critical thinking and reflection in nursing

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.

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Nurturing Leadership: 4 Key Strategies for Reflective Practice in Nursing

5 min read • February, 21 2024

Nursing leaders play a pivotal role in guiding change to enhance patient care and improve professional practice environments. Reflective practice stands out as a cornerstone for effective leadership, allowing nursing professionals to evaluate their experiences critically and foster continuous improvement. This article delves into four key reflective practices that can empower nursing leaders to drive meaningful change.

The Power of Reflection in Nursing Change

Reflective practice is more than a method; it's a mindset that enables nursing leaders to learn from their actions, make informed decisions, and engage their teams in the journey towards excellence. By incorporating reflective practices into their leadership approach , nurses can better navigate the complexities of healthcare, adapt to challenges, and implement strategies that align with their goals and values.

Understanding Your Change Goals

Q: What did you say you were going to do? A: Begin by revisiting your initial objectives. Clear articulation of your goals lays the foundation for accountability and sets the stage for impactful change. Reflect on the scope of the changes you envisioned and the outcomes you aimed to achieve. This honest appraisal is your first step towards meaningful progress.

Assessing Your Actions

Q: What did you actually do? A: Reality often diverges from our plans. Assessing your actions with candor enables you to identify discrepancies between your intentions and your actual practices. Acknowledge both your achievements and the areas where you fell short. This recognition is crucial for realistic self-assessment and sets the groundwork for authentic growth.

Learning from Experience

Q: What did you learn? A: Every step in the change process offers valuable lessons. Reflect on the insights gained from your experiences and how they can inform future strategies. These lessons are the silver lining, providing clarity and direction for your next moves.

Planning Your Next Steps

Q: What do you need to do next? A: Armed with new knowledge, plan your forward strategy. Consider who needs to be involved, the resources required, and the timeline for implementation. This step is about translating insights into actionable plans that drive further change.

Incorporating Reflective Practice into Your Routine

Integrating reflective practice into your leadership routine doesn't have to be daunting. Start small with regular reflection sessions, encourage team discussions that foster collective learning, and set aside time for personal and professional development. Embracing reflection as a habit can transform your leadership approach and significantly impact your team's performance and well-being.

Reflective practice is an invaluable tool for nursing leaders seeking to navigate the complexities of healthcare and drive positive change. By focusing on these four essential aspects of reflection, you can enhance your leadership effectiveness, improve patient care , and foster a culture of continuous learning and improvement . Start today by taking a moment to reflect on your practice and empower yourself and your team for the challenges and opportunities ahead.

Images sourced from Getty Images

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• Open access
• Published: 16 March 2023

Effectiveness of a critical reflection competency program for clinical nurse educators: a pilot study

• Sujin Shin 1 ,
• Inyoung Lee 2 ,
• Jeonghyun Kim 3 ,
• Eunyoung Oh 4 &
• Eunmin Hong 1  

BMC Nursing volume  22 , Article number:  69 ( 2023 ) Cite this article

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Metrics details

Critical reflection is an effective learning strategy that enhances clinical nurses’ reflective practice and professionalism. Therefore, training programs for nurse educators should be implemented so that critical reflection can be applied to nursing education. This study aimed to investigate the effects of a critical reflection competency program for clinical nurse educators on improving critical thinking disposition, nursing reflection competency, and teaching efficacy.

A pilot study was conducted using a pre- and post-test control-group design. Participants were clinical nurse educators recruited using a convenience sampling method. The program was conducted once a week for 90 min, with a total of four sessions. The effectiveness of the developed program was verified by analyzing pre- and post-test results of 26 participants in the intervention group and 27 participants in the control group, respectively. The chi-square test, independent t-test, Mann-Whitney U test, and analysis of covariance with age as a covariate were conducted.

The critical thinking disposition and teaching efficacy of the intervention group improved after the program, and the differences between the control and intervention groups were statistically significant (F = 14.751, p  < 0.001; F = 11.047, p  < 0.001). There was no significant difference in the change in nursing reflection competency between the two groups (F = 2.674, p  = 0.108).

The critical reflection competency program was effective in improving the critical thinking disposition and teaching efficacy of nurse educators. Therefore, it is necessary to implement the developed program for nurse educators to effectively utilize critical reflection in nursing education.

Peer Review reports

The critical thinking of clinical nurses is essential for identifying the needs of patients and providing safe care through prompt and accurate judgment [ 1 , 2 , 3 ]. Critical thinking can be practiced through critical reflection [ 4 ], a dynamic process in which nurses reflect on their nursing behavior to improve their perspective on a situation and change future nursing practices in a desirable direction [ 5 ]. Through critical reflection, nurses grasp the contextual meaning of a situation and reconstruct their experiences to apply their learning in practice, thereby identifying the meaning of nursing [ 3 ]. In other words, critical reflection can help nurses convert their experiences into practical knowledge [ 6 ]. Thus, critical reflection may be an effective learning strategy linking theory and practice in clinical nursing education [ 7 ].

Studies have reported that critical reflection is effective in improving nurses’ reflective practices and professionalism. Teaching methods that use critical reflection can improve nurses’ knowledge, communication skills, and critical thinking abilities [ 1 , 8 , 9 ]. These methods can be effective in improving clinical judgment and problem-solving abilities by providing new nurses with opportunities to apply their theoretical knowledge in clinical practice [ 10 , 11 ]. In addition, critical reflection has positive effects on the professionalism of new graduate nurses and reduces reality shock during the transition from university to clinical practice [ 12 ]. These advantages have led to the increasing application of critical reflection in training programs for new graduate nurses, including nursing residency programs [ 13 , 14 , 15 ].

In order to facilitate new nurses’ reflective thinking and practice by clinical nurse educators, educators must be trained to strengthen their critical thinking disposition, nursing reflection, and teaching efficacy competency. Educators help new nurses adapt and develop their expertise in clinical settings [ 16 , 17 ]. Moreover, continuing education for nurses to improve their teaching competency relates to the satisfaction of learners and nurse educators, which improves the quality of clinical nursing education [ 18 ]. Therefore, opportunities for nurse educators to develop teaching competency for critical reflection in education should be provided [ 19 ] and educational support for nurse educators to improve critical reflection competency is needed.

However, although there have been studies that have evaluated the effectiveness of the educational interventions concerning critical reflection to new nurses, few studies have been conducted on educational interventions on the critical reflection competencies of clinical nurse educators in charge of educating new nurses. Therefore, this study aimed to investigate the effects of a critical reflection competency program for clinical nurse educators on improving critical thinking disposition, nursing reflection competency, and teaching efficacy.

Study design

A pilot study was conducted with a pre- and post-test control group design to investigate the effects of the critical reflection competency program on the critical thinking disposition, nursing reflection competency, and teaching efficacy of nurse educators. The conceptual framework in this study was proposed that the critical reflection competency program will improve critical thinking disposition, nursing reflection, and teaching efficacy of clinical nurse educators [Fig.  1 ].

Conceptual Framework

Participants were clinical nurse educators in hospitals who were recruited using a convenience sampling method. Nurse educators were eligible to participate if they had dedicated nursing education in a clinical setting. They dedicated to nursing education focused on staff development of current nurses, especially the education for new nurses. They also included those who completed all four sessions of the program and participated in the data collection before and after the program. A recruitment document was sent to hospitals to recruit the participants, hospitals were selected with concerning role of clinical nurse educators. Participants were recruited from two hospitals of different sizes and the number of participants differed for each hospital, and they were allocated according to the order of registration.

The sample size required for the analysis was calculated using the G* Power 3.1.9.4. program with an effect size of 0.80, a significance level of 0.05, and a power of 0.80, following the literature [ 20 ]. By applying a self-reflection program for intensive care unit nurses [ 20 ], we calculated the effect size as large. Both the intervention and control groups required 26 participants. Considering a dropout rate of 20%, a total of 63 participants, including 32 in the intervention group and 31 in the control group, were recruited. From the intervention group, six participants who participated in the pre-test and completed all programs, but did not participate in the post-test, were excluded. In the control group, four participants who participated in the pre-test but not in the post-test were excluded. Thus, 26 and 27 participants in the intervention and control groups, respectively, were included in the final analysis [Fig.  2 ]. The pre-test for both groups was conducted in May 2021. Post-tests for the two groups were performed four weeks after the pre-test.

Flowchart of the study

Intervention

The intervention was developed and delivered by the first author, who has more than 15 years of teaching experience in nursing education, including critical reflection. The intervention was conducted between May 2021 and June 2021. Following previous studies that applied critical reflection in medical education [ 21 , 22 ], the intervention was conducted once a week for 90 min, with a total of four sessions. Owing to COVID-19, real-time online sessions were used to minimize contact between participants working in medical institutions. Every week before the sessions, the contents of the session, schedule, and Uniform Resource Locator (URL) were sent to participants via e-mail.

The intervention consisted of the following three steps in four sessions: (1) understanding critical reflection, (2) strategies to use critical reflection, and (3) practical uses of critical reflection [Fig.  3 ]. Synchronous online lectures were conducted in the first and second sessions. The contents of the first session included understanding of critical reflection and the clinical judgment process through critical reflection. Based on the content of the first session, the second outlined educational strategies using critical reflection in nursing education and the direction of critical reflection. In the third and fourth sessions, clinical nurses with experience of critically reflecting on themselves were invited as guest speakers to share their experiences and facilitate online discussions. Online discussions were also conducted in real time, and feedback from guest speakers and the author was immediately provided.

Critical reflection program for clinical nurse educators

Online self-report surveys were conducted before and after the program to assess the program’s effects. In both pre- and post-tests, critical thinking disposition, nursing reflection competency, and teaching efficacy were assessed, as well as information about participants, such as gender, age, experience in nursing education, and the type of institution and the number of beds they affiliated with.

Critical thinking disposition was measured using Yoon’s Critical Thinking Disposition Scale [ 23 ]. This scale comprises 27 items: 5 on “intellectual eagerness/curiosity,” 4 on “prudence,” 4 on “self-confidence,” 3 on “systematicity,” 4 on “intellectual fairness,” 4 on “healthy skepticism,” and 3 on “objectivity.” The items were evaluated on a five-point Likert scale (one point for “strongly disagree” to five points for “strongly agree”); a higher score indicated greater critical thinking disposition. The scale has good reliability as evidenced by a Cronbach’s alpha of 0.84 at the time of the development versus the reliability of the scale in this study was Cronbach’s alpha of 0.78.

Nursing reflection competency was assessed using the Nursing-Reflection Questionnaire, developed by Lee et al. [ 24 ]. This scale comprises four factors with 15 items, including 6 items on “review and analysis nursing behavior,” 5 on “development-oriented deliberative engagement,” 2 on “objective self-awareness,” and 2 on “contemplation of behavioral change.” Each item was evaluated on a five-point Likert scale (one point for “strongly disagree” to five points for “strongly agree”), with a higher score indicating greater nursing reflection competency. The scale has good reliability as evidenced by a Cronbach’s alpha of 0.86 at the time of the development versus the reliability of the scale in this study was Cronbach’s alpha of 0.82.

Teaching efficacy was evaluated using the Teaching Efficacy Scale developed by Park and Suh [ 25 ] to evaluate clinical nursing instructors. This scale consisted of six sub-factors with 42 items, including 12 items on “student instruction,” 9 on “teaching improvement,” 7 on “application of teaching and learning,” 7 on “interpersonal relationship and communication,” 4 on “clinical judgment,” and 3 on “clinical skill instruction.” Each item was evaluated on a five-point Likert scale (one point for “strongly disagree” to five points for “strongly agree”), with a higher score indicating greater teaching efficacy. The scale has good reliability as evidenced by a Cronbach’s alpha of 0.97 at the time of the development versus the reliability of the scale in this study was Cronbach’s alpha of 0.93.

Ethical considerations

This study was approved by the Institutional Review Board (IRB) of Ewha Womans University (IRB no. ewha-202105-0022-02). The need of written informed consent was exempted by IRB of Ewha Womans University. All methods were performed in accordance with the relevant guidelines and regulations. A description of the study, including its purpose, methods, and procedures, was posted on an online pre-test survey. Only those participants who agreed to participate were allowed to complete the questionnaire. The participants were also informed that they could withdraw from the study at any time and that the data of withdrawn participants would not be included in the final analysis. After the survey was completed, a mobile gift voucher was provided to those who agreed to provide their mobile phone number. Data were collected by researchers who did not participate in the program.

Data analysis

The collected data were analyzed using SPSS for Windows (version 28.0). Non-normally distributed data were analyzed using non-parametric tests. Descriptive statistics were used to calculate the frequency, percentage, mean, and standard deviation of participants’ general and institutional characteristics. Chi-square, independent t-, and Mann-Whitney U tests were conducted to test the homogeneity of the general characteristics and pre-test scores. The Shapiro-Wilk test was conducted to test the normality of the data. To test the difference between the pre- and post-tests for each group, analysis of covariance (ANCOVA) was used. As there was a significant difference in age between the intervention and control groups, an ANCOVA with age as a covariate was conducted for the difference in changes in test scores between the pre- and post-test.

Homogeneity test of general characteristics and dependent variables

All participants were female, with a mean nursing education experience of 27 and 23 months in the intervention and control groups, respectively. The homogeneity test of general and institutional characteristics, such as gender, nursing education experience, affiliated institution types, and the number of beds, were not statistically significant. However, the age differed significantly between the two groups. In the test for homogeneity of the pre-intervention scores, there were no significant differences in critical thinking disposition, nursing reflection competency, or teaching efficacy between the two groups, suggesting homogeneity of the dependent variables between the groups [Table  1 ].

Effects of critical reflection competency program

The effects of the critical reflection competency program are shown in Table  2 .

In the post-intervention phase, scores of critical thinking disposition, nursing reflection competency, and teaching efficacy all improved compared to the pre-intervention phase, and were higher in the experimental group than in the control group. The critical thinking disposition scores before and after the intervention were 3.61 ± 0.26 vs. 3.87 ± 0.04 in the intervention group and 3.76 ± 0.21 vs. 3.77 ± 0.04 in the control group, respectively. The nursing reflection competency scores before and after the intervention were 57.00 ± 3.42 vs. 60.86 ± 0.95 in the intervention group and 59.63 ± 5.24 vs. 59.04 ± 0.89 in the control group. The teaching efficacy scores before and after the intervention were 157.04 ± 10.60 vs. 171.98 ± 2.54 in the intervention group and 161.59 ± 14.77 vs. 160.48 ± 2.46 in the control group.

Age, which was significantly different between the intervention and control groups, was treated as a covariate to conduct the ANCOVA. The changes in critical thinking disposition (F = 14.751, p  < 0.001) and teaching efficacy (F = 11.047, p  < 0.001) scores were significantly different between the two groups. However, there was no significant difference in the change in the nursing reflection competency (F = 2.674, p  = 0.108) score between the two groups.

Reflective practice is crucial to clinical nurses’ professionalism. Reflective practice enables positive learning experiences through deep and meaningful learning, and is essential for integrating theory and practice. It also enables nurses to implement what they have learned into practice, understand their expertise, and develop clinical competencies [ 26 ]. In this respect, it is important for clinical nursing educators to have critical reflection competencies and promote experiential learning among new nurses. In this study, a critical reflection competency program was developed to enhance clinical nurse educators’ critical thinking and teaching competency.

This program was effective in improving critical thinking disposition. In interventions for critical reflection, various aspects, including the introduction of critical reflection and guidelines to promote critical reflection, such as small group discussions and feedback, can be considered [ 27 ]. The program reflected these aspects and helped improve participants’ critical thinking disposition. In the third and fourth sessions, synchronous discussions on sharing experiences of critical reflection were effective. This is consistent with previous studies in which discussions improved reflective competencies [ 21 , 28 ]. Therefore, sharing experiences in the discussion section should be a key element of future educational interventions for critical reflection competency.

Furthermore, the program was effective in improving teaching efficacy. Teaching efficacy is the instructor’s belief in one’s own ability to organize and implement teaching [ 29 ], and is closely related to age, clinical experience, educational experience, professional development, and teaching competency [ 30 , 31 , 32 ]. Nurses who are more clearly aware of their roles as instructors tend to exhibit higher confidence in their teaching abilities [ 33 , 34 ]. That is, the participants in this study were clearly aware of their roles and developed confidence by sharing their educational experiences about critical reflection.

However, the program did not have a significant effect on nursing reflection competencies. In a previous study [ 10 ], reflective practitioners (RPs) received four weeks of critical reflection training and trained new nurses for six months. During training, new nurses wrote critical reflective journals and RPs provided feedback and shared their experiences. In this study, it seems that the methods and frequency of using critical reflection in nursing education varied for each participant, resulting in insignificant results for nursing reflection competency. It is necessary to provide educational materials or guidelines so that nurse educators can use critical reflection in nursing education.

In this pilot study, the program was found to be effective in improving critical thinking disposition and teaching efficacy. The results show that the program can enhance the critical thinking disposition of nurse educators and help them develop teaching competency by critically reflecting on their educational experiences as instructors [ 35 , 36 ]. Therefore, various educational programs and training systems related to critical reflection are required [ 37 ]. However, many medical institutions find it difficult to provide sufficient educational support to nurses because of limited costs, time, and physical space [ 38 ]. Online real-time lectures and case-based discussions of the developed program can be useful alternatives to overcome barriers to nursing education support. Additionally, more effective educational content and platforms using e-learning can be developed based on the results of this study.

In this study, the critical reflection competency program for clinical nurse educators was developed and conducted. The program was an educational intervention to improve the critical reflection competency of clinical nurse educators in real time online. Several limitations must be considered when interpreting the present findings. The developed program did not affect nursing reflection competencies. Further, the post-test was conducted shortly after program completion. Therefore, there may be limitations to evaluating whether the developed program improves the quality of nursing education. In addition, the participants in this study were allocated regardless of their hospital’s characteristics. Considering variables such as the size of the hospitals, the number of new nurses, and the number of participants per hospital, it is necessary to assign nurse educators the intervention and control groups and to verify the effects of the program. Future studies should consider improving the study design to measure the long-term effects of the program and randomize the participants.

The effects of the program on critical thinking disposition, nursing reflection competency, and teaching efficacy were assessed. The results showed that the program was effective in improving the critical thinking disposition and teaching efficacy of nurse educators. However, there was no significant difference in nursing reflection competency, but it may vary depending on the methods or time of using critical reflection in nursing education. Therefore, it is necessary to provide the critical reflection utilization strategies that can be used by clinical nurse educators in the clinical settings. In addition, further research, such as evaluating the reflective practice of new nurses trained by clinical nurse educators, is needed. This suggests that the critical reflection competency program should be expanded in the future for nurse educators. It is necessary to develop e-learning content and educational platforms to expand the program, and it should be possible to share the experience of critical reflection in various forms. Also, sufficient support for competency improvement of nurse educators is needed to effectively use critical reflection in nursing education. Nursing leaders in hospital and healthcare settings should recognize the importance of using critical reflection in clinical practice and improving the competency of clinical nursing educators who educate new nurses, and make efforts to improve the quality of nursing education through support for these. Lastly, based on the results of this study, we recommend further longitudinal and randomized studies to evaluate additional effects of the program.

Data availability

The datasets used or analyzed during the current study are available from the corresponding author on reasonable request.

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This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (No. 2020R1F1A1057096).

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Shin, S., Lee, I., Kim, J. et al. Effectiveness of a critical reflection competency program for clinical nurse educators: a pilot study. BMC Nurs 22 , 69 (2023). https://doi.org/10.1186/s12912-023-01236-6

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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.

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

The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.

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

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

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

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

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

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

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

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• DOI: 10.1186/s12912-024-02089-3
• Corpus ID: 270637227

Can internship programs affect nursing students’ critical thinking disposition, caring behaviors, and professional commitment?

• Zahra Sarkoohi , M. Nematollahi , +4 authors Jamileh Farokhzadian
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How reflective practice improves nurses' critical thinking ability

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• 1 St. Michael's Hospital, Toronto, Ontario, Canada. [email protected]
• PMID: 18156956
• DOI: 10.1097/01.SGA.0000305221.78403.e9

Purposeful reflection is consistent with adult learning theory. It is known to lead to a deeper understanding of issues and to develop judgment and skill. Required by law to ensure members' competence in their professional practice, the College of Nurses of Ontario recommends and has developed a tool for evaluating reflective practice. The tool focuses on key attributes said to be demonstrated by competent practitioners, including critical thinking (CT) and job knowledge. This study aimed to determine whether nurses engage in reflective practice and whether they perceive that it enhances their CT ability. Surveys were sent to 60 gastroenterology nurses at a large teaching hospital; 34 surveys were anonymously returned. All respondents engaged in reflective practice, and 24 reported using the college's tool. Nineteen respondents strongly agreed that their nursing practice had improved as a result. Critical thinking is difficult to assess because of a lack of clear-cut performance criteria. Improvement of CT was difficult to evaluate from the responses, even though all respondents participated in reflective practice. Both CT and reflective practice need to be better defined in order to examine and explain their relationship.

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Effectiveness of artificial intelligence integration in design-based learning on design thinking mindset, creative and reflective thinking skills: An experimental study

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Integrating Artificial Intelligence (AI) into learning activities is an essential opportunity to develop students' varied thinking skills. On the other hand, design-based learning (DBL) can more effectively foster creative design processes with AI technologies to overcome real-world challenges. In this context, AI-supported DBL activities have a significant potential for teaching and developing thinking skills. However, there is a lack of experimental interventions in the literature examining the effects of integrating AI into learner-centered methods on active engagement and thinking skills. The current study aims to explore the effectiveness of AI integration as a guidance and collaboration tool in a DBL process. In this context, the effect of the experimental application on the participants’ design thinking mindset, creative self-efficacy (CSE), and reflective thinking (RT) self-efficacy levels and the relationship between them were examined. The participants used ChatGPT and Midjourney in the digital story development process as part of the experimental treatment. The only difference between the control and experimental groups in the digital storytelling process is the AI applications used in the experimental treatment (ChatGPT and Midjourney). In this quasi-experimental method study, participants were randomly assigned to treatment, an AI integration intervention, at the departmental level. 87 participants (undergraduate students) in the experimental group and 99 (undergraduate students) in the control group. The implementation process lasted five weeks. Partial Least Squares (PLS), Structural Equation Modeling (SEM), and Multi-Group Analysis (MGA) were made according to the measurements made at the T0 point before the experiment and at the T1 point after the experiment. According to the research result, the intervention in both groups contributed to the creative self-efficacy, critical reflection, and reflection development of the participants. On the other hand, the design thinking mindset levels of both groups did not show a significant difference in the comparison of the T0 point and the T1 point.

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1 Introduction

Developments such as artificial intelligence are followed by theoretical and applied studies on integrating these new technologies into learning processes (Aksu Dünya & Yıldız Durak, 2023 ; Durak & Onan, 2023 ). Technological developments change how businesses do (Kandlhofer et al., 2016 ) and the ways of learning and teaching. Chatbot platforms have components that will profoundly affect learning-teaching processes, including various threats and opportunities (Yildiz Durak, 2023a ). Although preparing student homework through such environments is a threat, these environments have essential advantages, such as accessing information in the learning-teaching process and providing integration of favorable aspects with methods that support various student activities and creativity. There is a lack of experimental intervention in the literature examining the effects of the integration of artificial intelligence into learner-centered methods on learner active participation and creativity (Lund & Wang, 2023 ). In this context, this study includes an experimental intervention to address the shortcomings mentioned in the literature.

Design thinking is a skill teachers should have for the effective use of technology in education (Beckwith, 1988 ; Tsai & Chai, 2012 ). Teachers’ lack of design thinking skills is defined as one obstacle in technology integration. These barriers are classified in the literature as primary, secondary, and tertiary (Ertmer, 1999 ; Ertmer et al., 2012 ; Tsai & Chai, 2012 ). Primary barriers are related to a lack of infrastructure, training, and support (Snoeyink & Ertmer, 2001 ). Secondary barriers generally include teachers’ affective perceptions (e.g., belief, openness to change, self-confidence, and attitude) toward technology integration (Ertmer et al., 2012 ; Keengwe et al., 2008 ). Removing primary and secondary barriers does not guarantee that technology integration will provide meaningful learning (Saritepeci, 2021 ; Yildiz Durak, 2021 ). Tsai and Chai ( 2012 ) explained this situation with tertiary barriers. The learning process is not static; it is dynamic and constantly changing. Therefore, teachers need to have design thinking skills to transform this variable nature of the learning process (Tsai & Chai, 2012 ; Yildiz Durak et al., 2023 ). Overcoming tertiary barriers significantly facilitates the effective use of technology in education. Beckwith’s ( 1988 ) Educational Technology III perspective, which expresses the most effective form of technology use in education, is a flexible structure to provide learners with more meaningful experiences instead of following a systematic process strictly dependent on instructional design, methods, and techniques in educational environments. The Educational Technology III perspective refers to design-based learning practices.

The dizzying developments that occur with technological innovations in today’s business, social, and economic life make our predictions about what kind of job a K12 student will do in the future (Darling-Hammond, 2000 ; Saritepeci, 2021 ). In this case, removing the educational technology III perspective and the tertiary barriers to technology integration is essential. Teachers and pre-service teachers should have the skills to be successful in the coming years, which are uncertain in many ways, and to create opportunities to support these learners. The design-based learning approach has remarkable importance in developing the design-oriented thinking skills of the pre-service teacher. In this context, a structure in which artificial intelligence applications are integrated into the digital storytelling method application processes, one of the most effective applications of the design-based learning approach in learning processes, will support the design-oriented thinking skills of pre-service teachers.

2 Related works

Studies on the use of artificial intelligence in education focus on various areas such as intelligent tutoring system (ITS), (Chen, 2008 ; Rastegarmoghadam & Ziarati, 2017 ), personalized learning (Chen & Hsu, 2008 ; Narciss et al., 2014 ; Zhou et al., 2018 ), assessment-feedback (Cope et al., 2021 ; Muñoz-Merino et al., 2018 ; Ramnarain-Seetohul et al., 2022 ; Ramesh & Sanampudi, 2022 ; Samarakou et al., 2016 ; Wang et al., 2018 ), educational data mining (Chen & Chen, 2009 ; Munir et al., 2022 ) and adaptive learning (Arroyo et al., 2014 ; Wauters et al., 2010 ; Kardan et al., 2015 ). These studies aim to improve the quality of the learning-teaching process by providing individualized learning experiences and increasing the effectiveness of teaching methods.

The intelligent tutoring system is the most prominent study subject in studies on the use of AI in education (Tang et al., 2021 ). ITS focuses on using AI to provide learners with personalized and automated feedback and guide them through the learning process. Indeed, there is evidence in the literature that using ITS in various teaching areas can improve learning outcomes. Huang et al. ( 2016 ) reported that using ITS in mathematics teaching reduces the gaps between advantaged and disadvantaged learners.

Personalized learning environments, another prominent use of AI in education, aim to provide an experience where the learning process is shaped within the framework of learner characteristics. In addition, supporting the learning of individuals who are disadvantaged in subjects such as learning disabilities is a promising field of study. Indeed, Walkington ( 2013 ) noted that personalized learning experience provides more positive and robust learning outcomes. Similarly, Ku et al. ( 2007 ) investigated the effect of a personalized learning environment on solving math problems. The study results show that the experimental group learners, especially those with lower-level mathematics knowledge, performed better than the control group.

Assessment and feedback, one of the forms of AI in education, is another area where the number of studies on the COVID-19 epidemic has increased (Ahmad et al., 2022 ; Hooda et al., 2022 ). Ahmad et al. ( 2022 ) compared artificial intelligence and machine learning techniques for assessment, grading, and feedback and found that accuracy rates ranged from 71 to 84%. Shermis and Burstein ( 2016 ) stated that the automatic essay evaluation system gave similar scores to student work with human evaluators, but the system had difficulties in studies that were different in terms of creativity and structure organization. Accordingly, more development and research should be done to help AI systems produce more effective results in assessment and grading. In another study, AI-supported constructive and personalized feedback on the texts created by learners effectively improved reflective thinking skills (Liu et al., 2023 ). In the same study, this intervention reduced the cognitive load of the learners in the experimental group and improved self-efficacy and self-regulated learning levels.

The use of AI in educational data mining and machine learning has been increasing in recent years to discover patterns in students’ data, such as navigation and interaction in online learning environments, to predict their future performance or to provide a personalized learning experience (Baker et al., 2016 ; Munir et al., 2022 ; Rienties et al., 2020 ). Sandra et al. ( 2021 ) conducted a literature review of machine learning algorithms used to predict learner performance and they examined 285 studies published in the IEEE Access and Science Direct databases between 2019–2021. The study results show that the most frequently used machine learning algorithm to predict learner performance is the classification machine learning algorithm, followed by NN, Naïve Bayes, Logistic Regression, SVM, and Decision Tree algorithms.

The main purpose of artificial intelligence studies in the field of AI is to create an independent learning environment by reducing the supervision and control of any pedagogical entity by providing learners with a personalized learning process within the framework of the learner and subject area characteristics (Cui, 2022 ; Zhe, 2021 ). To achieve this, system designs for predicting learner behaviors with intelligent systems, providing automatic assessment, feedback, and personalized learning experiences, and intervention studies examining their effectiveness come first. This study develops a different perspective and experiences of the learner’s create-to-learn process in collaboration with AI. There are predictions in various studies that AI and collaborative learning processes can support the creativity of learners (Kafai & Burke, 2014 ; Kandlhofer et al., 2016 ; Lim & Leinonen, 2021 ; Marrone et al., 2022 ). In this regard, Lund and Wang ( 2023 ) emphasized that the focus should be on developing creativity and critical thinking skills by enabling learners to use AI applications in any learning task (Fig.  1 ).

Proposed structural model. * T0: Time 0 (pretest), T1: Time 1 (posttest). * CSE: Creative self-efficacy, RT_R: Reflective thinking- Reflection, RT_CR: Reflective thinking- Critical reflection, DTM: Design thinking mindset

3 Focus of study

This study investigates the effectiveness of artificial intelligence integration (Chat GPT and Midjourney application) as a guidance and collaboration tool in the design-based process integrated into educational environments in a design-based learning process. In this context, whether the experimental application was effective in the design thinking mindset levels of the participants and their relationship with creative, reflective thinking self-efficacy was examined.

Participants were tasked with developing a digital story in a design-based process. In the context of experimental treatment, participants were systematically encouraged to use Chat GPT and Midjourney as guidance tools in the digital story development process. Apart from this treatment, the design-based learning process of the control group is very similar to the experimental group.

Therefore, all participants were exposed to the same environment at the university where the application was made, and they did not enroll in any additional technology education courses. This pretest–posttest experimental method study with a control group continued for four weeks, during which the student-produced an active product in design-based learning. In the current research context, the following research questions were addressed:

RQ1: Is the integration of artificial intelligence in a design-based learning process effective on the levels of design thinking mindset, and creative and reflective thinking self-efficacy?

RQ2: Do the relationships between design thinking mindset and creative and reflective thinking self-efficacy levels differ in the context of the experimental process?

In line with these research questions, the following hypotheses were tested:

H1a. Creative self-efficacy for 5 weeks is greater for the experimental group.

H1b. Influence of creative self-efficacy on the design thinking mindset is similar for two groups.

H1c. Influence of creative self-efficacy after 5 weeks on the design thinking mindset is similar for two groups.

H1d. Influence of creative self-efficacy after 5 weeks on the design thinking mindset is greater for the experimental group.

H2a . Influence of critical reflection on the design thinking mindset is similar for two groups.

H2b Influence of critical reflection on the design thinking mindset after 5 weeks is greater for the experimental group.

H2c. Critical reflection for 5 weeks is greater for the experimental group.

H2d. Influence of critical reflection after 5 weeks on the design thinking mindset is greater for the experimental group.

H3a . Influence of reflection on the design thinking mindset is similar for two groups.

H3b. Influence of reflection on the design thinking mindset after 5 weeks is greater for the experimental group.

H3c. Reflection for 5 weeks is greater for the experimental group.

H3d. Influence of reflection after 5 weeks on the design thinking mindset is greater for the experimental group.

H4. Design thinking mindset for 5 weeks is greater for the experimental group.

4.1 Research design

This study is a quasi-experimental method study with the pretest–posttest control group (Fig.  2 ). In this experimental methodology study, participants were randomly assigned to treatment, an AI integration intervention, at the departmental level. There were 87 (46.8%) participants in the experimental group and 99 (53.2%) participants in the control group. The participants were pre-service teachers studying in the undergraduate program of the faculty of education.

Implementation Process

The treatment in this study also served the purposes of the educational technology course as the application of design-based learning activity as an important tool in educational technology that participants (pre-service teachers) might consider using in their future teaching careers.

In addition, all participants have been exposed to the same opportunities regarding the use of digital technologies in education and none of them attended an additional course. Therefore, the prior knowledge of both groups was similar. Participation in the surveys is completely voluntary. For this reason, although 232 and 260 participants participated in the pretest and posttest, respectively, 186 students who filled in both questionnaires and participated in the application were included in the study. However, both groups were given the same input on design-based learning activities and tasks. Therefore, there is no learning loss for the control group.

4.2 Participants

The participants were 186 pre-service teachers studying at a state university in Turkey. All participants are enrolled in an undergraduate instructional technology course and study in five different departments. The ages of the participants vary between 17–28 years, with an average age of 19.12. 74.2% of the participants were female and 25.8% were male. The high rate of women is because the education faculties in Turkey have a similar demographic structure. The majority of the participants are first-year and second-year students.

The daily use of social technology (social media, etc.) is 3.89 (in hours). Technology usage time for entertainment (watching movies and series, listening to music, etc.) is 2.7 h. While the daily use of technology for gaming (mobile, computer, console games, etc.) is 0.81, the period of use of technology for educational purposes is 1.74. The participants use technology primarily for social and entertainment purposes.

4.3 Procedure

4.3.1 experimental group.

In this group, students performed the DST task as a DBL activity using ChatGPT and MidJourney artificial intelligence applications. These tasks include selecting topics, collaborative story writing with ChatGPT, scripting, creating scripted scenes with MidJourney, and voice acting, as well as integrating them. Examples of multimedia items prepared by the students in this group are shown in Fig.  3 .

Experimental group student products-screenshot

The artificial intelligence applications they will use in this task were introduced one week before the application. Students did various free activities with these applications. In the first week of the application, students were asked to choose a topic within a specific context. The students researched their chosen topic and chatted with ChatGPT to deepen their knowledge. The students created the stories within the steps of the instruction presented by the instructor in collaboration with ChatGPT. (1) ChatGPT should be asked three questions while creating the story setup. Each question should contribute to the formation of the story. (2) A story should be created by organizing ChatGPT's answers. (3) At least 20% and a maximum of 50% of the story must belong to the student. To assess whether the students executed these three steps accurately and to offer feedback when needed, they shared the link to the page containing their conversations with the questions and answers they used to create their stories with the course instructor. The instructor compared the text accessed from this page with the final text of the student's story. He scanned the final versions of the student stories on Turnitin to check if the student's contribution to the story creation was no more than 50%.

In the next stage (weeks 2 and 3), students created each scene using MidJourney artificial intelligence bots in line with the storyboards they created by scripting their stories. The most important challenge for the students was to ensure continuity in interrelated and successive scenes using MidJourney bots, and they created the audio files by voicing the texts related to each scene. In the fourth week, students combined elements such as scenarios, scenes, and sound recordings using digital story development tools (Canva, Animaker, etc.). The final version of the digital stories was shared on the Google Classroom platform.

Learners sent the product they created for each application step and information about the process from the activity links on the Google Classroom course page. The course instructor reviewed these posts and provided corrective feedback to the students.

4.3.2 Control group

In this group, students were tasked with preparing a digital story on a topic as DBL activities. This task includes choosing a subject, writing a story, scripting, preparing multimedia elements, and integrating them. Products such as storyboards and videos produced by students in DBL activities carried out in this group are shown in Fig.  4 .

Control group student products-screenshot

In the first week of the application, the participants were asked to choose a topic within a context, as in the experimental group. The students researched the determined topic, created a story related to the subject, then scripted the story and prepared the storyboards. In the second and third weeks of the application, the students created the audio files by vocalizing the texts related to each scene (according to the scenario) in line with the storyboard. Furthermore, pictures, backgrounds, and characters were created in line with the scenario (usually compiled from ready-made pictures and characters). In the fourth week, digital story development tools combined scenarios, pictures, backgrounds, sound recordings, and characters. The final version of the stories was shared on the Google Classroom platform.

4.4 Data collection and analysis

Data were collected at two-time points via the online form. Personal Information Form and three different data collection tools were used in this study.

4.4.1 Instrumentation

Self-description form.

There are 8 questions in the personal information form. These were created to collect information about gender, age, department, class, and total hours spent using digital technologies for different purposes.

Design Thinking Mindset Scale

The scale was developed by Ladachart et al. ( 2021 ) and consists of six sub-dimensions: being comfortable with problems, user empathy, mindfulness of the process, collaborative working with diversity, orientation to learning, and creative confidence. The rating is in a 5-point Likert type. The validity and reliability values of the scale are presented in Sect. 5.

Reflective Thinking Scale

Kember et al. ( 2000 ) developed this scale to measure students’ belief in their ability to be creative; the Turkish adaptation of this scale was created by Başol and Evin Gencel ( 2013 ). Although the scale consists of four sub-dimensions, two were included in the study because they were suitable for the study, and the rating is in a 5-point Likert type. The validity and reliability values of the scale are presented in Sect. 5.

Creative Self-Efficacy Scale

The original scale, developed by Tierney and Farmer ( 2011 ) to measure their belief in their ability to be creative, was adapted into Turkish by Atabek ( 2020 ). The scale consists of three items, and the rating is a 7-point Likert type. In the context of this study, the data before the analysis was converted into a 5-point Likert structure, and the validity and reliability values of the scale are presented in Sect. 5.

4.4.2 Analysis

The effect of design-based learning activities integrated with artificial intelligence as a teaching intervention was tried to be measured by repeated measurement. Data collection tools were applied in the first week (T0) and the fifth week (T1) in the experimental and control groups. For analysis, only the responses (survey data) provided by students who fully participated in the application and answered the data collection tools at both T0 and T1 points were included. Partial Least Squares-Structural Equation Modeling (PLS-SEM) was used to analyze the data and test the hypotheses. SmartPLS 4 was used in the analysis (Ringle et al., 2022 ). The PLS-SEM method allowed the parameters of complex models to be estimated without making any distribution assumptions on the data. In addition, the differences between the experimental and control groups were examined using the Multiple Group Analysis (MGA) features in PLS-SEM, and it was tested whether there was a significant difference between MGA and group-specific external loads and path coefficients.

In the first stage, the measurement model was tested. In the second stage, the structural model was evaluated in the context of MGA.

5.1 Measurement model

When the measurement and structural models were evaluated, the indicator loads were higher than the recommended value of 0.7 (See Appendix Table 7 ).

Internal consistency reliability is represented by Cronbach’s alpha, composite reliability (CR), and rho_a (See Table  1 ). All values are above the threshold value of 0.70 by default. For convergent validity, the average variance extracted (AVE) value is used and this value is expected to be above 0.5. The values in the model were found to be higher than this threshold value.

Heterotrait-monotrait ratio (HTMT) and the Fornell-Larcker criterion were used for discriminant validity. The values found indicate that discriminant validity has been achieved, as seen in Tables 2 and 3 .

Considering all the data obtained, the measurement model of the proposed model is suitable for testing hypotheses.

The structural model of the PLS-SEM was examined as it provides the measurement model assumptions. PLS-SEM was run using 1000 bootstrapping. The significant differences in the path coefficients of the assumed relationships between design thinking mindset levels and creative and reflective thinking self-efficacy between the experimental and control groups were examined, and the findings are presented in Table  4 .

According to Table  4 , the structural model was examined in terms of significant differences in the path coefficients of the assumed relationships to test the research hypotheses, and the creative self-efficacy and reflective thinking dimensions for the students in the experimental and control groups differed after the treatment process.

R2 values indicate the explanatory power of the structural model and these values show moderate to significant power (See Table  5 ).

To examine whether there is a significant difference between the path coefficients for the experimental and control groups, the PLS-MGA Parametric test values were examined and the results are presented in Table  6 .

According to Table  6 , the findings show that there is no significant difference in the effect of creative self-efficacy, and reflective thinking on design thinking mindset between the two groups. After the treatment process, there is no significant difference in the relationships between creative self-efficacy, reflective thinking, and design thinking mindset. The significance levels of the path coefficients showed that the hypotheses were not supported.

6 Discussion and conclusion

This study examined the effect of AI integration, which is integrated into the digital storytelling process, a design-based learning method, on design thinking mindset and whether it is effective in its relations with creative, reflective thinking self-efficacy. The participants used ChatGPT and Midjourney applications in the digital story development process as part of the experimental treatment. The only difference in the digital storytelling process between the control and experimental groups is the AI applications used in the experimental treatment. The experimental intervention covers four weeks. Data were collected from the participants before (T0) and after the application (T1) with data collection tools. There is a significant difference at the T1 point compared to the T0 point in both groups' creative self-efficacy, critical reflection, and reflection levels. Accordingly, the intervention in both groups contributed to the participants' creative self-efficacy, critical reflection, and reflection development. On the other hand, the design thinking mindset levels of both groups did not show a significant difference in the comparison of the T0 point and the T1 point.

According to the multigroup comparison of the creative self-efficacy level at T0 and T1 points, there was no significant difference between the groups. When compared to T0 at the T1 point, creative self-efficacy improvement was achieved in both groups. This is valuable as it shows that the creative self-efficacy contribution of intensive use of AI support in a design-based learning environment is similar. Indeed, creativity, recognized as one of the core competencies in education, is part of CSE, which includes the belief that an individual is capable of producing creative results (Yildiz Durak, 2023b ). There are predictions in various studies that AI and collaborative learning processes can support the creativity of learners (Kafai & Burke, 2014 ; Kandlhofer et al., 2016 ; Lim & Leinonen, 2021 ; Marrone et al., 2022 ). Marrone et al. ( 2022 ) provided eight-week training sessions on creativity and AI to middle school students. In their subsequent interviews with the students, the most dominant opinion was that AI support had a crucial role in supporting their creativity. In support of this, the experimental treatment in our study requires various creative interventions from the students: (1) Students asked at least three questions to ChatGPT while creating a story. (2) Each question contained abstracting from the previous AI answer and directions on how to continue. (3) they also created their constructs by creating connecting sentences and paragraphs to gather the answers given by ChatGPT. In addition, the second part where creativity came into play was creating scenes related to the story in the Midjourney environment. (4) While creating these scenes, the student had to plan scenes by abstracting the story he had created in collaboration with AI, create those scenes, and provide detailed parameters to the Midjourney bot to ensure continuity between the scenes. It may be that, relatively, in the expectation control group, the realization of this whole process by the students through various creative practices will further support creativity and self-efficacy. Regarding this situation, Riedl and O’Neill ( 2009 ) highlighted that although these tools (Canva, Animaker, etc.) make it possible to develop creative content, the user may not get significant results. In this context, they pose an essential question: “Can an intelligent system augment non-expert creative ability?”. Lim and Leinonen ( 2021 ) argued that AI-powered structures can effectively support creativity and that humans and machines can learn from each other to produce original works. Taking this one step further, AI will contribute to students’ creativity in learning and teaching processes (Kafai & Burke, 2014 ). Indeed, Wang et al. ( 2023 ) found a significant relationship between students' AI capability levels and their creativity, explaining 28.4% of the variance in creativity.

According to the research findings, all ways between reflective thinking scale sub-dimensions critical reflection and reflection and design thinking mindset are insignificant (H2a, H2b, H2d, H3a, H3b, H3d). In addition, there is no significant difference between the groups according to the multi-group comparison at T0—T1 points for reflection and critical reflection. On the other hand, there is a significant improvement in the critical reflection and reflection levels at the T1 point of both groups compared to the T0 point. Accordingly, AI collaboration has a similar effect to the process in the control group on the learners’ reflective thinking levels in the design-based learning process. In support of this, we have evidence that incorporating AI in various forms in educational processes has essential outcomes for reflective thinking. Indeed, Liu et al. ( 2023 ) reported that an intervention involving incorporating AI into the learning process as a feedback tool to support reflective thinking in foreign language teaching resulted in remarkable improvements in learning outcomes and student self-efficacy.

DBL involves learners assimilating new learning content to overcome authentic problems and creating innovative products and designs to showcase this learning in the simplest way possible. In this study, DST processes, which allow the application of DBL to different learning areas, are included in both interventions. In the literature, DST helps learners reflect on what they have learned (Ivala et al., 2014 ; Jenkins & Lonsdale, 2007 ; Nam, 2017 ; Robin, 2016 ; Sandars and Murray, 2011 ) and develop reflective thinking skills (Durak, 2018 ; Durak, 2020 ; Malita & Martin, 2010 ; Sadik, 2008 ; Sarıtepeci, 2017 ) is a method with critical elements. The critical implication here is that all processes of AI collaboration on reflection and critical reflection have a similar effect as the DST process planned by the learners. The similar effect of AI collaboration allowed learners to understand the benefits of AI in the DST process and to develop in-depth learning by combining their thought processes with AI and finding creative ways to reflect on their learning. Indeed, Shum and Lucas ( 2020 ) claims that AI can help individuals think more deeply about challenging experiences. The DST process includes stages (story writing, scenario creation, planning scenes, etc.) that allow learners to embody their reflections on their learning (Ohler, 2006 ; Sarıtepeci, 2017 ).

The multi-group analysis results of the road between the design thinking mindset T0 – T1 points are insignificant (H4). In addition, there was no significant improvement in design thinking mindset scores in both groups compared to T0 at the T1 point. Accordingly, the effect of the design-based learning process carried out in the experimental and control groups on the learners’ design thinking mindset scores was limited. The study’s expectation was the development of the design thinking levels of the learners and, as a result, meaningful improvements in the design thinking mindset levels. This result may be because the application process is not long enough to develop versatile skills such as design thinking. Razzouk and Shute ( 2012 ) emphasized that design thinking is challenging to acquire in a limited context. However, they argue that students can learn to design thinking skills together with scaffolding, feedback, and sufficient practice opportunities. The DST process included scaffolding and feedback processes in both groups. Although there are different stages for acquiring and developing design thinking skills during the application process, the similar characteristics of the design thinking mindset level may indicate the need for more extended practice. However, the fact that the design thinking mindset is a self-reporting tool limits our predictions about individuals' design thinking skill acquisition and development in the process.

7 Conclusion

In conclusion, the intensive use of AI support in a design-based learning environment similarly impacts the development of participants' creative self-efficacy, reflective thinking, and design thinking mindset levels. The AI collaboration process showed a similar effect to the planned design-based learning process by allowing learners to understand the benefits of AI in the design thinking mindset and to develop in-depth learning by combining their thought processes with AI. However, it is essential to note that the study's expectation of meaningful improvements in the design thinking mindset levels was unmet. This suggests that more extended practice periods and more support and feedback processes may be necessary to effectively develop versatile skills such as design thinking.

The research contributes to our understanding of the impact of AI collaboration on learners' levels of creative self-efficacy, reflective thinking, and design thinking mindset. Further studies with extended practice periods and additional scaffolding and feedback processes could provide valuable insights into the effective development of design thinking skills in AI-supported design-based learning environments.

Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

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Saritepeci, M., Yildiz Durak, H. Effectiveness of artificial intelligence integration in design-based learning on design thinking mindset, creative and reflective thinking skills: An experimental study. Educ Inf Technol (2024). https://doi.org/10.1007/s10639-024-12829-2

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Capturing New Nurses' Experiences and Supporting Critical Thinking

This study analyzed the contents of critical reflective journals written by new nurses during their orientations using a text network. This study aimed to find ways to reduce turnover and improve clinical field adaptability among new nurses. The authors analyzed the content of reflective journals written by 143 new nurses from March 2020 to January 2021. Text network analysis was performed using the NetMiner 4.4.3 program. After data preprocessing, frequency of occurrence, degree centrality, closeness centrality, betweenness centrality, and eigenvector community were analyzed. In total, 453 words were extracted and refined, and words with high simple frequency and centrality were “incompetence,” “preparation,” “explanation,” “injection,” “time,” “examination,” and “first try.” “Medication” had the highest frequency of occurrence, and “incompetence” was the most important keyword in the centrality analysis. In addition, component analysis and eigenvector community analysis revealed three sub-theme groups: (1) basic nursing skills required for new nurses, (2) insufficient competency, and (3) explanation of nursing work. Significantly, this study is the first to use the text network method to analyze the subjective experiences of the critical reflective journals of new nurses. In conclusion, changes are needed to improve the education system for new nurses and promote efficient sharing of nursing tasks.

“New nurses” are nurses who work in hospitals within their first year of acquiring a nursing license. New nurses experience several challenges while adapting to the clinical environment because they often identify patient problems and make high-quality clinical decisions in rapidly changing clinical settings. Critical thinking ability is essential to overcoming difficulties in meeting these demands. 1 In particular, critical thinking ability positively affects clinical decisions through communication and may help new nurses adapt to their working environment. 2 However, new nurses tend to have lower critical thinking abilities than tenured nurses and require time to develop clinical competencies. 3 Because inadequate critical thinking skills may make it difficult for new nurses to provide optimal nursing care and thus may negatively affect patient safety, 3 new nurses must develop strong critical thinking skills.

Furthermore, critical thinking is a reflective thinking process that enables one to decide what to believe and what to do, 4 and reflection is essential to enhance critical thinking ability. 5 Reflective journaling is an approach to internalizing learned knowledge through reflective thinking and objectifying activities, 6 which in turn may strengthen critical thinking and clinical decision-making abilities. 3 Reflective thinking connects new knowledge with existing knowledge, enables abstract thinking, and enables individuals to use specific solution-oriented strategies based on their knowledge and experiences in response to new problems. 7 In the context of nursing education, reflective journaling crucially allows learners to observe their emotional and psychological states. 8 For new nurses, the process of transitioning from being a nursing student to working as a nurse may be confusing and difficult, and reflective journaling during this period may improve clinical decision-making skills, relieve the challenges associated with the transition process, and promote communication with preceptors and nursing managers. 9 , 10

Reflective journaling is a clinically viable educational method for the self-analysis of clinical decision making in residency programs for new nurses. 11 In particular, reflective journaling is a useful educational method for strengthening clinical adaptation capacity in new nurses. 8 – 10 Analyzing the content of these journals can reveal how best to shape pedagogy to strengthen the competencies of new nurses.

Many studies have been conducted to help new nurses adapt and decrease their turnover. These studies include research on the factors affecting the retention intention and turnover of new nurses, 12 , 13 qualitative research on the practical adaptation experience of new nurses, and literature reviews on new nurse education programs. 14 , 15 However, no study has yet analyzed the reflective journals written by new nurses; therefore, it is necessary to review these journals, which offer insights into the actual experiences of new nurses. Other disciplines, such as pedagogy, have applied text network analysis (TNA) for more objective document research by linking content analysis and social network analysis. 16 The TNA method is an analysis technique that interprets a phenomenon using a network that displays the relationships between the words appearing in the text as “links.” Notably, TNA is a useful analysis method to identify the relationship between core keywords and other keywords. 17 In addition, this method can enhance knowledge of related phenomena through quantitatively examining the words appearing in text and identifying words that co-occur with other specific words. 18 Recently, in the field of nursing, studies have used network analyses to uncover research trends and knowledge structures, 19 , 20 including by analyzing the contents of the practices of nursing students. 21

In response to the gap in the literature, the authors sought to uncover the clinical experiences of new nurses during the orientation period by analyzing their critical reflective journals using the TNA method. In particular, the authors examined the relationships between keywords and main words and experiences. This study's specific objectives were as follows:

• To extract keywords based on their frequency and identify core keywords.
• To identify core topic and sub-theme groups.

Research Design

In this quantitative content analysis study, the authors applied the TNA method to identify the core keywords from new nurses' critical reflective journals on their clinical experiences during their orientation period.

Research Sample and Data Collection

The authors analyzed the critical reflective journals written by 143 new nurses who joined a university hospital located in an urban area of Korea from March 2020 to January 2021. The nurses recorded their experiences in the critical reflective journals six times during the orientation period (8 weeks). The nurses were instructed to record, in the form of narration, the most memorable aspects of their nursing interactions with patients and list their performance strengths and shortcomings in each situation. The journal structure was configured to assist them in establishing and writing goals, as well as with developing plans to improve their shortcomings. The researcher obtained the nurses' consent to participate in the study after detailing the purpose and method of writing critical reflective journals for 30 minutes during the common orientation period. New nurses were introduced to critical thinking as a very important and necessary process for improving clinical judgment. In addition, clinical nurse educators prompted new nurses to reflect on the situations they experienced in the field when writing in their journals; in particular, they asked the nurses to contextualize these situations and consider alternative ways they may have solved problems they encountered in the field. The researchers explained to the new nurses that the journals would only be used to analyze basic data to uncover how best to help new nurses adapt to the field. Next, new nurses who voluntarily agreed to participate were provided with a journal before being assigned to a department. Research participants were notified they could withdraw from the study at any time, and they were asked to contact the clinical nurse educators with any difficulties or questions related to journaling. After orientation, the nursing education team collected the journals.

Data Analysis

In the analysis of the collected data, the main semantic structure was visualized as a sociogram through preprocessing and network analysis. Analysis was performed using NetMiner 4.4.3 (Cyram Co. Ltd., Gyeonggi-do, Korea).

Preprocessing Stages

The journals were transcribed to Microsoft Office Excel (Microsoft Inc., Redmond, WA, USA) and converted into databases. Four researchers divided the reflective journals, copied them, and then went through the process of reconfirming each other's work. The data were extracted from long texts and included only nouns identified using the morpheme analysis function of NetMiner 4.4.3. Using the NetMiner's “import unstructured text” menu, the database data were read and morphemes were extracted. A thesaurus was created to unify words with similar meanings. While examining the extracted morphemes, meaningful morphemes were extracted using the thesaurus, defined words, and excluded words, and word purification was performed using the extraction results.

The thesaurus grouped words (phrases) with similar meanings, and the researcher designated the representative words for each group. 22 In Korean alphabet (Hangeul), words with the same meaning are often presented differently, 23 so the authors paid attention to the selection of representative words and their registration in the thesaurus. For example, “alcohol cotton” was made to represent “alcohol swab,” “disinfection cotton,” “cotton,” and “alcohol.” Phrases consisting of two or more words were also added to the dictionary to establish that the multiple words comprising the phrase should be read as a unit. 24 For example, the words “intravenous” and “injection” were registered within the dictionary as comprising “intravenous injection.” The dictionary of excluded words went through a refining process to exclude stop words, such as pronouns and adverbs without important meanings. The process of word refinement involved several rounds of consultation between joint researchers to reduce subjective bias. In addition, “frequency of appearance” refers to the number of times a keyword appears in an entire document. In order to exclude commonly used words that appear frequently in all documents, words with a term frequency–inverse document frequency (TF-IDF) value of 0.5 or less were excluded by referring to previous studies. 25 The frequency of words appearing in one document is called “term frequency,” and the number of documents in which a word appears is called “document frequency.” “Inverse document frequency” is the logarithmic expression of the inverse of document frequency. A high term frequency value may be recognized as a keyword due to a high frequency in one document, but if the term frequency value is equally high in other documents, it is considered a commonly used word in several documents, even if it may not be necessarily a keyword. Therefore, it should be excluded when extracting keywords by calculating inverse document frequency values of words. For this purpose, TF-IDF, which represents the importance of any word in a particular document, is obtained by multiplying term frequency and inverse document frequency, and used for word extraction. The larger the TF-IDF value, the higher the importance of any word in the document. 26 In this study, five words with a TF-IDF value of 0.5 or less (eg, “teacher,” “patient,” “work,” “think,” and “confirm”) were included in the dictionary of excluded words.

Finally, 274 thesaurus, 301 defined words, and 1759 excluded words were registered in the user dictionary. As a result, a total of 453 words were extracted in the critical reflective journals written by the new nurses. In this study, the top 30 keywords' frequency of appearance was analyzed based on refined words to extract keywords. To intuitively represent keywords, frequency of appearance was generated by using NetMiner 4.4.3.

Process of Network Formation

The network formation process generated a keyword co-occurrence matrix to reflect that the two keywords appeared next to each other in one sentence or were located among the other keywords. 27 Repeated co-occurrence can be interpreted as forming a semantic structure between the words. The higher the degree of connection, the more co-occurrence exists across different types of keywords, which yields a semantic structure in various contexts. In the one-mode matrix of the “keyword × keyword” relationship, the degree value was 1 to 48, 70.4% (1649) for less than 1 and 85.4% (1999) for less than 2.

To grasp the main phenomenon in network analysis, only keywords with an appropriate level of connection are included, but the reference value for the connection degree is not presented, 28 and the study result is determined considering ease of interpretation and network visualization. 27 In this study, a one-mode matrix composed of 401 keywords with a connection degree of two or higher was generated and used for network analysis.

Network Statistical Analysis and Visualization

Statistical analysis was performed and visualized using a one-mode network to discover the core keywords in the journals.

The centrality of the network was analyzed for degree centrality, closeness centrality, and betweenness centrality, which are indicators of centrality, and the average and concentration of each centrality were confirmed. Centrality indicators show that words with high centrality are considered core keywords to the extent that words in the network are centered. 29 The value of the centrality indicator exists between 0 and 1; the larger the value, the higher the centrality of the word. 28 The average centrality indicator refers to the center value of the entire network centrality indicator, and centralization represents the degree to which a network is structurally concentrated or distributed across a specific word. Thus, an intensive link flow in a small number of words indicates that the network is highly concentrated. 29

Degree centrality refers to the degree of connection between nodes (in this study, keywords used in the analysis) in the network; this indicates co-occurrence between words and indicates the number of connections between nodes. 28 Keywords with high connection centrality are often connected to other keywords, which means that they are important keywords. Closeness centrality refers to the degree to which a node is located close to another node in the network. 28 Keywords with high proximity centrality may be interpreted as keywords that play a central role in the network while reaching other keywords the fastest. Betweenness centrality refers to the degree to which other nodes and intermediaries play a role in the network. 28 Keywords with high mediation betweenness centrality serve as bridges that interconnect sub-keywords between networks. The top 30 words with high degree centrality, closeness centrality, and betweenness centrality were visualized as sociograms. The larger the node size, the larger the centrality index, and the thicker the link, the higher the co-occurrence frequency.

Sub-theme Analysis

To identify the sub-theme groups, the authors first extracted the largest component based on cohesion in the NetMiner program and then performed an eigenvector community analysis. A component is a group in which keywords are connected without being broken. Communities refer to subgroups with relatively low modularity, high connection density inside the group, and relatively low connection density outside the group within the component structure. The modularity value is used to determine the optimality of the community structure; eigenvector community modularity can have a value between negative (−) infinity and “1”—the larger the value, the better the modularity. 30

Ethical Considerations

This study was approved by the institutional review board (CNUH-2020-247) of the university hospital located in an urban area of Korea to protect the participants, where the current study was conducted. Participants were informed about the purpose of the study, their rights to anonymity and confidentiality, and their freedom to withdraw from the study. Written informed consent was obtained from those who wished to participate in the study.

Keywords of the Critical Reflective Journal of New Nurses

The top 30 keywords by simple frequency, degree centrality, closeness centrality, and betweenness centrality were identified as core keywords in the journals (Table ​ (Table1). 1 ). The simple frequency appeared in following order: “medication,” “intravenous (IV) cannulation,” “preparation,” “incompetence,” and “explanation.” In this study, the means of the degree centrality, closeness centrality, and betweenness centrality of the word networks were 0.216, 0.501, and 0.037, respectively, and the concentrations were 24.9%, 30.2%, and 14.0%, respectively. Regarding degree centrality, “incompetence,” “explanation,” “preparation,” “medication,” and “properly” were the most important keywords. Regarding closeness centrality, “incompetence,” “preparation,” “explanation,” and “time” were the most important keywords. Regarding betweenness centrality, “incompetence,” “preparation,” “first try,” “understand,” and “explanation” were the most important keywords. In the analysis of the most memorable events during the orientation period for new nurses, words such as “incompetence,” “preparation,” “explanation,” and “injection” were high in both frequency and centrality. Regarding the simple frequency, “medication” was the most frequent keyword. Regarding the centrality analysis, “incompetence” was the most important keyword.

Top 30 Keywords That Emerged From the Reflective Journal of New Nurses

Visualizing the Main Semantic Structure

Figure ​ Figure1 1 presents a sociogram, a graph consisting of nodes and links, of the top 30 keywords. The size of a node indicates the degree centrality, and the thickness of a link indicates the strength of the connection, that is, the frequency of co-occurrence. The researchers examined the semantic structure by focusing on five core topics: “medication,” which is strongly tied with “study,” “explanation,” “examination,” and “remember”; “preparation,” which is part of a semantic structure with “injection,” “operation,” “medication,” “time,” and “fluid”; “time,” which is strongly tied with “nursing” and “performance”; and “explanation,” which is part of a semantic structure with “caregiver,” “incompetence,” and “nursing.” Finally, “IV cannulation,” “fluid,” and “organization” formed the semantic structures; “first try,” “IV cannulation,” “admission,” and “night” appeared as meaningful structures; and “properly” and “explanation,” “need,” and “study” appeared as meaningful structures.

Keyword network analysis of the reflective journal of new nurses.

Regarding degree centrality and closeness centrality, “night,” “operation,” “condition,” and “suction” showed low degree centrality and centered on “incompetent,” which demonstrated the highest centrality. Regarding betweenness centrality, “night,” “blood glucose management,” “fluid,” “condition,” “operation,” and “suction” showed low betweenness centrality and centered on “incompetent,” which again demonstrated the highest centrality.

Sub-thematic Groups

The component analysis and eigenvector community analysis based on cohesion in the keyword network yielded three sub-thematic groups with an optimal modularity of 0.257 identified with sociograms (Figure ​ (Figure2). 2 ). Group 1 was classified into “medication,” “preparation,” “IV cannulation,” “first try,” “administration,” “injection,” “examination,” “blood glucose management,” “operation,” “fluid,” “blood sampling,” “blood,” “night,” and “caregiver.” Group 2 was classified into “incompetence,” “time,” “nursing,” “properly,” “electronic medical record (EMR),” “understand,” “study,” “organization,” “performance,” “condition,” and “suction.” Group 3 was classified into “explanation,” “need,” “remember,” “situation,” and “admission.” The research topic groups were named based on the contexts in which the keywords of each subgroup were used. The three sub-themes were (1) basic nursing skills required for new nurses, (2) insufficient competency, and (3) explanation of nursing work.

Visualization of subgroup analysis from the reflective journal of new nurses.

This study sought to understand the work experiences of new nurses by using a TNA method to analyze the contents of the critical reflective journals they wrote during their orientation (the first 8 weeks after they began working in the hospital). The main semantic structure specifically showed the context of the core topic.

More specifically, the frequency and centrality analyses confirmed that, in terms of working directly with patients, the new nurses had the most difficulty with tasks related to medication. The contents of the analysis suggest that a new nurse must prepare drugs for patients and explain the medication to the patient while administering the drug through injection. The new nurses described their experiences with this process in their journals as follows: “When I went to the patient to inject the drugs, the patient asked a question about why the drug was being used, but I did not explain the reason properly” and “I don't know how to explain the efficacy and side effects of various types of drugs administered to patients.” These excerpts suggest that new nurses lack knowledge about medications and experience job stress and low confidence; if these problems are not resolved, they may lead to job turnover. 31 New nurses must learn to administer medications; this is a core basic nursing skill in nursing colleges. A practical training room in the hospital is necessary to provide systematic and sufficient opportunities for repeated practice to improve the confidence of new nurses in their core basic nursing skills and reduce work stress. 32

This study uncovered the following main semantic structures. First, new nurses experience a lack of clinical knowledge about medication and feel a need to study on their own. In addition, a lack of drug-related knowledge caused new nurses to feel burdened when teaching a patient or their caregivers about a medication before administering it. Additionally, new nurses felt that they should remember what they learned on their own and in clinical practice from their preceptors. They also felt the need to learn and study the drugs used in many tests. Medication errors are an important factor in patient safety and are the most frequent medical accidents. 33 Administering the correct drug to the correct patient, providing information about the drug to the patient, and confirming and reporting the side effects of a drug is necessary to reduce medication errors; therefore, it is crucial to emphasize this in nursing programs. 33 Because this study found that new nurses experienced many difficulties with medication, it is necessary to establish a protocol for clinical practice and improve systematic education through simulation. 34

Second, this study confirmed that new nurses must prepare to successfully give injections, oral medications, and fluids and to facilitate operations (eg, preparing dressing materials). 35 In addition, new nurses were frequently pressed for time while taking care of patients. The results were similar to those from a study in which new nurses reported that the confidence level for the item “I can completely care for a patient within the allotted time” was low at 20%–50%. 36 New nurses often work overtime at hospitals; for example, some nurses go to work 2 hours early and complete their records after work because they do not have enough time to complete their duties within their scheduled hours. 37 This suggests that nursing tasks should be more appropriately distributed. 36

Third, new nurses need skills to explain their care to patients or caregivers while working. Accordingly, new nurses need to have strong relationship and communication skills. 38 The journals revealed that new nurses feel their work requires them to be able to properly explain different elements of care to patients and their caregivers; however, they often felt that they did not have the knowledge or skills necessary to carry out this duty. Moreover, the new nurses themselves felt they needed to study to ensure that they were not ignorant in ways that may harm the patient. Therefore, a system should be established to help new nurses strengthen their skills by actively utilizing support resources at the hospital level; notably, this may reduce turnover. Along these lines, a simulation program related to communication should be used during orientation to increase the communication abilities of new nurses. 39

Fourth, new nurses reported difficulties with IV cannulation and their first inpatient admissions. They felt pressured to complete an IV cannulation for the first time and struggled to connect and arrange various fluids. Simulations that teach new nurses how to administer intravenous injections should be included in orientations in response to this trend. Most wards in this research institute use functional nursing, with different numbers of people per service. Therefore, new nurses completed different tasks during day and evening shifts, such as IV cannulation, injection, and vital sign and blood glucose testing during the former and overseeing patients, checking prescriptions, and entering records during the latter. Accordingly, they reported that night work was very complicated and that they felt that they were lacking in their skills to complete it successfully. Previous studies reported that new nurses in Korea experienced excessive workload, communication difficulties, and low confidence in their work, suggesting that active intervention is needed to improve clinical adaptation in new nurses. 36 Therefore, there is a need to develop various programs, such as communication programs and basic nursing skill simulations, for new nurses.

Finally, based on the analysis of the three sub-thematic groups, the first subject group was “basic nursing skills required for new nurses.” The ability to perform basic nursing skills is an essential element for new nurses to adapt to practice: when nursing skills are lacking, they experience overload in the clinical field; this leads to increased stress, which increases the resignation rate. 40 In 2019, Korean institutions began to ensure they were offering clinical nurse educator systems and training programs to reduce the resignation rate of new nurses by improving their competency. 41 Programs that intensively train new nurses in basic nursing skills at the initial stage of their employment are essential in hospitals to help new nurses adapt to practice. The second thematic group was “insufficient competency.” New nurses start clinical work with insufficient clinical experience and competency; experience difficulties in providing and selecting appropriate treatments for patients; and must cope with overload, which increases their role burden. 37 Therefore, it is necessary to reduce the amount of work assigned to new nurses and to develop educational programs that can identify problems by presenting various situations that can help them understand their work. The third topic group was “explanation of nursing work.” New nurses most frequently deal with patients and caregivers and thus feel pressured to properly explain things to them (eg, why patients are hospitalized, what medications they are receiving); this feeds their desire to remember what they have learned. In addition, new nurses often complain of communication difficulties 38 ; accordingly, clinical communication programs should be developed to overcome this problem.

Unlike previous studies, this study analyzed the experiences of new nurses by applying TNA to the critical reflective journals they wrote during orientation. However, the information was only collected over the course of a year, which limits the generalizability of the research results. In addition, the fact that the nursing manager reports and provides feedback on the journals may have limited direct expression. To overcome these limitations, a program for the in-depth analysis of new nurses' experiences should be implemented in the future. Ultimately, this study sets the foundation for further analysis of the experiences of new nurses by being the first to use a TNA to effectively explore the subjective experiences of new nurses.

This study applied a TNA to identify, group, and analyze core keywords in the critical reflective journals new nurses wrote during their orientation at tertiary general hospitals in Korea. New nurses' most memorable events during orientation were reflected by high-frequency and high-centrality words, such as “incompetence,” “preparation,” “explanation,” and “injection.”

This study's results can guide best practice for improving the field adaptability of new nurses and reducing their turnover rate. Currently, nursing students in Korea nursing mainly complete observation-oriented practicums; this increases the burden on their basic nursing skills. Being compelled to perform extensive duties beyond their competencies is causing exhaustion among new nurses. To mitigate these issues, changes should be made to the new nurse education system to better prepare new nurses and nursing duties should be more efficiently distributed.

This study was financially supported from Back Ui Association, Chonnam National University Hospital (2021).

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Ethical Approval: The study was approved by the Chonnam National University Hospital Institutional Review Board (approval number: CNUH-2020-247).

Hye Won Jeong: https://orcid.org/0000-0001-5664-8672

Shin Hye Ahn: https://orcid.org/0000-0002-1403-2711