. [ Google Scholar ]

• Subscribe to journal Subscribe
• Get new issue alerts Get alerts

Secondary Logo

Journal logo.

Colleague's E-mail is Invalid

Your message has been successfully sent to your colleague.

Save my selection

Effectiveness of Problem-Based Learning on Development of Nursing Students’ Critical Thinking Skills

A systematic review and meta-analysis.

Wei, Baojian MD; Wang, Haoyu BS; Li, Feng MSc; Long, Yan MSc; Zhang, Qi MSc; Liu, Hang MSc; Tang, Xiujun MSc; Rao, Mingjun MD

Author Affiliations: Adjunct Professor (Dr Wei), School of Nursing, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian, Shandong, China; and Instructor (Messrs Wang, Li, Zhang, Liu, and Tang and Ms Long), Professor (Mr Tang), and Adjunct Professor (Dr Rao), Department of Plastic Surgery, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China.

Correspondence: Dr Rao ( [email protected] ) and Mr Tang ( [email protected] ) , Department of Plastic Surgery, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China.

This work was supported by the Research Program of Taishan Medical College Education and Teaching Research Project (No. XY2018051).

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website ( www.nurseeducatoronline.com ).

Accepted for publication: September 17, 2023

Early Access: November 16, 2023

Cite this article as: Wei B, Wang H, Li F, Long Y, Zhang Q, Liu H, Tang X, Rao M. Effectiveness of problem-based learning on development of nursing students’ critical thinking skills: a systematic review and meta-analysis. Nurse Educ . 2024;49(3):E115-E119. doi:10.1097/NNE.0000000000001548

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Background: 

Problem-based learning (PBL) is a student-centered approach to teaching that has been applied in medical and nursing education. The effectiveness of PBL in promoting critical thinking in nursing students has been studied extensively with mixed results.

Purpose: 

The meta-analysis aimed to investigate the impact of PBL interventions on critical thinking skills of nursing students.

Methods: 

PubMed, Embase, Cochrane, and CINAHL databases were electronically searched. Methodological quality was examined using the Newcastle-Ottawa Scale and version 2 of the Cochrane risk-of-bias tool. Data were analyzed with 95% confidence intervals based on random-effect models.

Results: 

Nineteen studies involving 1996 nursing students were included in the analysis. The results of the analysis demonstrated greater improvement in critical thinking skills compared with the control group (overall critical thinking scores: standardized mean difference [SMD] = 0.47, 95% CI = 0.33-0.61, P < .01).

Conclusions: 

The meta-analysis indicates that PBL can help nursing students to improve their critical thinking.

Nursing occupies a critical role in health care. The profession entails a myriad of responsibilities, including recognizing patients’ symptoms, taking measures to administer medications, providing other measures to help relieve symptoms, and collaborating with other health care workers to optimize patients’ comfort and families’ understanding and adaptation. 1 To effectively fulfill these responsibilities, nurses require professional knowledge across various aspects of health care. 2 , 3 Critical thinking, an essential cognitive capacity, plays a pivotal role in enabling nurses to make informed decisions and fulfill their diverse roles. 4 It involves a combination of cognitive skills and affective dispositions, as defined by the American Philosophical Association, and positively influences clinical practice, patient health, student education, and the growth of nursing science. 5 , 6

Problem-based learning (PBL) is an innovative teaching method that has gained widespread application among institutions worldwide, particularly in the fields of medical and nursing education. 6 , 7 As described by Zakaria et al, 8 PBL is a student-centered, outcome-based approach that has been proven to enhance the quality of learning across various disciplines and academic levels. PBL is described as a process-focused teaching strategy that employs small groups centered on solving well-integrated clinical problems. Unlike traditional instruction, which relies heavily on lectures and limited self-directed learning, PBL encourages active problem-solving and collaboration among students. 9 PBL has been hailed as the “most significant innovation in education for professions in many years,” a testament to its transformative impact on the field of education. 10-12 Indeed, PBL has emerged as a game-changer in medical education, and its effects on nursing education have also been studied extensively. 13

Numerous studies have shown that PBL significantly enhances critical thinking skills (CT skills) among medical students. 14 As Hajrezayi et al note, critical thinking involves purposeful, self-regulatory judgment that results in interpretation, analysis, evaluation, and inference, skills that are invaluable in the clinical setting. 15 PBL, as a teaching strategy, focuses on engaging students in group discussions to address complex and ambiguous clinical problems. This process involves analyzing problems, setting objectives, gathering information, summarizing ideas, and reflecting on problem-solving experiences. 16 Research has demonstrated that this teaching strategy effectively develops critical thinking abilities in medical students. 17

However, the efficacy of PBL as a teaching method for enhancing critical thinking in nursing students remains a topic of debate among researchers. Previous systematic reviews evaluating critical thinking in PBL have produced mixed results, with some studies supporting a positive relationship between PBL and critical thinking and others disputing it. 18-20

To address these inconsistencies and provide a more comprehensive understanding of the effectiveness of PBL in promoting critical thinking in nursing students, we synthesized the data of previous studies published and conducted a more comprehensive meta-analysis.

Methodology for Meta-analysis

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure a systematic and transparent process. The PRISMA statement comprises a 27-item checklist and a 4-phase flow diagram, which guide the analysis. 21 We carefully applied each item on the checklist to guarantee transparent reporting of our systematic review, while the flow diagram helped us visualize and track the different stages of our analysis. The review protocol was registered on PROSPERO (PROSPERO ID: CRD42023406592).

Search Strategy

We conducted a comprehensive search of the literature using electronic databases (PubMed via National Library of Medicine, Embase via Elsevier, Cochrane via Cochrane library, and CINAHL via EBSCO) from inception to September 9, 2023, supplemented by a manual search of reference lists of relevant articles. There was no limit to search date, language, and publication period. We used a combination of keywords and MeSH terms related to the topic to optimize the search results, detailed in the supplementary material (see Supplemental Digital Content 1, available at: https://links.lww.com/NE/B450 ).

Study Selection

Two reviewers (R.M. and W.B.) independently screened the titles and abstracts for eligibility. Articles that did not meet the inclusion criteria were excluded. The same 2 reviewers then independently reviewed full texts of remaining articles for inclusion in the meta-analysis. Discrepancies were resolved through discussion and consensus with a third reviewer (T.X.).

Included studies satisfied the following criteria: (1) participants were nursing students including graduate and undergraduate nursing students, (2) the intervention group used PBL, (3) the control group used traditional lectures, (4) trials evaluated critical thinking, (5) reported sample size, mean difference, and standard deviation of critical thinking scores. Excluded studies included nonnursing subjects, interventions other than PBL, no critical thinking evaluation, and incomplete/duplicate articles. Both randomized and nonrandomized controlled trials were included.

Data Extraction

Two reviewers independently extracted data from the included studies using a standardized data extraction form. The data extracted included study characteristics (author, year of publication, and country), participant characteristics (sample size and grade), description of PBL, teaching methods combined with PBL, research of design, and critical thinking tools (the mean difference from baseline to post-test, as well as standard deviation). Any discrepancies were resolved through discussion and consensus with a third reviewer.

Quality Assessment

Two reviewers independently assessed the quality of the included studies using a Newcastle-Ottawa Scale (NOS) for cohort studies, and version 2 of the Cochrane risk-of-bias tool for randomized trials. A study was considered as high quality if the NOS score was 7 or more, moderate quality if the NOS score between 4 and 7, and low quality if the NOS score less than 4. As for version 2 of the Cochrane risk-of-bias tool, when there are “some concerns” (or high risk of bias ratings) in some domains, the overall risk of bias is rated as “some concerns” (or high), respectively. Any discrepancies were resolved through discussion and consensus with a third expert.

Data Analysis

We used a random-effects model to pool the effect sizes across studies. To determine the significance of our findings, we set a threshold of a 2-sided P value less than .05 for all analyses. We assessed heterogeneity using the I 2 statistic and P value of Cochran's Q statistic, P value < .10 and I 2 > 50% were considered as heterogeneity. The I 2 statistic, which indicates the percentage of variation attributed to heterogeneity, was an easily interpretable way to assess the degree of heterogeneity. We considered an I 2 statistic of 25% to 50% to indicate low heterogeneity, 50% to 75% to indicate moderate heterogeneity, and more than 75% to indicate high heterogeneity. If there is heterogeneity, we explored potential sources of heterogeneity using subgroup analyses based on the duration of PBL intervention (hours or weeks), the grade of nursing students, and the assessment tools of CT skills. We conducted sensitivity analyses to examine the robustness of the findings and assessed publication bias using funnel plots and Egger's test. All analyses are conducted using R software.

Ethics Approval

As this study is a meta-analysis of previously published studies, no ethical approval was required.

We conducted a thorough review of available literature on PBL interventions for nursing students and ultimately obtained 19 studies (see Supplemental Digital Content 2, available at: https://links.lww.com/NE/B451 ).

Study Characteristics

All included studies were published between 2004 and 2021 and involved 1996 nursing students from Iran (n = 3), South Korea (n = 8), China (n = 6), the United States (n = 1), and Turkey (n = 1). The participants included first-year, second-year, third-year, fourth-year, and graduates with a work experience ranging from 1 to 21 years; 1876 participants were undergraduate nursing students while 120 participants were graduate nursing students with a work experience ranging from 1 to 21 years. The length of the PBL intervention period varied, with 7 articles lasting less than 12 weeks and 9 articles lasting 12 weeks or more. PBL interventions were integrated with various teaching methods, including simulation, case-based learning, teamwork, concept mapping, clinical practice, internet, and tutors as guides (tutors help clarify concepts and answer questions).

To assess the critical thinking, 18 included studies adopted different assessment tools including the California Critical Thinking Skills Test (CCTST, n = 6), California Critical Thinking Dispositions Inventory (CCTDI, n = 5), Assessment Technologies Institute Critical Thinking Test (n = 1), Watson-Glaser Critical Thinking Scale (n = 1), and critical thinking tools developed by Yoon (n = 2), Kwon (n = 2), Park (n = 1), McMaster University (n = 1). Among these assessment tools, the CCTST and CCTDI stand out as the primary tools utilized in the studies. The detailed characteristics were presented in Supplemental Digital Content 3, available at: https://links.lww.com/NE/B452 .

Risk of Bias

Nine of the 12 cohort studies had a low risk of bias (see Supplemental Digital Content 4, available at https://links.lww.com/NE/B453 ). However, all 7 randomized controlled studies had a high risk of bias (see Supplemental Digital Content 5, available at: https://links.lww.com/NE/B454 ). None of the randomized controlled studies specified whether the allocation sequence was concealed until participants were enrolled and assigned to interventions, nor were they able to conceal their allocation from the participants, the teachers, and the outcome assessors during the trial.

Meta-analysis Results

Nineteen studies involving 1996 participants (PBL group = 941, lecture group = 1055) reported overall critical thinking scores. The pooled effect size showed significant difference (standardized mean difference [SMD] = 0.47, 95% CI = 0.33-0.61, P < .001) in favor of PBL, compared with traditional lectures (see Supplemental Digital Content 6, available at: https://links.lww.com/NE/B455 ). There was moderate heterogeneity ( I 2 = 52%, P < .01).

Subgroup Analysis and Publication Bias

We conducted further subgroup analyses to explore the underlying sources of heterogeneity. Regarding nursing students of different grades, compared with second-year students, the critical thinking scores of the first- and third-year improved more, but there was no clear pattern of higher or lower critical thinking scores among higher grades (see Supplemental Digital Content 7, available at: https://links.lww.com/NE/B456 ). Additionally, we conducted subgroup analysis based on the different assessment tools used in the studies and discovered that nursing students who took the CCTST had higher scores compared with the CCTDI. Furthermore, the subgroup analysis based on intervention time showed that an intervention duration with fewer weeks and more hours had a greater improvement in critical thinking scores (see Supplemental Digital Content 7, available at: https://links.lww.com/NE/B456 ). This may suggest that nursing students who receive more intensive PBL course arrangements exhibited a higher improvement in critical thinking scores.

Furthermore, during the PBL process, nursing students who visualize the ideas, concepts, and terms using concept mapping show better improvement in critical thinking abilities (see Supplemental Digital Content 7, available at: https://links.lww.com/NE/B456 ). Additionally, students who receive help from teachers to clarify concepts and solve problems also demonstrate better improvement in critical thinking abilities. It is worth noting that among the 9 studies where teachers played a significant role in guiding students (clarifying concepts and answering questions rather than simply directing the slow of the PBL), all were published in 2008 or later. In contrast, among the 9 clinical studies where teachers only assisted in implementing PBL, 4 were published before 2008. This suggests that teachers play a more important role during the development of the PBL teaching strategy.

We conducted a funnel plot analysis to determine the degree of symmetry in our results and conducted Egger's regression test to determine publication bias (see Supplemental Digital Content 8, available at: https://links.lww.com/NE/B457 ). The results showed no publication bias, with bias = 0.7445 ( t = 0.6, df = 7, P = .5580).

In this meta-analysis, we found that PBL has a greater impact on CT skills of nursing students compared with traditional lectures. In the past 2 decades, there have been several meta-analyses published on this topic, but the earlier meta-analysis did not support our current conclusion, that the PBL teaching strategy can improve nursing students’ critical thinking ability compared with traditional lectures. 18 After incorporating more studies, our meta-analyses has new findings that differ from previous meta-analysis.

The discrepancy between our conclusions and those of earlier meta-analyses can be attributed to the continuous improvement of the PBL teaching strategy itself. 22 , 23 Our meta-analysis supported that teachers played a more important role in the development of the PBL teaching strategy. Teachers in the earlier studies mainly helped implement the PBL teaching strategy, teachers in the more recent studies encouraged students to think critically and gave timely feedback. Originally introduced as a novel teaching strategy in medical education, teachers primarily act as a procedural guide, our meta-analysis suggests that increased teacher engagement in the PBL teaching process can enhance nursing students’ critical thinking abilities. Although exhaustively providing students with answers to their questions as a directive lecturer is not conducive to fostering students’ critical thinking abilities, students might be dismayed when their teachers rarely directly answer a question, but instead ask questions back and let the student find the answer independently. 24

Throughout the ongoing improvement of the PBL teaching strategy, case-based learning has been integrated. Cases present clinical problems to nursing students in a fragmented manner, fostering their autonomy in constructing a knowledge framework to investigate the problems and address the presented challenges. 25 Furthermore, the assistance of concept mapping and teamwork during the PBL teaching process further improved the PBL teaching strategy. 26 , 27

Despite various advantages demonstrated by the PBL teaching strategy over the past few decades, it is imperative that we carefully evaluate both the benefits and drawbacks of adopting this teaching strategy over traditional lecture-based learning methods. One of the most celebrated aspects of the PBL teaching strategy is its ability to situate information within the context of real-life clinical problem-solving, bridging the gap between textbook knowledge and practical application. 23 On the other hand, PBL necessitates teachers to invest substantial effort in guiding students’ self-directed learning, while medical institutions should acknowledge adequate resources to support the PBL teaching strategy. 28 Nevertheless, it is worth noting that implementing the PBL teaching strategy effectively may pose challenges for teachers who are accustomed to traditional lecture-based strategy, necessitating additional training to ensure competence in the PBL teaching strategy.

Furthermore, we must acknowledge that clinical problem-solving through the PBL teaching strategy is a complex cognitive task that involves hypothesis generation from ambiguous clues. It requires reasoning based partly on fuzzy categorical knowledge, partly on probabilities, and partly on understanding the urgency and risk-benefit relationship of potential treatments. 29 In essence, for clinical problem-solving to become a meaningful experience, nursing students must possess knowledge and experience directly tied to the clinical problems. Traditional lecture-based learning methods afford teachers the opportunity to assist students in constructing knowledge frameworks based on their own expertise experience. 30 However, in the realm of PBL teaching, students, due to their limited foundational knowledge, may pose numerous seemingly inconsequential questions, potentially appearing chaotic, time-consuming, and misguided in the eyes of teachers. 31 To mitigate this challenge, some studies have leveraged concept mapping and the internet to facilitate rapid access to relevant knowledge, aiding nursing students in comprehending clinical problems. 32 , 33 Moreover, experienced PBL teachers play a pivotal role in helping nursing students build a robust knowledge base by promptly answering their questions. 34

Moreover, the current trend in PBL teaching involves employing cases as guides for learning in specific content areas. In this situation, nursing students typically only learn the definition of possible treatments when the clinical problems are presented. This approach often simplifies the complexities and exceptional aspects of clinical cases, which may serve as illustrative examples of important concepts, which may lack practicality in the actual practice of clinical problem-solving. 31 , 35 However, as nursing students engage in independent collection of background information, teachers help guide them in applying and refining their critical thinking skills to attempt to understand the reading materials, not limiting themselves to textbooks or the small world of their peers and teachers. They are quickly guided into a broader world, namely the current cutting-edge medical issues, by the latest medical articles as well as expert teachers. 25

Our meta-analysis indicates that the PBL teaching strategy can enhance critical thinking skills in nursing students.

• Cited Here |
• Google Scholar

critical thinking skill; meta-analysis; nursing students; problem-based learning

Supplemental Digital Content

• NE_2023_09_27_RAO_2023453_SDC1.docx; [Word] (18 KB)
• NE_2023_09_27_RAO_2023453_SDC2.docx; [Word] (37 KB)
• NE_2023_09_27_RAO_2023453_SDC3.docx; [Word] (33 KB)
• NE_2023_09_27_RAO_2023453_SDC4.docx; [Word] (24 KB)
• NE_2023_09_27_RAO_2023453_SDC5.docx; [Word] (277 KB)
• NE_2023_09_27_RAO_2023453_SDC6.docx; [Word] (463 KB)
• NE_2023_09_27_RAO_2023453_SDC7.docx; [Word] (17 KB)
• NE_2023_09_27_RAO_2023453_SDC8.docx; [Word] (116 KB)
• + Favorites
• View in Gallery

Readers Of this Article Also Read

Aligning simulation-based education with didactic learning in prelicensure..., a scoping review of nurse educator competencies: mind the gap, a hostile environment: an exploratory study of prelicensure nursing student..., mapping critical thinking, clinical reasoning, and clinical judgment across the ..., curriculum mapping for competency-based education: collecting objective data.

Critical thinking definition

Critical thinking, as described by Oxford Languages, is the objective analysis and evaluation of an issue in order to form a judgement.

Active and skillful approach, evaluation, assessment, synthesis, and/or evaluation of information obtained from, or made by, observation, knowledge, reflection, acumen or conversation, as a guide to belief and action, requires the critical thinking process, which is why it's often used in education and academics.

Some even may view it as a backbone of modern thought.

However, it's a skill, and skills must be trained and encouraged to be used at its full potential.

People turn up to various approaches in improving their critical thinking, like:

• Developing technical and problem-solving skills
• Engaging in more active listening
• Actively questioning their assumptions and beliefs
• Seeking out more diversity of thought
• Opening up their curiosity in an intellectual way etc.

Is critical thinking useful in writing?

Critical thinking can help in planning your paper and making it more concise, but it's not obvious at first. We carefully pinpointed some the questions you should ask yourself when boosting critical thinking in writing:

• What information should be included?
• Which information resources should the author look to?
• What degree of technical knowledge should the report assume its audience has?
• What is the most effective way to show information?
• How should the report be organized?
• How should it be designed?
• What tone and level of language difficulty should the document have?

Usage of critical thinking comes down not only to the outline of your paper, it also begs the question: How can we use critical thinking solving problems in our writing's topic?

Let's say, you have a Powerpoint on how critical thinking can reduce poverty in the United States. You'll primarily have to define critical thinking for the viewers, as well as use a lot of critical thinking questions and synonyms to get them to be familiar with your methods and start the thinking process behind it.

Are there any services that can help me use more critical thinking?

We understand that it's difficult to learn how to use critical thinking more effectively in just one article, but our service is here to help.

We are a team specializing in writing essays and other assignments for college students and all other types of customers who need a helping hand in its making. We cover a great range of topics, offer perfect quality work, always deliver on time and aim to leave our customers completely satisfied with what they ordered.

The ordering process is fully online, and it goes as follows:

• Select the topic and the deadline of your essay.
• Provide us with any details, requirements, statements that should be emphasized or particular parts of the essay writing process you struggle with.
• Leave the email address, where your completed order will be sent to.
• Select your prefered payment type, sit back and relax!

With lots of experience on the market, professionally degreed essay writers , online 24/7 customer support and incredibly low prices, you won't find a service offering a better deal than ours.