how is critical thinking used as a nurse

The Value of Critical Thinking in Nursing

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

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

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

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

How Do Nurses Use Critical Thinking?

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

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

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

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

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

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

Top 5 Ways Nurses Can Improve Critical Thinking Skills

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

Case-Based Approach

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

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

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

Practice Self-Reflection

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

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

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

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

Develop a Questioning Mind

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

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

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

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

Practice Self-Awareness in the Moment

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

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

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

Use a Process

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

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

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

Common Critical Thinking Pitfalls in Nursing

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

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

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

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

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

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

An Essential Skill for All Nurses

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

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

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

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

How does nursing school develop critical thinking skills?

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

Do only nurse managers use critical thinking?

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

Meet Our Contributors

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

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

Jenna Liphart Rhoads, Ph.D., RN

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

Nicholas McGowan, BSN, RN, CCRN

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

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

how is critical thinking used as a nurse

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?

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

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

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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

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

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

What Is Critical Thinking in Nursing?

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

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

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

How Is Critical Thinking Important for Nurses? 

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

Elements of Critical Thinking in Nursing

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

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

A diverse group of three (3) nursing students working together on a group project. The female nursing student is seated in the middle and is pointing at the laptop screen while talking with her male classmates.

How to Develop and Apply Critical-Thinking Skills in Nursing

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

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

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

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

Images sourced from Getty Images

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

What-is-Critical-thinking-in-nursing-levels-important-why-how-process-fundamental

Last updated on August 23rd, 2023

Critical thinking is a foundational skill applicable across various domains, including education, problem-solving, decision-making, and professional fields such as science, business, healthcare, and more.

It plays a crucial role in promoting logical and rational thinking, fostering informed decision-making, and enabling individuals to navigate complex and rapidly changing environments.

In this article, we will look at what is critical thinking in nursing practice, its importance, and how it enables nurses to excel in their roles while also positively impacting patient outcomes.

how-to-apply-critical-thinking-in-nursing-concepts-for-critical-thinker

What is Critical Thinking?

Critical thinking is a cognitive process that involves analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

It’s a mental activity that goes beyond simple memorization or acceptance of information at face value.

Critical thinking involves careful, reflective, and logical thinking to understand complex problems, consider various perspectives, and arrive at well-reasoned conclusions or solutions.

Key aspects of critical thinking include:

Analysis: Critical thinking begins with the thorough examination of information, ideas, or situations. It involves breaking down complex concepts into smaller parts to better understand their components and relationships.
Evaluation: Critical thinkers assess the quality and reliability of information or arguments. They weigh evidence, identify strengths and weaknesses, and determine the credibility of sources.
Synthesis: Critical thinking involves combining different pieces of information or ideas to create a new understanding or perspective. This involves connecting the dots between various sources and integrating them into a coherent whole.
Inference: Critical thinkers draw logical and well-supported conclusions based on the information and evidence available. They use reasoning to make educated guesses about situations where complete information might be lacking.
Problem-Solving: Critical thinking is essential in solving complex problems. It allows individuals to identify and define problems, generate potential solutions, evaluate the pros and cons of each solution, and choose the most appropriate course of action.
Creativity: Critical thinking involves thinking outside the box and considering alternative viewpoints or approaches. It encourages the exploration of new ideas and solutions beyond conventional thinking.
Reflection: Critical thinkers engage in self-assessment and reflection on their thought processes. They consider their own biases, assumptions, and potential errors in reasoning, aiming to improve their thinking skills over time.
Open-Mindedness: Critical thinkers approach ideas and information with an open mind, willing to consider different viewpoints and perspectives even if they challenge their own beliefs.
Effective Communication: Critical thinkers can articulate their thoughts and reasoning clearly and persuasively to others. They can express complex ideas in a coherent and understandable manner.
Continuous Learning: Critical thinking encourages a commitment to ongoing learning and intellectual growth. It involves seeking out new knowledge, refining thinking skills, and staying receptive to new information.

Definition of Critical Thinking

Critical thinking is an intellectual process of analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

What is Critical Thinking in Nursing?

Critical thinking in nursing is a vital cognitive skill that involves analyzing, evaluating, and making reasoned decisions about patient care.

It’s an essential aspect of a nurse’s professional practice as it enables them to provide safe and effective care to patients.

Critical thinking involves a careful and deliberate thought process to gather and assess information, consider alternative solutions, and make informed decisions based on evidence and sound judgment.

This skill helps nurses to:

Assess Information: Critical thinking allows nurses to thoroughly assess patient information, including medical history, symptoms, and test results. By analyzing this data, nurses can identify patterns, discrepancies, and potential issues that may require further investigation.
Diagnose: Nurses use critical thinking to analyze patient data and collaboratively work with other healthcare professionals to formulate accurate nursing diagnoses. This is crucial for developing appropriate care plans that address the unique needs of each patient.
Plan and Implement Care: Once a nursing diagnosis is established, critical thinking helps nurses develop effective care plans. They consider various interventions and treatment options, considering the patient’s preferences, medical history, and evidence-based practices.
Evaluate Outcomes: After implementing interventions, critical thinking enables nurses to evaluate the outcomes of their actions. If the desired outcomes are not achieved, nurses can adapt their approach and make necessary changes to the care plan.
Prioritize Care: In busy healthcare environments, nurses often face situations where they must prioritize patient care. Critical thinking helps them determine which patients require immediate attention and which interventions are most essential.
Communicate Effectively: Critical thinking skills allow nurses to communicate clearly and confidently with patients, their families, and other members of the healthcare team. They can explain complex medical information and treatment plans in a way that is easily understood by all parties involved.
Identify Problems: Nurses use critical thinking to identify potential complications or problems in a patient’s condition. This early recognition can lead to timely interventions and prevent further deterioration.
Collaborate: Healthcare is a collaborative effort involving various professionals. Critical thinking enables nurses to actively participate in interdisciplinary discussions, share their insights, and contribute to holistic patient care.
Ethical Decision-Making: Critical thinking helps nurses navigate ethical dilemmas that can arise in patient care. They can analyze different perspectives, consider ethical principles, and make morally sound decisions.
Continual Learning: Critical thinking encourages nurses to seek out new knowledge, stay up-to-date with the latest research and medical advancements, and incorporate evidence-based practices into their care.

In summary, critical thinking is an integral skill for nurses, allowing them to provide high-quality, patient-centered care by analyzing information, making informed decisions, and adapting their approaches as needed.

It’s a dynamic process that enhances clinical reasoning , problem-solving, and overall patient outcomes.

What are the Levels of Critical Thinking in Nursing?

Levels-of-Critical-Thinking-in-Nursing-3-three-level

The development of critical thinking in nursing practice involves progressing through three levels: basic, complex, and commitment.

The Kataoka-Yahiro and Saylor model outlines this progression.

1. Basic Critical Thinking:

At this level, learners trust experts for solutions. Thinking is based on rules and principles. For instance, nursing students may strictly follow a procedure manual without personalization, as they lack experience. Answers are seen as right or wrong, and the opinions of experts are accepted.

2. Complex Critical Thinking:

Learners start to analyze choices independently and think creatively. They recognize conflicting solutions and weigh benefits and risks. Thinking becomes innovative, with a willingness to consider various approaches in complex situations.

3. Commitment:

At this level, individuals anticipate decision points without external help and take responsibility for their choices. They choose actions or beliefs based on available alternatives, considering consequences and accountability.

As nurses gain knowledge and experience, their critical thinking evolves from relying on experts to independent analysis and decision-making, ultimately leading to committed and accountable choices in patient care.

Why Critical Thinking is Important in Nursing?

Critical thinking is important in nursing for several crucial reasons:

Patient Safety:

Nursing decisions directly impact patient well-being. Critical thinking helps nurses identify potential risks, make informed choices, and prevent errors.

Clinical Judgment:

Nursing decisions often involve evaluating information from various sources, such as patient history, lab results, and medical literature.

Critical thinking assists nurses in critically appraising this information, distinguishing credible sources, and making rational judgments that align with evidence-based practices.

Enhances Decision-Making:

In nursing, critical thinking allows nurses to gather relevant patient information, assess it objectively, and weigh different options based on evidence and analysis.

This process empowers them to make informed decisions about patient care, treatment plans, and interventions, ultimately leading to better outcomes.

Promotes Problem-Solving:

Nurses encounter complex patient issues that require effective problem-solving.

Critical thinking equips them to break down problems into manageable parts, analyze root causes, and explore creative solutions that consider the unique needs of each patient.

Drives Creativity:

Nursing care is not always straightforward. Critical thinking encourages nurses to think creatively and explore innovative approaches to challenges, especially when standard protocols might not suffice for unique patient situations.

Fosters Effective Communication:

Communication is central to nursing. Critical thinking enables nurses to clearly express their thoughts, provide logical explanations for their decisions, and engage in meaningful dialogues with patients, families, and other healthcare professionals.

Aids Learning:

Nursing is a field of continuous learning. Critical thinking encourages nurses to engage in ongoing self-directed education, seeking out new knowledge, embracing new techniques, and staying current with the latest research and developments.

Improves Relationships:

Open-mindedness and empathy are essential in nursing relationships.

Critical thinking encourages nurses to consider diverse viewpoints, understand patients’ perspectives, and communicate compassionately, leading to stronger therapeutic relationships.

Empowers Independence:

Nursing often requires autonomous decision-making. Critical thinking empowers nurses to analyze situations independently, make judgments without undue influence, and take responsibility for their actions.

Facilitates Adaptability:

Healthcare environments are ever-changing. Critical thinking equips nurses with the ability to quickly assess new information, adjust care plans, and navigate unexpected situations while maintaining patient safety and well-being.

Strengthens Critical Analysis:

In the era of vast information, nurses must discern reliable data from misinformation.

Critical thinking helps them scrutinize sources, question assumptions, and make well-founded choices based on credible information.

How to Apply Critical Thinking in Nursing? (With Examples)

critical-thinking-skill-in-nursing-skills-how-to-apply-critical-thinking

Here are some examples of how nurses can apply critical thinking.

Assess Patient Data:

Critical Thinking Action: Carefully review patient history, symptoms, and test results.

Example: A nurse notices a change in a diabetic patient’s blood sugar levels. Instead of just administering insulin, the nurse considers recent dietary changes, activity levels, and possible medication interactions before adjusting the treatment plan.

Diagnose Patient Needs:

Critical Thinking Action: Analyze patient data to identify potential nursing diagnoses.

Example: After reviewing a patient’s lab results, vital signs, and observations, a nurse identifies “ Risk for Impaired Skin Integrity ” due to the patient’s limited mobility.

Plan and Implement Care:

Critical Thinking Action: Develop a care plan based on patient needs and evidence-based practices.

Example: For a patient at risk of falls, the nurse plans interventions such as hourly rounding, non-slip footwear, and bed alarms to ensure patient safety.

Evaluate Interventions:

Critical Thinking Action: Assess the effectiveness of interventions and modify the care plan as needed.

Example: After administering pain medication, the nurse evaluates its impact on the patient’s comfort level and considers adjusting the dosage or trying an alternative pain management approach.

Prioritize Care:

Critical Thinking Action: Determine the order of interventions based on patient acuity and needs.

Example: In a busy emergency department, the nurse triages patients by considering the severity of their conditions, ensuring that critical cases receive immediate attention.

Collaborate with the Healthcare Team:

Critical Thinking Action: Participate in interdisciplinary discussions and share insights.

Example: During rounds, a nurse provides input on a patient’s response to treatment, which prompts the team to adjust the care plan for better outcomes.

Ethical Decision-Making:

Critical Thinking Action: Analyze ethical dilemmas and make morally sound choices.

Example: When a terminally ill patient expresses a desire to stop treatment, the nurse engages in ethical discussions, respecting the patient’s autonomy and ensuring proper end-of-life care.

Patient Education:

Critical Thinking Action: Tailor patient education to individual needs and comprehension levels.

Example: A nurse uses visual aids and simplified language to explain medication administration to a patient with limited literacy skills.

Adapt to Changes:

Critical Thinking Action: Quickly adjust care plans when patient conditions change.

Example: During post-operative recovery, a nurse notices signs of infection and promptly informs the healthcare team to initiate appropriate treatment adjustments.

Critical Analysis of Information:

Critical Thinking Action: Evaluate information sources for reliability and relevance.

Example: When presented with conflicting research studies, a nurse critically examines the methodologies and sample sizes to determine which study is more credible.

Making Sense of Critical Thinking Skills

What is the purpose of critical thinking in nursing.

The purpose of critical thinking in nursing is to enable nurses to effectively analyze, interpret, and evaluate patient information, make informed clinical judgments, develop appropriate care plans, prioritize interventions, and adapt their approaches as needed, thereby ensuring safe, evidence-based, and patient-centered care.

Why critical thinking is important in nursing?

Critical thinking is important in nursing because it promotes safe decision-making, accurate clinical judgment, problem-solving, evidence-based practice, holistic patient care, ethical reasoning, collaboration, and adapting to dynamic healthcare environments.

Critical thinking skill also enhances patient safety, improves outcomes, and supports nurses’ professional growth.

How is critical thinking used in the nursing process?

Critical thinking is integral to the nursing process as it guides nurses through the systematic approach of assessing, diagnosing, planning, implementing, and evaluating patient care. It involves:

Assessment: Critical thinking enables nurses to gather and interpret patient data accurately, recognizing relevant patterns and cues.
Diagnosis: Nurses use critical thinking to analyze patient data, identify nursing diagnoses, and differentiate actual issues from potential complications.
Planning: Critical thinking helps nurses develop tailored care plans, selecting appropriate interventions based on patient needs and evidence.
Implementation: Nurses make informed decisions during interventions, considering patient responses and adjusting plans as needed.
Evaluation: Critical thinking supports the assessment of patient outcomes, determining the effectiveness of intervention, and adapting care accordingly.

Throughout the nursing process , critical thinking ensures comprehensive, patient-centered care and fosters continuous improvement in clinical judgment and decision-making.

What is an example of the critical thinking attitude of independent thinking in nursing practice?

An example of the critical thinking attitude of independent thinking in nursing practice could be:

A nurse is caring for a patient with a complex medical history who is experiencing a new set of symptoms. The nurse carefully reviews the patient’s history, recent test results, and medication list.

While discussing the case with the healthcare team, the nurse realizes that the current treatment plan might not be addressing all aspects of the patient’s condition.

Instead of simply following the established protocol, the nurse independently considers alternative approaches based on their assessment.

The nurse proposes a modification to the treatment plan, citing the rationale and evidence supporting the change.

This demonstrates independent thinking by critically evaluating the situation, challenging assumptions, and advocating for a more personalized and effective patient care approach.

How to use Costa’s level of questioning for critical thinking in nursing?

Costa’s levels of questioning can be applied in nursing to facilitate critical thinking and stimulate a deeper understanding of patient situations. The levels of questioning are as follows:


Level 1: Gathering	1. What are the common side effects of the prescribed medication? 2. When was the patient’s last bowel movement? 3. Who is the patient’s emergency contact person? 4. Describe the patient’s current level of pain. 5. What information is in the patient’s medical record?
	1. What would happen if the patient’s blood pressure falls further? 2. Compare the patient’s oxygen saturation levels before and after administering oxygen. 3. What other nursing interventions could be considered for wound care? 4. Infer the potential reasons behind the patient’s increased heart rate. 5. Analyze the relationship between the patient’s diet and blood glucose levels.
	1. What do you think will be the patient’s response to the new pain management strategy? 2. Could the patient’s current symptoms be indicative of an underlying complication? 3. How would you prioritize care for patients with varying acuity levels in the emergency department? 4. What evidence supports your choice of administering the medication at this time? 5. Create a care plan for a patient with complex needs requiring multiple interventions.

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Critical thinking in nursing is the foundation that underpins safe, effective, and patient-centered care.

Critical thinking skills empower nurses to navigate the complexities of their profession while consistently providing high-quality care to diverse patient populations.

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Potter, P.A., Perry, A.G., Stockert, P. and Hall, A. (2013) Fundamentals of Nursing

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

Affiliations.

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

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

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

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Why Critical Thinking in Nursing Is Important

8 examples of critical thinking in nursing, improving the quality of patient care, the importance of critical thinking in nursing.

Jul 24, 2024

While not every decision is an immediate life-and-death situation, there are hundreds of decisions nurses must make every day that impact patient care in ways small and large.

“Being able to assess situations and make decisions can lead to life-or-death situations,” said nurse anesthetist Aisha Allen . “Critical thinking is a crucial and essential skill for nurses.”

The National League for Nursing Accreditation Commission (NLNAC) defines critical thinking in nursing this way: “the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief-based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research.”

An eight-year study by Johns Hopkins reports that 10% of deaths in the U.S. are due to medical error — the third-highest cause of death in the country.

“Diagnostic errors, medical mistakes, and the absence of safety nets could result in someone’s death,” wrote Dr. Martin Makary , professor of surgery at Johns Hopkins University School of Medicine.

Everyone makes mistakes — even doctors. Nurses applying critical thinking skills can help reduce errors.

“Question everything,” said pediatric nurse practitioner Ersilia Pompilio RN, MSN, PNP . “Especially doctor’s orders.” Nurses often spend more time with patients than doctors and may notice slight changes in conditions that may not be obvious. Resolving these observations with treatment plans can help lead to better care.

Key Nursing Critical Thinking Skills

Some of the most important critical thinking skills nurses use daily include interpretation, analysis, evaluation, inference, explanation, and self-regulation.

Interpretation: Understanding the meaning of information or events.
Analysis: Investigating a course of action based on objective and subjective data.
Evaluation: Assessing the value of information and its credibility.
Inference: Making logical deductions about the impact of care decisions.
Explanation: Translating complicated and often complex medical information to patients and families in a way they can understand to make decisions about patient care.
Self-Regulation: Avoiding the impact of unconscious bias with cognitive awareness.

These skills are used in conjunction with clinical reasoning. Based on training and experience, nurses use these skills and then have to make decisions affecting care.

It’s the ultimate test of a nurse’s ability to gather reliable data and solve complex problems. However, critical thinking goes beyond just solving problems. Critical thinking incorporates questioning and critiquing solutions to find the most effective one. For example, treating immediate symptoms may temporarily solve a problem, but determining the underlying cause of the symptoms is the key to effective long-term health.

Here are some real-life examples of how nurses apply critical thinking on the job every day, as told by nurses themselves.

Example #1: Patient Assessments

“Doing a thorough assessment on your patient can help you detect that something is wrong, even if you’re not quite sure what it is,” said Shantay Carter , registered nurse and co-founder of Women of Integrity . “When you notice the change, you have to use your critical thinking skills to decide what’s the next step. Critical thinking allows you to provide the best and safest care possible.”

Example #2: First Line of Defense

Often, nurses are the first line of defense for patients.

“One example would be a patient that had an accelerated heart rate,” said nurse educator and adult critical care nurse Dr. Jenna Liphart Rhoads . “As a nurse, it was my job to investigate the cause of the heart rate and implement nursing actions to help decrease the heart rate prior to calling the primary care provider.”

Nurses with poor critical thinking skills may fail to detect a patient in stress or deteriorating condition. This can result in what’s called a “ failure to rescue ,” or FTR, which can lead to adverse conditions following a complication that leads to mortality.

Example #3: Patient Interactions

Nurses are the ones taking initial reports or discussing care with patients.

“We maintain relationships with patients between office visits,” said registered nurse, care coordinator, and ambulatory case manager Amelia Roberts . “So, when there is a concern, we are the first name that comes to mind (and get the call).”

“Several times, a parent called after the child had a high temperature, and the call came in after hours,” Roberts said. “Doing a nursing assessment over the phone is a special skill, yet based on the information gathered related to the child’s behavior (and) fluid intake, there were several recommendations I could make.”

Deciding whether it was OK to wait until the morning, page the primary care doctor, or go to the emergency room to be evaluated takes critical thinking.

Example #4: Using Detective Skills

Nurses have to use acute listening skills to discern what patients are really telling them (or not telling them) and whether they are getting the whole story.

“I once had a 5-year-old patient who came in for asthma exacerbation on repeated occasions into my clinic,” said Pompilio. “The mother swore she was giving her child all her medications, but the asthma just kept getting worse.”

Pompilio asked the parent to keep a medication diary.

“It turned out that after a day or so of medication and alleviation in some symptoms, the mother thought the child was getting better and stopped all medications,” she said.

Example #5: Prioritizing

“Critical thinking is present in almost all aspects of nursing, even those that are not in direct action with the patient,” said Rhoads. “During report, nurses decide which patient to see first based on the information gathered, and from there they must prioritize their actions when in a patient’s room. Nurses must be able to scrutinize which medications can be taken together, and which modality would be best to help a patient move from the bed to the chair.”

A critical thinking skill in prioritization is cognitive stacking. Cognitive stacking helps create smooth workflow management to set priorities and help nurses manage their time. It helps establish routines for care while leaving room within schedules for the unplanned events that will inevitably occur. Even experienced nurses can struggle with juggling today’s significant workload, prioritizing responsibilities, and delegating appropriately.

Example #6: Medication & Care Coordination

Another aspect that often falls to nurses is care coordination. A nurse may be the first to notice that a patient is having an issue with medications.

“Based on a report of illness in a patient who has autoimmune challenges, we might recommend that a dose of medicine that interferes with immune response be held until we communicate with their specialty provider,” said Roberts.

Nurses applying critical skills can also help ease treatment concerns for patients.

“We might recommend a patient who gets infusions come in earlier in the day to get routine labs drawn before the infusion to minimize needle sticks and trauma,” Robert said.

Example #7: Critical Decisions

During the middle of an operation, the anesthesia breathing machine Allen was using malfunctioned.

“I had to critically think about whether or not I could fix this machine or abandon that mode of delivering nursing anesthesia care safely,” she said. “I chose to disconnect my patient from the malfunctioning machine and retrieve tools and medications to resume medication administration so that the surgery could go on.”

Nurses are also called on to do rapid assessments of patient conditions and make split-second decisions in the operating room.

“When blood pressure drops, it is my responsibility to decide which medication and how much medication will fix the issue,” Allen said. “I must work alongside the surgeons and the operating room team to determine the best plan of care for that patient’s surgery.”

“On some days, it seems like you are in the movie ‘The Matrix,’” said Pompilio. “There’s lots of chaos happening around you. Your patient might be decompensating. You have to literally stop time and take yourself out of the situation and make a decision.”

Example #8: Fast & Flexible Decisions

Allen said she thinks electronics are great, but she can remember a time when technology failed her.

“The hospital monitor that gives us vitals stopped correlating with real-time values,” she said. “So I had to rely on basic nursing skills to make sure my patient was safe. (Pulse check, visual assessments, etc.)”

In such cases, there may not be enough time to think through every possible outcome. Critical thinking combined with experience gives nurses the ability to think quickly and make the right decisions.

Nurses who think critically are in a position to significantly increase the quality of patient care and avoid adverse outcomes.

“Critical thinking allows you to ensure patient safety,” said Carter. “It’s essential to being a good nurse.”

Nurses must be able to recognize a change in a patient’s condition, conduct independent interventions, anticipate patients and provider needs, and prioritize. Such actions require critical thinking ability and advanced problem-solving skills.

“Nurses are the eyes and ears for patients, and critical thinking allows us to be their advocates,” said Allen.

Image courtesy of iStock.com/ davidf

Last updated on Jul 24, 2024. Originally published on Aug 25, 2021.

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28.2 Developing Critical Thinking Skills

Learning objectives.

By the end of this section, you will be able to:

Analyze the types of thinking used in nursing
Recognize when to use the different types of thinking in nursing
Explore the application of knowledge to thinking in nursing
Appy Critical Thinking Indicators (CTIs) to decision making

Thinking is something we usually do subconsciously, because we are not usually “thinking about thinking.” However, with the ever-increasing autonomy being afforded to nurses, there is also an increased need for nurses to be able to critically think effectively and intentionally. Being able to critically think helps nurses’ problem solve, generate solutions, and make sound clinical judgments that affect the lives of their patients. Keep reading to learn more about how nurses use critical thinking in practice and how you can develop your own critical thinking skills.

Types of Thinking Used in Nursing

Nurses make decisions while providing patient care by using critical thinking and clinical reasoning. In nursing, critical thinking is a broad term that includes reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” On the other hand, clinical reasoning is defined as a complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions. Each of these types of thinking is described in more detail in the following sections.

Cognitive Thinking

The term cognitive thinking refers to the mental processes and abilities a nurse uses to interpret, analyze, and evaluate information in their practice. Basically, it encompasses how nurses think about the practice decisions they are making. Cognitive thinking and critical thinking go hand in hand because nurses must be able to use their knowledge and mental processes to devise solutions and actions when caring for patients. Using critical thinking means that nurses take extra steps to maintain patient safety and do not just follow orders. It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research. Critical thinkers possess certain attitudes that foster rational thinking:

confidence: believing in yourself to complete a task or activity
curiosity: asking “why” and wanting to know more
fair-mindedness: treating every viewpoint in an unbiased, unprejudiced way
independence of thought: thinking on your own
insight into egocentricity and sociocentricity: thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
integrity: being honest and demonstrating strong moral principles
intellectual humility: recognizing your intellectual limitations and abilities
interest in exploring thoughts and feelings: wanting to explore different ways of knowing
nonjudgmental: using professional ethical standards and not basing your judgments on your own personal or moral standards
perseverance: persisting in doing something despite it being difficult

Cognitive thinking is significant to nursing because it provides a foundation on which nurses can make rapid and accurate decisions in clinical practice. Nurses must be able to think quickly and make informed decisions to promote optimal patient outcomes.

Effective Thinking

To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process. Effective thinking in nursing involves the integration of clinical knowledge and critical thinking to make the best decisions for patients. For example, if a nurse was caring for a patient who presents with hypertension and new-onset left-sided weakness, it is important that the nurse be able to quickly consider potential causes for the weakness and implement immediate stroke protocols. Without the ability to critically think, the nurse may overlook the weakness as being unrelated to the hypertension and not consider the possibility of stroke, leading to a poor patient outcome. Thus, it is imperative that nurses develop effective thinking skills.

Inductive Reasoning

The term inductive reasoning involves noticing cues, making generalizations, and creating hypotheses. Cues are data that fall outside of expected findings and give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A generalization is a judgment formed on the basis of a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes clearer. On the basis of generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. Remember, a hypothesis is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored. No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to act quickly, especially in emergency situations. They can see how certain objects or events form a pattern (or a generalization) that indicates a common problem.

Consider this example: A nurse assesses a patient who has undergone surgery and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.

Deductive Reasoning

Another type of critical thinking is deductive reasoning ; it is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.

Think about this example: On the basis of research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking, because the intervention is applied to all patients regardless of whether they have difficulty sleeping or not.

Identify the Purpose of Thinking

Rationalizing the purpose of thinking is probably not something you do often, but it is the foundational first step in critical thinking. To effectively use critical thinking in practice, the nurse must first identify the purpose of thinking. For example, the nurse is caring for a patient who presents with fever, tachycardia, and shortness of breath. The patient also has an open, infected wound on the left foot that is not healing. The nurse must recognize that the patient is exhibiting signs and symptoms that may be indicative of an underlying problem. At this point, the nurse must be able to identify that the purpose of thinking with regard to the patient is to consider what might be happening with the patient and formulate a plan of care. This begins the process of critical thinking, which involves several steps: thinking ahead, thinking in action, and reflection on thinking.

Thinking Ahead

Thinking ahead in nursing involves considering what may be going on with the patient to anticipate potential outcomes and complications that may arise. Remember competent nurses are proactive versus reactive. Reactive nursing is letting situations arise and then responding to the change, but proactive nursing is recognizing cues behaviors and patterns that are leading up to a complicated event. Additionally, the nurse will formulate goals of care and must try to anticipate specific needs the patient will have. Considering the patient discussed in the preceding paragraph, the nurse should begin the process of thinking ahead about potential outcomes and complications. The nurse may hypothesize that the patient is starting to develop sepsis from the open wound on the foot so severe sepsis and/or septic shock could be a complication to begin preparing for. The nurse thinks ahead about goals of care for the patient and determines that wound care to prevent infection spread and sepsis is the priority goal at this time.

Thinking in Action

Thinking in action encompasses the thought processes occurring while the nurse is performing interventions. So, if the nurse in our example begins performing wound care, they are thinking about the best dressing to use, how to clean the wound, and if antibiotics should be considered. All of these thoughts are likely occurring as the nurse is providing the care; thus, they are examples of how the nurse is using thinking in action.

Reflection on Thinking

After performing interventions or making decisions, the nurse should reflect on the thinking that occurred. The nurse will use this thinking process to determine if the decision was reactive or responsive. Reactive decision-making involves responding to situations after they have occurred, often in a hurried or unplanned manner. These decisions tend to be impulsive and are driven by immediate needs or crises. Responsive decisions, on the other hand, involve careful deliberation about how to address a situation based on careful consideration of information. In our example, the nurse’s decision appears to have been responsive. The patient was exhibiting some altered vital signs, but nothing indicated that the situation had become emergent yet. The nurse was able to think carefully about the patient’s situation and determine that wound care was the highest priority and begin to implement care in a calm, deliberate manner. In an ideal world, all nursing decisions would be responsive, but in a lot of cases, they must be reactive because of situation severity and medical emergencies.

Application of Knowledge

During the outset of the critical thinking process, nurses must judge whether their knowledge is accurate, complete, factual, timely, and relevant. This can be done by applying knowledge to nursing practice in a multitude of ways, including drawing from past education and experience in nursing and using professional resources and standards. Each of these is discussed in more detail in the following sections.

Knowledge Base

Becoming a nurse requires years of schooling, which contributes to the development of a robust knowledge base. Nurses receive formal education and training that provides them foundational knowledge in anatomy, physiology, pharmacology, and patient care techniques, among many others. Additionally, nurses are required to complete continuing education courses specific to their chosen practice setting, further developing their knowledge base. When applying knowledge in practice, nurses can draw from their knowledge base and make informed decisions about patient care.

Experience in Nursing

Nursing is considered a practice. Nursing practice means we learn from our mistakes and our past experiences and apply this knowledge to our next patient or to the next population we serve. As nurses gain more experience, they can use what they have learned in practice and apply it to new patient situations. Each new encounter with a patient presents unique challenge and learning opportunities that contribute to the development of clinical expertise. Reflecting on these experiences allows nurses to recognize patterns, anticipate patient outcomes, and refine their decision-making processes. Whether they are identifying effective nursing interventions for common conditions, adapting care plans to individual patient needs, or navigating complex situations with compassion, nurses draw upon their accumulated knowledge base from clinical experience to provide high-quality, patient-centered care. Through reflection and continuous learning from past experiences, nurses enhance their clinical skills, ultimately improving patient outcomes.

Professional Resources and Standards

In addition to foundational knowledge bases and experience, nurses can also use professional resources and standards to gain and apply knowledge in practice. Nurses can refer to clinical practice guidelines that have been established by professional organizations and healthcare institutions to help provide a framework for implementing nursing interventions based on the best evidence. By following the guidelines, nurses are ensuring that their care aligns with established standards and promotes optimal patient outcomes. Additionally, nurses should remain up to date about new and emerging research in their practice area, which can be obtained by reading professional journals and publications and attending conferences, workshops, and other trainings. Nurses can use the information learned from these resources to influence practice and ensure the highest standards of care are being performed in their practice setting. By staying informed about the latest developments in nursing and health care, nurses enhance their knowledge base and can adapt their practice to incorporate new evidence and innovations. Along with professional development and staying current with professional practices, nursing students should actively seek and join professional organizations such as critical care nursing or oncology nursing societies because this will lead the student to become expert in that subject and stay relevant with current evidence and practice guidelines.

Clinical Safety and Procedures (QSEN)

Qsen competency: evidence-based practice.

Definition: Providing quality patient care based on up-to-date, theory-derived research and knowledge, rather than personal beliefs, advice, or traditional methods.

Knowledge: The nurse will describe how the strength and relevance of available evidence influences the choice of intervention in provision of patient-centered care.

Skill: The nurse will:

subscribe to professional journals that produce original research and evidence-based reports related to their specific area of practice
become familiar with current evidence-based clinical practice topics and guidelines
assist in creating a work environment that welcomes new evidence into standards of practice
question the rational for traditional methods of care that result in sub-par outcomes or adverse events

Attitude: The nurse will appreciate the importance of regularly reading relevant professional journals.

Critique of Decision

After determining the best course of action based on the application of knowledge, the nurse can critique the decisions that were made. Specifically, the nurse will use self-reflection to review their actions and thoughts that led them to the decision. The nurse will consider the outcomes of their chosen interventions, reflect on the effectiveness of their approach, and identify areas of improvement. Additionally, the nurse may seek feedback from colleagues to obtain different perspectives about decisions made. Soliciting input from others helps the nurse gain insight and learn from their peers to further inform their future practice. Reflection questions that the nurse may ask themselves to critique their decision include the following:

Was the patient goal or outcome met?
Could the intervention have been done differently? Could it have been done better?
What are alternative decisions that could have been made? What are the merits of each?

Critical Thinking Indicators

Certain behaviors that demonstrate the knowledge, skills, and attitudes that promote critical thinking are called critical thinking indicators (CTIs) . Critical thinking indicators are tangible actions that are performed to assess and improve your thinking skills.

4-Circle CT Model

There are many models and frameworks within nursing and other disciplines that attempt to explain the process of critical thinking. One of the most popular is Alfaro-LeFevre’s 4-Circle CT Model (Alfaro-LeFevre, 2016). This model breaks critical thinking into four components: personal characteristics, intellectual and cognitive abilities, interpersonal abilities and self-management, and technical skills. These four components overlap, forming interconnections in critical thinking.

Link to Learning

Learn more here about the 4-Circle CT Model and see an illustration of it.

Personal Critical Thinking Indicators

Personal CTIs are behaviors that are indicative of critical thinkers. Some of these behaviors that are most relevant to nursing include:

confidence and resilience: showing ability to reason and learn and overcoming problems
curiosity and inquisitiveness: asking questions and looking for the “why” behind things
effective communication: listening well, showing understanding for others thoughts and feelings, and speaking and writing with clarity
flexibility: changing approaches as needed to obtain the best results
honesty: looking for the truth and demonstrating integrity while adhering to moral and ethical standards
self-awareness: being able to identify one’s own knowledge gaps and acknowledge when thinking may be negatively influenced by emotions or self-interests.

Personal Knowledge and Intellectual Skills

Personal knowledge and intellectual skills encompass the knowledge gained from nursing school and clinical experiences. Examples of each of these kinds of skills are listed in Table 28.3 .

Personal Knowledge	Intellectual Skills

Interpersonal and Self-Management Skills

Interpersonal and self-management skills encompass the knowledge and skills needed for effective collaboration. These include:

addressing conflicts fairly
advocating for patients, self, and others
dealing with complaints constructively
establishing empowered partnerships
facilitating and navigating change
fostering positive interpersonal relationships and promoting teamwork
giving and taking constructive criticism
leading, motivating, and managing others
managing stress, time, and energy
promoting a learning and safety culture
upholding healthy workplace standards
using skilled communication in high-stake situations

Technical Skills

Technical skills in nursing refer to the practical abilities and competencies that nurses use in the delivery of patient care. These skills are typically learned through education, training, and hands-on experience. Some common technical skills in nursing include:

administering medications
assisting with personal hygiene and activities of daily living
documentation and charting
inserting intravenous catheters
inserting urinary catheters and nasogastric tubes
performing tracheostomy care
performing wound care
taking vital signs

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Why Critical Thinking Is Important in Nursing

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

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

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

Why Critical Thinking Is Important in Nursing?

Why Are Critical Thinking Skills in Nursing Important?

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

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

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

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

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

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

How can you develop your critical thinking skills?

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

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

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

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

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

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

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

Reasons Critical Thinking In Nursing Is Important

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

Following are the reasons:

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

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

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

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

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

Skills that Critical Thinkers Need

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

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

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

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

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

The decisions need to be based on sound reasoning:

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

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

Critical Thinking Pitfalls

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

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

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

Conclusion:

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

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

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Critical Thinking in Nursing

First Online: 02 January 2023

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Şefika Dilek Güven 3

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

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

Graphical Abstract/Art Performance

Critical thinking in nursing.

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

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

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

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

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

By Hannah Meinke on 07/05/2021

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

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

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

Why are critical thinking skills in nursing important?

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

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

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

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

How are critical thinking skills acquired in nursing school?

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

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

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

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

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

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

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

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

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

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

How are critical thinking skills applied in nursing?

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

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

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

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

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

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

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

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

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

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

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

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

Beyond thinking

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

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

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

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Enhancing Critical Thinking in Clinical Practice

Implications for critical and acute care nurses.

Shoulders, Bridget MS, ACNP-BC, CCRN-CMC; Follett, Corrinne MS, FNP-BC, CCRN, RN-BC, RCIS; Eason, Joyce MS, ANP-BC, RN-BC

Bridget Shoulders, MS, ACNP-BC, CCRN-CMC , is a nurse practitioner in the cardiology department at the James A. Haley VA Hospital in Tampa, Florida.

Corrinne Follett, MS, FNP-BC, CCRN, RN-BC, RCIS, is a nurse practitioner in the cardiology department at the James A. Haley VA Hospital in Tampa, Florida.

Joyce Eason, MS, ANP-BC, RN-BC, is a nurse practitioner in the cardiology department at the James A. Haley VA Hospital in Tampa, Florida.

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

Address correspondence and reprint requests to: Bridget Shoulders, MS, ACNP-BC, 31047 Whitlock Dr, Wesley Chapel, FL 33543 ( [email protected] ).

The complexity of patients in the critical and acute care settings requires that nurses be skilled in early recognition and management of rapid changes in patient condition. The interpretation and response to these events can greatly impact patient outcomes. Nurses caring for these complex patients are expected to use astute critical thinking in their decision making. The purposes of this article were to explore the concept of critical thinking and provide practical strategies to enhance critical thinking in the critical and acute care environment.

The complexity of patients in the critical and acute care settings requires that nurses be skilled in early recognition and management of rapid changes in patient condition. The interpretation and response to these events can greatly impact patient outcomes. The purpose of this article is to explore the concept of critical thinking and provide practical strategies to enhance critical thinking in the critical and acute care environment.

The complexity of patients in the critical and acute care settings requires that nurses be skilled in early recognition and management of rapid changes in patients’ condition. Caring for patients with complex conditions, decreased length of stay, sophisticated technology, and increasing demands on time challenges new and experienced nurses alike to use astute critical thinking in clinical decision making. The decisions made directly affect patient care outcomes. 1 Bedside nurses, preceptors, and nurse leaders play a pivotal role in the development of critical thinking ability in the clinical setting. The purposes of this article were to explore the concept of critical thinking and to provide nurses with practical strategies to enhance critical thinking in clinical practice.

WHAT IS CRITICAL THINKING?

Critical thinking is a learned process 2 that occurs within and across all domains. There are numerous definitions of critical thinking in the literature, often described in terms of its components, features, and characteristics. Peter Facione, an expert in the field of critical thinking, led a group of experts from various disciplines to establish a consensus definition of critical thinking. The Delphi Report, 3 published in 1990, characterized the ideal critical thinker as “habitually inquisitive, well-informed, trustful of reason…, diligent in seeking relevant information, and persistent in seeking results.” Although this definition was the most comprehensive attempt to define critical thinking 4 at the time, it was not nursing specific.

Scheffer and Rubenfeld 4 used the Delphi technique to define critical thinking in nursing. An international panel of expert nurses in practice, education, and research provided input into what habits of the mind and cognitive skills were at the core of critical thinking. After discussion and analysis, the panel provided the following consensus statement: “Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge.” This definition expanded on the consensus definition in the Delphi Report to include the additional components of creativity and intuition.

Skilled critically thinking nurses respond quickly to changes in patients’ conditions, changing priorities of care based on the urgency of the situation. They accurately interpret data, such as subtle changes in vital signs or laboratory values. 5 They are not just looking at the numbers but also assessing the accuracy and relevancy of the findings. Critical thinking helps the nurse to recognize events as part of the bigger picture and center in on the problem.

Lack of critical thinking is evident when nurses depend heavily on structured approaches, such as protocols, to make clinical decisions. These guidelines should not be viewed as mandates because the practice is always more complex than what can be captured by pathways and protocols. 6 Without critical thinking, nurses are merely performing task-oriented care.

One example of how nurses use critical thinking is with medication administration. This task may appear to be primarily a technical process, but it requires astute critical thinking. Eisenhauer and Hurley 7 interviewed 40 nurses to illustrate their thinking processes during medication administration. The nurses described communicating with providers, sharing their interpretation of patient data to ensure safe administration of medication. They used their judgment about the timing of as-needed medication (eg, timing pain medication before physical therapy). Nurses integrated their knowledge of the patient’s laboratory values or pattern of response to medication to determine the need for a change in the drug dose or time. They assessed whether a medication was achieving the desired effect and took precautionary measures in anticipating potential side effects. It is evident in these examples that safe administration of medication involves critical thinking beyond the 5 rights that nurses are taught in the academic setting .

INTEGRATING RESEARCH, EVIDENCE-BASED PRACTICE, AND CRITICAL THINKING

Nursing research is a scientific process that validates and refines existing knowledge and generates new knowledge that influences nursing practice. 8 Evidence-based practice integrates the best available research with clinical expertise and patient’s needs and values. Different types of evidence have different strengths and weaknesses in terms of credibility. The typical evidence hierarchy places meta-analysis of randomized clinical trials at the top and expert opinion at the bottom of what counts as good evidence. 6

It is important to recognize that nursing knowledge is not always evidence based. Nurses have historically acquired knowledge through a variety of nonscientific sources such as trial and error, role modeling, tradition, intuition, and personal experiences. 8 Although these sources have been “handed down” over the years and continue to influence nursing practice, nurses are expected to use the best available evidence to guide their decision making. Evidence-based practice redirects nursing from making decisions based on tradition to practicing based on the best research evidence.

Barriers for nurses to implement evidence-based practices include lack of knowledge of research, difficulty interpreting findings and applying to practice, lack of time, and lack of autonomy to implement changes. 9 Universities can overcome these barriers by incorporating nursing research throughout all clinical and nonclinical courses. Joint endeavors between hospitals and universities to educate nurses in the use of research will increase the level of comfort with evidence-based practice. 10 Specialized research departments devoted to promotion and education of staff nurses in research evaluation, utilization, and implementation would allow nursing staff to experience an increased level of support and awareness of the need for research utilization.

Nurse leaders need to create an environment that supports transformation from outdated practices and traditions. Nurses must feel empowered to question nursing practice and have available resources to support the search for evidence. Critical thinking and evidence-based practice must be connected and integrated for nurses, starting in their basic education programs and fostered throughout their lifetime. 11

THE NURSING PROCESS AND CRITICAL THINKING

The nursing process is the nurse’s initial introduction to a thinking process used to collect, analyze, and solve patient care problems. The steps of the nursing process are similar to the scientific method. In both processes, information is gathered, observations are made, problems are identified, plans are developed, actions are taken, and processes are reviewed for effectiveness. 8 The nursing process, used as a framework for making clinical judgments, helps guide nurses to think about what they do in their practice.

Chabeli 12 described how critical thinking can be facilitated using the framework of the nursing process. During the assessment phase, the nurse systematically gathers information to identify the chief complaint and other health problems. The nurse uses critical thinking to examine and interpret the data, separating the relevant from the irrelevant and clarifying the meaning when necessary. During the diagnosis phase, nurses use the diagnostic reasoning process to draw conclusions and decide whether nursing intervention is indicated. The planning and implementation of interventions should be mutual, research based, and realistic and have measurable expected outcomes. The evaluation phase addresses the effectiveness of the plan of care and is ongoing as the patient progresses toward goal achievement. The author concludes that when the nursing process is used effectively for the intended purpose, it is a powerful scientific vehicle for facilitating critical thinking.

HOW DO WE LEARN CRITICAL THINKING IN NURSING?

Nurses initially learn to think critically in the academic environment, using assessments designed to measure critical thinking. It is conceivable that a nurse could pass an examination in the classroom but have difficulty making the transition to think critically in the clinical setting. Improving critical thinking ability should be viewed as a process and, as with the development of any skill, requires practice. 13

Most nurses develop their critical thinking ability as they gain clinical expertise. Patricia Benner 14 described the development of clinical expertise, as nurses transition from novice to expert. The beginning, or novice nurse, has theoretical knowledge as a foundation and minimal practical experiences to draw from. As similar situations are encountered, experience is accrued over time as the nurse evolves toward competency. As proficiency is developed, the nurse is able to perceive situations as a whole and recognize the significant aspects. As the proficient nurse reaches toward expertise, decision making becomes automatic, drawing from the enormous background of experience acquired over the years. Experience is more than the passage of time and is required at each stage before progressing to the next level of clinical expertise. As nurses progress along the novice-to-expert continuum and gain competence, they develop their ability to think critically. 15

Preceptors play a significant role in transitioning nurses into professional practice. It is essential that preceptors have the necessary skills to facilitate the critical thinking development of new nurses. Forneris and Peden-McAlpine 16 investigated the impact of the preceptor’s coaching component of a reflective learning intervention on novice nurses’ critical thinking skills. The following coaching strategies were used to educate preceptors: context (eg, understanding the big picture), dialogue, reflection, and time (eg, the use of past experiences to discern change over time). After completing the educational intervention, the preceptors used these strategies to coach the novice nurses in the development of their critical thinking skills. This study found that these strategies stimulated the novice nurses to engage in an intentional, reflective dialogue. The preceptors acknowledged a change in their preceptor style, moving from describing critical thinking as prioritizing and organizing task to a dialogue to share thinking and understand rationale.

Nurses must have the necessary dispositions (eg, attributes, attitudes, habits of the mind) to be effective critical thinkers. 11 Finn 17 defined thinking dispositions that influence critical thinking. Open mindedness was described as the willingness to seek out and consider new evidence or possibilities. Fair mindedness referred to an unprejudiced examination of evidence that might question beliefs or a viewpoint contrary to the nurse’s own beliefs. Reflectiveness was described as the willingness to gather relevant evidence to carefully evaluate an issue, rather than making hasty judgments. Counterfactual thinking referred to the willingness to ponder what could or would happen if the facts were considered under different conditions or perspectives. The opposite thinking styles directed toward maintaining the status quo included being close minded, biased, and rigid.

Rung-Chaung et al 18 investigated the critical thinking competence and disposition of nurses at different rankings on the clinical ladder. Using Benner’s novice to expert model as their theoretical framework, a stratified random sampling of 2300 nurses working at a medical center were classified according to their position on the clinical ladder. Ten to fifteen percent of this population were randomly selected for each ladder group, with the final sample size totaling 269. Data were collected using a modified version of the Watson-Glaser Critical Thinking Appraisal tool, designed to assess critical thinking competence in the categories of inference, recognition of assumptions, deduction, interpretation, and evaluation. The participants’ cumulative average score for critical thinking competence was 61.8 of a possible score of 100, ranking highest in interpretation and lowest in inference. Participants completed a modified version of the California Critical Thinking Disposition Inventory, designed to measure the following characteristics of critical thinking: inquisitiveness, systematic analytical approach, open mindedness, and reflective thinking. Participants scored highest in reflective thinking and lowest in inquisitiveness.

Analysis of the data indicated that older nurses with more years of experience and a more prominent position on the clinical ladder were predictive of a higher critical thinking disposition. Overall, critical thinking was shown to be only partially developed. The authors recommended training programs, such as problem-based learning, group discussion, role-playing, and concept mapping be adopted to enhance nurse critical thinking skills.

Chang el al 19 examined the relationship between critical thinking and nursing competence, using the Watson-Glaser Critical Thinking Appraisal and the Nursing Competence Scale. A total of 570 clinical nurses participated in the study. These nurses scored highest in interpretation ability and lowest in inference ability. These findings were consistent with the results reported in the Rung-Chuang study. Analysis of the data indicated that critical thinking ability was significantly higher in older nurses and nurses with more than 5 years of experience. The findings of this study indicated that critical thinking ability, working years, position/title, and education level were the 4 significant predictors of nursing competence. There were significantly positive correlations between critical thinking ability and nursing competence, indicating that the higher the critical thinking ability, the better the nursing competence is.

STRATEGIES TO ENHANCE CRITICAL THINKING ABILITY

To improve critical thinking, the learning needs of nurses must first be identified. The Performance Based Development System, a scenario-based tool, was used in a study to identify critical thinking learning needs of 2144 new and experienced nurses. 20 Results were reported as either meeting (identifying the appropriate actions) or not meeting the expectations. Most participants (74.9%) met the expectations by identifying the appropriate actions. Of the approximately 25% who did not meet the expectations, the learning needs identified included initiating appropriate nursing interventions (97.2%), differentiating urgency (67%), reporting essential clinical data (65.4%), anticipating relevant medical orders (62.8%), understanding decision rationale (62.6%), and problem recognition (57.1%). As expected, nurses with the most experience had the highest rate of identifying the appropriate actions on the Performance-Based Development System assessment. These findings were consisted with Benner’s novice to expert framework. These types of assessment tools can be used to identify learning needs and help facilitate individualized orientation. The authors acknowledged that further research is needed to identify areas of critical thinking deficiency and to test objective, educational strategies that enhance critical thinking in the nursing population.

The Institute of Medicine report on the future of nursing 21 emphasized the importance of nursing residency programs to provide hands-on experience for new graduates transitioning into practice. According to the report, these programs have been shown to help new nurses develop critical competencies in clinical decision making (eg, critical thinking) and autonomy in providing patient care. Implementing successful methods to expedite the development of critical thinking in new nurses has the potential to improve patient safety, nurse job satisfaction, and recruitment and retention of competent nurse professionals. 22

Although critical thinking skills are developed through clinical practice, there are many experienced nurses who possess less than optimal critical thinking skills. 5 As part of an initiative to elevate the critical thinking of nurses on the frontline, Berkow et al 23 reported the development of the Critical Thinking Diagnostic, a tool designed to assess critical thinking of experienced nurses. The tool includes 25 competencies, identified by nursing leaders as core skills at the heart of critical thinking. These competencies were grouped into 5 components of critical thinking: problem recognition, clinical decision making, prioritization, clinical implementation, and reflection. The potential application of this tool may enable nurse leaders to identify critical thinking strengths and individualize learning activities based on the specific needs of nurses on the frontline.

The critical thinking concepts, identified in the Delphi study of nurse experts, were used to teach critical thinking in a continuing education course. 24 The objective of the course was to help nurses develop the cognitive skills and habits of the mind considered important for practice. The course focused on the who, what, where, when, why, and how of critical thinking, using the case study approach. The authors concluded that critical thinking courses should include specific strategies for application of knowledge and opportunities to use cognitive strategies with clinical simulations.

Journal clubs encourage evidence-based practice and critical thinking by introducing nurses to new developments and broader perspectives of health care. 11 Lehna et al 25 described the virtual journal club (VJC) as an alternative to the traditional journal club meetings. The VJC uses an online blog format to post research-based articles and critiques, for generation of discussion by nurses. Recommendations for practice change derived from the analysis are forwarded to the appropriate decision-making body for consideration. The VJC not only exposes the nursing staff to scientific evidence to support changing their practice but also may lead to institutional policy changes that are based on the best evidence. The VJC overcomes the limitations of the traditional journal clubs by being available to all nurses at all times.

The integration of simulation technology in nursing exposes nursing students and nurses to complex patient care scenarios in a safe environment. Kirkman 26 reported a study to investigate nursing students’ ability to transfer knowledge and skill learned during high-fidelity simulations to the clinical setting, over time. The sample of 42 undergraduate students were rated on their ability to perform a respiratory assessment, using observation and a performance evaluation tool. The findings indicated there was a significant difference in transfer of learning demonstrated by participants over time. These results provide evidence that students were able to transfer knowledge and skills from high-fidelity simulations to the traditional clinical setting.

Jacobson et al 27 reported using simulated clinical scenarios to increase nurses’ perceived confidence and skill in handling emergency situations. During a 7-month period, the scenarios were conducted a total of 97 times with staff nurses. Each scenario presented a patient’s evolving story to challenge nurses to assess and synthesize the clinical information. The scenarios included a critical point at which the nurses needed to recognize and respond to significant deterioration in the patient’s condition. Postproject survey data found that most of the nurses perceived an improvement in their confidence and skill in managing emergency situations. More than half of the nurses reported that their critical thinking skills improved because of participation in this project.

Individual nurses can enhance critical thinking by developing a questioning attitude and habits of inquiry, where there is an appreciation and openness to other ways of doing things. Nurses should routinely reflect on the care provided and the outcomes of their interventions. Using reflection encourages nurses to think critically about what they do in everyday practice and learn from their experiences. 28 This strategy is beneficial for nurses to validate knowledge and examine nursing practice. 5 Nurses must be comfortable with asking and being asked “why” and “why not.” Seeking new knowledge and updating or refining current knowledge encourage critical thinking by practicing based on the evidence. “We’ve always done it that way” is no longer an acceptable answer. A list of other useful strategies for enhancing critical thinking is included in Table 1 .

USING THE INTERACTIVE CASE STUDY APPROACH TO ENHANCE CRITICAL THINKING

Case studies provide a means to attain experience in high-risk and complex situations in a safe environment. The purpose of a case study is to apply acquired knowledge to a specific patient situation, using actual or hypothetical scenarios. Waxman and Telles 32 discussed using Benner’s model to develop simple to complex scenarios that match the learning level of the nurse. The case study should ideally provide all the relevant information for analysis, without directing the nurse’s thinking in a particular direction. Participants are encouraged to use thinking processes similar to that used in a real situation.

A well-developed case study defines objectives and expected outcomes. The questions should be geared toward the outcomes to be met. 30 The focus of the questions should be on the underlying thought processes used to arrive at the answer, rather than the answer alone. This helps nurses identify the reasons behind why a decision is made. In some cases, the case study may build on the information shared, instead of presenting all the information at one time. At the very least, case studies should have face validity or represent what they were developed to represent. 33

Case studies can be developed for specific purposes, such as analyzing data or improving the nurse’s skill in responding to specific clinical situations. 30 This strategy can be useful in building nurses’ confidence in managing complex or emergency situations. The case can be tailored to specific patient populations or clinical events. Covering the course of care that a patient receives over time is effective in putting together the whole picture. 31 For the purpose of improving patient outcomes, the case study should represent the overall patient experience. Case studies may be used to review specific actions that led to positive outcomes or the processes that led to negative outcomes. This can help determine if the care was the most appropriate for the situation. 34

The use of case studies with simulation technology provides nurses with the opportunity to critically think through a critical situation in a controlled setting. The latest human patient simulators (HPSs) are programmed to respond to the nurse’s intervention, with outcomes determined as a result of the intervention. Howard et al 35 compared the teaching strategies of HPSs and the traditional interactive case study (ICS) approach, using scenarios with the same subject matter. A sample of 49 senior nursing students were given pretest and posttest designed to measure the students’ knowledge of the content presented and their ability to apply that content to clinical problems. Participants in the HPS group scored significantly higher on the posttest than the ICS group did. Students reported that the HPS assisted them in understanding concepts, was a valuable learning experience, and helped to stimulate their critical thinking. There was no significant difference between the HPS and ICS groups’ responses to the statement that the educational intervention was realistic.

The Figure depicts an example of a heart failure case study with the objective of applying critical thinking to a common problem encountered in practice. Expert clinical nurses would be ideal to serve as facilitators of this learning experience. Their role would be to present the scenario, describe the physiological findings, ask open-ended questions that require thinking and analysis, and guide the discussion and problem-solving process. Discussion and questioning strategies that are helpful in eliciting reflective responses during the learning experience are included in Table 2 . This case study could be tailored to meet the learning needs of the target audience.

THE INFLUENCE OF THE WORKPLACE ENVIRONMENT

The workplace environment can enhance or hinder nurses’ motivation to develop their critical thinking abilities. Cornell and Riordan 36 reported an observational study that assessed workflow barriers to critical thinking in the workplace. A total of 2061 tasks were recorded on an acute care unit during 35.7 hours of observation. The activities found to consume nearly 70% of the nurses’ time included verbal communication, walking, administering medications, treatments, and documentation. Nurse workflow was characterized by frequent task switching, interruptions, and unpredictability. The authors recommended reallocating duties, delegating appropriate task to nonnursing personnel, reducing waste, deploying technology that reduces repetitive task, and continuing education and training to help nurses cope with the complex demands of nursing.

Factors in the work environment conducive to the development of critical thinking include an atmosphere of team support, staffing patterns that allow continuity of care, and exposure to a variety of patient care situations. Creating an environment where contributions are valued, nurses feel respected, and there is comfort with asking probing questions is very important in enhancing the development of critical thinking skills.

Critical thinking is an essential skill that impacts the entire spectrum of nursing practice. Studies have shown that the higher the critical thinking ability, the better the nursing competence is. It is essential that critical thinking of new and experienced nurses be assessed and learning activities developed based on the specific needs of the nurses. The concept of critical thinking should be included in orientation, ongoing education, and preceptor preparation curriculums. These educational offerings should be designed to help nurses develop the cognitive skills and habits of the mind considered important for practice.

Bedside nurses can integrate a critical thinking approach by developing clinical expertise, making a commitment to lifelong learning, and practicing based on the evidence. Nurses should routinely reflect on the care provided and the outcomes of their interventions.

Further research is needed to identify areas of critical thinking deficiency and evaluate strategies aimed at enhancing critical thinking. These strategies will ultimately lead to improved clinical decision making and patient outcomes. Bedside nurses, preceptors, and nurse leaders are encouraged to work together collaboratively to create a culture where critical thinking is an integral part of nursing practice.

Acute care; Critical thinking; Decision making

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

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

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

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

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

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

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

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

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

Competing interests: No competing interests

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Critical thinking definition

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

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

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

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

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

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

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Which information resources should the author look to?
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What is the most effective way to show information?
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What tone and level of language difficulty should the document have?

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

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

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Open access
Published: 02 September 2024

Clinical supervisor’s experiences of peer group clinical supervision during COVID-19: a mixed methods study

Owen Doody ORCID: orcid.org/0000-0002-3708-1647 1 ,
Kathleen Markey ORCID: orcid.org/0000-0002-3024-0828 1 ,
James Turner ORCID: orcid.org/0000-0002-8360-1420 2 ,
Claire O. Donnell ORCID: orcid.org/0000-0003-2386-7048 1 &
Louise Murphy ORCID: orcid.org/0000-0003-2381-3963 1

BMC Nursing volume 23 , Article number: 612 ( 2024 ) Cite this article

Metrics details

Providing positive and supportive environments for nurses and midwives working in ever-changing and complex healthcare services is paramount. Clinical supervision is one approach that nurtures and supports professional guidance, ethical practice, and personal development, which impacts positively on staff morale and standards of care delivery. In the context of this study, peer group clinical supervision provides allocated time to reflect and discuss care provided and facilitated by clinical supervisors who are at the same grade/level as the supervisees.

To explore the clinical supervisor’s experiences of peer group clinical supervision a mixed methods study design was utilised within Irish health services (midwifery, intellectual disability, general, mental health). The Manchester Clinical Supervision Scale was used to survey clinical supervisors ( n = 36) and semi-structured interviews ( n = 10) with clinical supervisors were conducted. Survey data were analysed through SPSS and interview data were analysed utilising content analysis. The qualitative and quantitative data’s reporting rigour was guided by the CROSS and SRQR guidelines.

Participants generally had a positive encounter when providing clinical supervision. They highly appreciated the value of clinical supervision and expressed a considerable degree of contentment with the supervision they provided to supervisees. The advantages of peer group clinical supervision encompass aspects related to self (such as confidence, leadership, personal development, and resilience), service and organisation (including a positive working environment, employee retention, and safety), and patient care (involving critical thinking and evaluation, patient safety, adherence to quality standards, and elevated levels of care).

There are many benefits of peer group clinical supervision at an individual, service, organisation, and patient level. Nevertheless, there is a need to address a lack of awareness and misconceptions surrounding clinical supervision to create an environment and culture conducive to realising its full potential. It is crucial that clinical supervision be accessible to nurses and midwives of all grades across all healthcare services, with national planning to address capacity and sustainability.

Peer Review reports

Within a dynamic healthcare system, nurses and midwives face growing demands, underscoring the necessity for ongoing personal and professional development. This is essential to improve the effectiveness and efficiency of care delivery for patients, families, and societies. Despite the increased emphasis on increasing the quality and safety of healthcare services and delivery, there is evidence highlighting declining standards of nursing and midwifery care [ 1 ]. The recent focus on re-affirming and re-committing to core values guiding nursing and midwifery practice is encouraging such as compassion, care and commitment [ 2 ], competence, communication, and courage [ 3 ]. However, imposing value statements in isolation is unlikely to change behaviours and greater consideration needs to be given to ways in which compassion, care, and commitment are nurtured and ultimately applied in daily practice. Furthermore, concerns have been raised about global staff shortages [ 4 ], the evidence suggesting several contributing factors such as poor workforce planning [ 5 ], job dissatisfaction [ 6 ], and healthcare migration [ 7 ]. Without adequate resources and staffing, compromising standards of care and threats to patient safety will be imminent therefore the importance of developing effective strategies for retaining competent registered nurses and midwives is paramount in today’s climate of increased staff shortages [ 4 ]. Clinical supervision serves as a means to facilitate these advancements and has been linked to heightened job satisfaction, enhanced staff retention, improved staff effectiveness, and effective clinical governance, by aiding in quality improvements, risk management, and heightened accountability [ 8 ].

Clinical supervision is a key component of professional practice and while the aim is largely known, there is no universally accepted definition of clinical supervision [ 8 ]. Clinical supervision is a structured process where clinicians are allowed protected time to reflect on their practice within a supportive environment and with the purpose of developing high-quality clinical care [ 9 ]. Recent literature published on clinical supervision [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ] highlights the advantages and merits of clinical supervision. However, there are challenges also identified such as a lack of consensus regarding the meaning and goal, implementation issues, variations in approaches in its operationalisation, and an absence of research evidence on its effectiveness. Duration and experience in clinical supervision link to positive benefits [ 8 ], but there is little evidence of how clinical supervision altered individual behaviours and practices. This is reinforced by Kuhne et al., [ 15 ] who emphasise that satisfaction rather than effectiveness is more commonly examined. It is crucial to emphasise that reviews have pinpointed that clinical supervision lowers the risks of adverse patient outcomes [ 9 ] and demonstrates enhancements in the execution of certain care processes. Peer group clinical supervision is a form of clinical supervision whereby two or more practitioners engage in a supervision or consultation process to improve their professional practice [ 17 ]. There is limited evidence regarding peer group clinical supervision and research on the experiences of peer clinical supervision and stakeholders is needed [ 13 ]. In Ireland, peer group clinical supervision has been recommended and guidelines have been developed [ 18 ]. In the Irish context, peer clinical supervision is where both clinical supervisees and clinical supervisors are peers at the same level/grade. However, greater evidence is required to inform future decisions on the implementation of peer group clinical supervision and the purpose of this study is to explore clinical supervisors’ experiences of peer group clinical supervision. As the focus is on peer group supervisors and utilising mixed methods the experiences of the other stakeholders were investigated and reported separately.

A mixed methods approach was used (survey and semi-structured interviews) to capture clinical supervisor’s experiences of clinical supervision. The study adhered to the Consensus-Based Checklist for Reporting of Survey Studies guidelines [ 19 ] (Supplementary File S1 ) and Standards for Reporting Qualitative Research guidelines [ 20 ] (Supplementary File S2 ).

Participants

This study was conducted with participants who successfully completed a professionally credited award: clinical supervision module run by a university in Ireland (74 clinical supervisors across 5 programmes over 3 years). The specific selection criteria for participants were that they were registered nurses/midwives delivering peer group clinical supervision within the West region of Ireland. The specific exclusion criteria were as follows: (1) nurses and midwives who haven’t finished the clinical supervision module at the University, (2) newly appointed peer group clinical supervisors who have yet to establish their groups and initiate the delivery of peer group clinical supervision.

Measures and procedures

The Manchester Clinical Supervision Scale-26 was used to survey participants in February/March 2022 and measure the peer group clinical supervisors’ overall experiences of facilitating peer group clinical supervision. The Manchester Clinical Supervision Scale-26 is a validated 26-item self-report questionnaire with a Likert-type (1–5) scale ranging from strongly disagree (1) to strongly agree (5) [ 21 ]. The Manchester Clinical Supervision Scale-26 measures the efficiency of and satisfaction with supervision, to investigate the skills acquisition aspect of clinical supervision and its effect on the quality of clinical care [ 21 ]. The instrument consists of two main sections to measure three (normative, restorative, and formative) dimensions of clinical supervision utilising six sub-scales: (1) trust and rapport, (2) supervisor advice/support, (3) improved care/skills, (4) importance/value of clinical supervision, (5) finding time, (6) personal issues/reflections and a total score for the Manchester Clinical Supervision Scale-26 is also calculated. Section two consisted of the demographic section of the questionnaire and was tailored to include eight demographic questions concerning the supervisor’s demographics, supervisee characteristics, and characteristics of clinical supervision sessions. There were also two open field questions on the Manchester Clinical Supervision Scale-26 (model of clinical supervision used and any other comments about experience of peer group clinical supervision). The main question about participants’ experiences with peer clinical supervision was “What was your experience of peer clinical supervision?” This was gathered through individual semi-structured interviews lasting between 20 and 45 min, in March/April 2022 (Supplementary file 3 ).

Ethical considerations

Health service institutional review boards of two University hospitals approved this study (Ref: 091/19 and Ref: C.A. 2199). Participants were recruited after receiving a full explanation of the study’s purpose and procedure and all relevant information. Participants were aware of potential risks and benefits and could withdraw from the study, or the survey could be stopped at any time. Informed consent was recorded, and participant identities were protected by using a pseudonym to protect anonymity.

Data analysis method

Survey data was analysed using the data analysis software package Statistical Package for the Social Sciences, version 26 (SPSS Inc., Chicago, Il, USA). Descriptive analysis was undertaken to summarise responses to all items and categorical variables (nominal and ordinal) were analysed using frequencies to detail the number and percentage of responses to each question. Scores on the Manchester Clinical Supervision Scale-26 were reverse scored for 9 items (Q1-Q6, Q8, Q20,21) and total scores for each of the six sub-scales were calculated by adding the scores for each item. Raw scores for the individual sub-scales varied in range from 0 to 20 and these raw scores were then converted to percentages which were used in addition to the raw scores for each sub-scale to describe and summarise the results of the Manchester Clinical Supervision Scale-26. Cronbach’s alpha coefficient was undertaken with the 26 questions included within the Manchester Clinical Supervision Scale-26 and more importantly with each of the dimensions in the Manchester Clinical Supervision Scale-26. The open-ended questions on the Manchester Clinical Supervision Scale-26 and interviews were analysed using content analysis guided by Colorafi and Evans [ 22 ] and categories were generated using their eight steps, (1) creating a coding framework, (2) adding codes and memos, (3) applying the first level of coding, (4) categorising codes and applying the second level of coding, (5) revising and redefining the codes, (6) adding memos, (7) visualising data and (8) representing the data.

Research rigour

To ensure the validity and rigour of this study the researchers utilised the Manchester Clinical Supervision Scale-26 a recognised clinical supervision tool with good reliability and wide usage. Interviews were recorded, transcribed, and verified by four participants, data were collected until no new components appeared, data collection methods and analysis procedures were described, and the authors’ biases were minimised throughout the research process. The Manchester Clinical Supervision Scale-26 instrument internal consistency reliability was assessed which was overall good (α = 0.878) with individual subscale also good e.g., normative domain 0.765, restorative domain 0.864, and formative domain 0.900. Reporting rigour was demonstrated using the Consensus-Based Checklist for Reporting of Survey Studies guidelines [ 19 ] and Standards for Reporting Qualitative Research guidelines [ 20 ].

Quantitative data

Participant and clinical supervision characteristics.

Thirty-six of the fifty-two (69.2%) peer group clinical supervisors working across a particular region of Ireland responded to the Manchester Clinical Supervision Scale-26 survey online via Qualtrics. Table 1 identifies the demographics of the sample who were predominantly female (94.4%) with a mean age of 44.7 years (SD. 7.63).

Peer group clinical supervision session characteristics (Table 2 ) highlight over half of peer group clinical supervisors ( n = 20, 55.6%) had been delivering peer group clinical supervision for less than one year and were mainly delivered to female supervisees ( n = 28, 77.8%). Most peer group clinical supervision sessions took place monthly ( n = 32, 88.9%) for 31–60 min ( n = 27, 75%).

Manchester Clinical Supervision Scale-26 results

Participants generally viewed peer group clinical supervision as effective (Table 3 ), the total mean Manchester Clinical Supervision Scale-26 score among all peer group clinical supervisors was 76.47 (SD. 12.801) out of 104, Surpassing the clinical supervision threshold score of 73, which was established by the developers of the Manchester Clinical Supervision Scale-26 as the benchmark indicating proficient clinical supervision provision [ 21 ]. Of the three domains; normative, formative, and restorative, the restorative domain scored the highest (mean 28.56, SD. 6.67). The mean scores compare favourably to that of the Manchester Clinical Supervision Scale-26 benchmark data and suggest that the peer group clinical supervisors were satisfied with both the level of support, encouragement, and guidance they provided and the level of trust/rapport they had developed during the peer group clinical supervision sessions. 83.3% ( n = 30) of peer group clinical supervisors reported being either very satisfied ( n = 12, 33.3%) or moderately satisfied ( n = 18, 50%) with the peer group clinical supervision they currently delivered. Within the peer group clinical supervisor’s supervisee related issues ( n = 17, 47.2%), work environment-related issues ( n = 16, 44.4%), staff-related issues ( n = 15, 41.7%) were reported as the most frequent issues, with patient/client related issues being less frequent ( n = 8, 22.2%). The most identified model used to facilitate peer group clinical supervision was the Proctors model ( n = 8, 22.22%), which was followed by group ( n = 2, 5.55%), peer ( n = 2, 5.55%), and a combination of the seven-eyed model of clinical supervision and Proctors model ( n = 1, 2.77%) with some not sure what model they used ( n = 2, 5.553%) and 58.33% ( n = 21) did not report what model they used.

Survey open-ended question

‘Please enter any additional comments , which are related to your current experience of delivering Peer Group Clinical Supervision.’ There were 22 response comments to this question, which represented 61.1% of the 36 survey respondents, which were analysed using content analysis guided by Colorafi & Evans [ 22 ]. Three categories were generated. These included: personal value/benefit of peer group clinical supervision, challenges with facilitating peer group clinical supervision, and new to peer group clinical supervision.

The first category ‘personal value/benefit of peer group clinical supervision’ highlighted positive experiences of both receiving and providing peer group clinical supervision. Peer group clinical supervisors reported that they enjoyed the sessions and found them both worthwhile and beneficial for both the group and them as peer group clinical supervisors in terms of creating a trusted supportive group environment and motivation to develop. Peer group clinical supervision was highlighted as very important for the peer group clinical supervisors working lives and they hoped that there would be more uptake from all staff. One peer group clinical supervisor expressed that external clinical supervision was a ‘lifeline’ to shaping their supervisory journey to date.

The second category ‘challenges with facilitating peer group clinical supervision’, identified time constraints, lack of buy-in/support from management, staff shortages, lack of commitment by supervisees, and COVID-19 pandemic restrictions and related sick leave, as potential barriers to facilitating peer group clinical supervision. COVID-19 was perceived to have a negative impact on peer group clinical supervision sessions due to staff shortages, which resulted in difficulties for supervisees attending the sessions during work time. Peer group clinical supervisors felt that peer group clinical supervision was not supported by management and there was limited ‘buy-in’ at times. There was also a feeling expressed that peer group clinical supervision was in its infancy, as COVID-19 and its related restrictions impacted on this by either slowing down the process of commencing peer group clinical supervision in certain areas or having to move online. However, more recently improvements in managerial support and supervisee engagement with the peer group clinical supervision process are noted.

The final category ‘new to peer group clinical supervision’ highlighted that some peer group clinical supervisors were new to the process of providing peer group clinical supervision and some felt that this survey was not a true reflection of their experience of delivering peer group clinical supervision, as they were not fully established yet as clinical supervisors due to the impact of COVID-19. Peer group clinical supervisors identified that while they were new to providing peer group clinical supervision, they were enjoying it and that it was a learning curve for them.

Qualitative data

The qualitative phase explored peer group clinical supervisors’ ( n = 10) own experiences of preparation received and experiences of being a peer group clinical supervisor. Three themes were identified through data analysis, building the foundations, enacting engagement and actions, and realities (Table 4 ).

Building the foundations

This theme highlights the importance of prior knowledge, awareness, and training but also the recruitment process and education in preparing peer group clinical supervisors.

Knowledge and awareness

Participant’s prior knowledge and awareness of peer group clinical supervision was mixed with some reporting having little or no knowledge of clinical supervision.

I’m 20 years plus trained as a nurse , and I had no awareness of clinical supervision beforehand , I really hadn’t got a clue what all of this was about , so it was a very new concept to me (Bernie) .

Others were excited about peer group clinical supervision and while they could see the need they were aware that there may be limited awareness of the value and process of clinical supervision among peers.

I find that there’s great enthusiasm and passion for clinical supervision as it’s a great support mechanism for staff in practice , however , there’s a lack of awareness of clinical supervision (Jane) .

Recruitment

Some participants highlighted that the recruitment process to become a peer group clinical supervisor was vague in some organisations with an unclear and non-transparent process evident where people were chosen by the organisation’s management rather than self-selecting interested parties.

It was just the way the training was put to the people , they were kind of nominated and told they were going and there was a lot of upset over that , so they ended up in some not going at all (Ailbhe) .

In addition, the recruitment process was seen as top loaded where senior grades of staff were chosen, and this limited staff nurse grade opportunities where there was a clear need for peer group clinical supervisors and support.

We haven’t got down to the ground level like you know we’ve done the directors , we’ve done the CNM3s the CNM2s we are at the CNM1s , so we need to get down to the staff nurse level so the nurses at the direct frontline are left out and aren’t receiving supervision because we don’t have them trained (Bernie) .

Training and education

Participants valued the training and education provided but there was a clear sense of ‘imposter syndrome’ for some peer group clinical supervisors starting out. Participants questioned their qualifications, training duration, and confidence to undertake the role of peer group clinical supervisor.

Because it is group supervision and I know that you know they say that we are qualified to do supervision and you know we’re now qualified clinical supervisors but I’m not sure that a three-month module qualifies you to be at the top of your game (Maria) .

Participants when engaged in the peer group clinical supervisor educational programme did find it beneficial and the true benefit was the actual re-engagement in education and published evidence along with the mix of nursing and midwifery practice areas.

I found it very beneficial , I mean I hadn’t been engaged in education here in a while , so it was great to be back in that field and you know with the literature that’s big (Claire) .

Enacting engagement and actions

This theme highlights the importance of forming the groups, getting a clear message out, setting the scene, and grounding the group.

Forming the groups

Recruitment for the group was of key importance to the peer group clinical supervisor and they all sent out a general invitation to form their group. Some supervisors used invitation letters or posters in addition to a general email and this was effective in recruiting supervisees.

You’re reaching out to people , I linked in with the ADoN and I put together a poster and circulated that I wasn’t ‘cherry picking , and I set up a meeting through Webex so people could get a sense of what it was if they were on the fence about it or unsure if it was for them (Karen) .

In forming the peer clinical supervision groups consideration needs to be given to the actual number of supervisees and participants reported four to six supervisees as ideal but that number can alter due to attendance.

The ideal is having five or six consistent people and that they all come on board and that you get the dynamics of the group and everything working (Claire) .

Getting a clear message out

Within the recruitment process, it was evident that there was a limited and often misguided understanding or perception of peer group clinical supervision.

Greater awareness of what actually clinical supervision is , people misjudge it as a supervision where someone is appraising you , when in fact it is more of a support mechanism , I think peer support is the key element that needs to be brought out (Jane) .

Given the lack of clarity and understanding regarding peer group clinical supervision, the participants felt strongly that further clarity is needed and that the focus needs to be on the support it offers to self, practice, and the profession.

Clinical supervision to me is clinical leadership (Jane) .

Setting the scene and grounding the group

In the initial phase of the group coming together the aspect of setting the scene and grounding the group was seen as important. A key aspect of this process was establishing the ground rules which not only set the boundaries and gave structure but also ensured the adoption of principles of trust, confidentiality, and safety.

We start with the ground rules , they give us structure it’s our contract setting out the commitment the expectation for us all , and the confidentiality as that’s so important to the trust and safety and building the relationships (Brid) .

Awareness of group dynamics is important in this process along with awareness of the group members (supervisees) as to their role and expectations.

I reiterate the role of each person in relation to confidentiality and the relationship that they would have with each other within the group and the group is very much aware that it is based on respect for each person’s point of view people may have a fear of contributing to the group and setting the ground rules is important (Jane) .

To ground the group, peer group clinical supervisors saw the importance of being present and allowing oneself to be in the room. This was evident in the time allocated at the start of each session to allow ‘grounding’ to occur in the form of techniques such as a short meditation, relaxation, or deep breathing.

At the start , I do a bit of relaxation and deep breathing , and I saw that with our own external supervisor how she settled us into place so very much about connecting with your body and you’ve arrived , then always come in with the contract in my first sentence , remember today you know we’re in a confidential space , of course , you can take away information , but the only information you will take from today is your own information and then the respect aspect (Mary Rose) .

This settling in and grounding was seen as necessary for people to feel comfortable and engage in the peer group clinical supervision process where they could focus, be open, converse, and be aware of their role and the role of peer group clinical supervision.

People have to be open, open about their practice and be willing to learn and this can only occur by sharing, clinical supervision gives us the space to do it in a space where we know we will be respected, and we can trust (Claire) .

This theme highlights the importance of the peer group clinical supervisors’ past experiences, delivering peer group clinical supervision sessions, responding to COVID-19, personal and professional development, and future opportunities.

Past experiences

Past experiences of peer group clinical supervisors were not always positive and for one participant this related to the lack of ground rules or focus of the sessions and the fact it was facilitated by a non-nurse.

In the past , I suppose I would have found it very frustrating as a participant because I just found that it was going round in circles , people moaning and you know it wasn’t very solution focused so I came from my situation where I was very frustrated with clinical supervision , it was facilitated by somebody that was non-nursing then it wasn’t very , there wasn’t the ground rules , it was very loose (Caroline) .

However, many did not have prior experience of peer group clinical supervision. Nonetheless, through the education and preparation received, there was a sense of commitment to embrace the concept, practice, and philosophy.

I did not really have any exposure or really much information on clinical supervision , but it has opened my eyes , and as one might say I am now a believer (Brid) .

Delivering peer group clinical supervision

In delivering peer group clinical supervision, participants felt supervisees were wary, as they did not know what peer group clinical supervision was, and they had focused more on the word supervision which was misleading to them. Nonetheless, the process was challenging, and buy-in was questioned at an individual and managerial level.

Buy-in wasn’t great I think now of course people will blame the pandemic , but this all happened before the pandemic , there didn’t seem to be you know , the same support from management that I would have expected so I kind of understood it in a way because then there wasn’t the same real respect from the practitioners either (Mary Rose) .

From the peer group clinical supervisor’s perspective, they were all novices in delivering/facilitating peer group clinical supervision sessions, and the support of the external clinical supervisors, and their own peer group clinical supervision sessions were invaluable along with a clinical supervision model.

Having supervision myself was key and something that is vital and needed , we all need to look at our practice and how we work it’s no good just facilitating others without being part of the process yourself but for me I would say the three principles of clinical supervision , you know the normative , formative and restorative , I keep hammering that home and bring that in regularly and revisit the contract and I have to do that often you know (Claire) .

All peer group clinical supervisors commented on the preparation for their peer group clinical supervision sessions and the importance of them having the right frame of mind and that often they needed to read over their course work and published evidence.

I want everybody to have a shared voice and you know that if one person , there is something that somebody feels very strongly and wants to talk about it that they e-mail in advance like we don’t have a set agenda but that’s agreed from the participant at the start (Caroline) .

To assist this, the peer group clinical supervisors noted the importance of their own peer group clinical supervision, the support of their peers, and external clinical supervisors. This preparation in an unpredictable situation can be difficult but drawing on one’s experience and the experience within the group can assist in navigating beyond unexpected situations.

I utilise the models of clinical supervision and this helps guide me , I am more of a facilitator of the group we are experts in our own area and our own role but you can only be an expert if you take the time to examine your practice and how you operate in your role (Brid) .

All clinical supervisors noted that the early sessions can be superficial, and the focus can be on other practice or management issues, but as time moves on and people become more engaged and involved it becomes easier as their understanding of supervision becomes clearer. In addition, there may be hesitancy and people may have difficulty opening up with certain people in the group and this is a reality that can put people off.

Initially there was so much managerial bashing and I think through supervision , I began to kind of think , I need the pillars of supervision , the governance , bringing more knowledge and it shifted everything in the room , trying to marry it with all the tensions that people have (Mary Rose) .

For some clinical supervisors, there were expected and unexpected challenges for them as clinical supervisors in terms of the discussions veering off course and expectations of their own ability.

The other big challenge is when they go off , how do you bring him back , you know when they veer off and you’re expected to be a peer , but you have to try and recoil that you have to get the balance with that right (Mary Rose) .

While peer group clinical supervision is accepted and seen as a valuable process by the peer group clinical supervisors, facilitating peer group supervision with people known to you can be difficult and may affect the process.

I’d love to supervise a group where I actually don’t know the people , I don’t know the dynamics within the group , and I’d love to see what it would be like in a group (Bernie) .

Of concern to clinical supervisors was the aspect of non-attendance and while there may be valid reasons such as COVID-19 the absence of a supervisee for several sessions can affect the group dynamics, especially if the supervisee has only engaged with early group sessions.

One of the ones that couldn’t attend because of COVID and whatever , but she’s coming to the next one and I just feel there’s a lot of issues in her area and I suppose I’m mindful that I don’t want that sort of thing to seep in , so I suppose it’s just for me just to keep reiterating the ground rules and the boundaries , that’s something I just have to manage as a facilitator , but what if they don’t attend how far will the group have progressed before she attends (Caroline) .

Responding to COVID-19

The advent of COVID-19 forced peer group clinical supervisors to find alternative means of providing peer group clinical supervision sessions which saw the move from face-to-face to online sessions. The online transition was seen as seamless for many established groups while others struggled to deliver sessions.

With COVID we did online for us it was fine because we were already formed (Corina) .

While the transition may have been positive many clinical supervisors came across issues because they were using an online format that would not be present in the face-to-face session.

We did have a session where somebody was in the main office and they have a really loud booming voice and they were saying stuff that was not appropriate to say outside of clinical supervision and I was like are you in the office can you lower it down a bit can you put your headphones on (Maria) .

However, two peer group clinical supervisors ceased or hasted the progress of rolling out peer group clinical supervision sessions mainly due to redeployment and staff availability.

With COVID it just had to be canceled here , it’s just the whole thing was canceled so it was very , very difficult for people (Mary Rose) .

It was clear from clinical supervisors that online sessions were appropriate but that they felt they were only appropriate for existing established groups that have had the opportunity to build relationships, develop trust, embed the ground rules, and create the space for open communication and once established a combined approach would be appropriate.

Since we weren’t as established as a group , not everybody knew each other it would be difficult to establish that so we would hold off/reschedule , obviously COVID is a major one but also I suppose if you have an established group now , and again , you could go to a remote one , but I felt like since we weren’t established as a group it would be difficult to develop it in that way (Karen) .

Within practice COVID-19 took priority and other aspects such as peer group clinical supervision moved lower down on the priority list for managers but not for the clinical supervisors even where redeployment occurred.

With COVID all the practical side , if one of the managers is dealing with an outbreak , they won’t be attending clinical supervision , because that has to be prioritised , whereas we’ve prioritised clinical supervision (Maria) .

The valuing of peer group clinical supervision was seen as important by clinical supervisors, and they saw it as particularly needed during COVID-19 as staff were dealing with many personal and professional issues.

During the height of COVID , we had to take a bit of a break for four months as things were so demanding at work for people but then I realised that clinical supervision was needed and started back up and they all wanted to come back (Brid) .

Having peer group clinical supervision during COVID-19 supported staff and enabled the group to form supportive relationships.

COVID has impacted over the last two years in every shape and they needed the supervision and the opportunity to have a safe supportive space and it gelled the group I think as we all were there for each other (Claire) .

While COVID-19 posed many challenges it also afforded clinical supervisors and supervisees the opportunity for change and to consider alternative means of running peer group clinical supervision sessions. This change resulted in online delivery and in reflecting on both forms of delivery (face-to-face and online) clinical supervisors saw the benefit in both. Face-to-face was seen as being needed to form the group and then the group could move online once the group was established with an occasional periodic face-to-face session to maintain motivation commitment and reinforce relationships and support.

Online formats can be effective if the group is already established or the group has gone through the storming and forming phase and the ground rules have been set and trust built , then I don’t see any problem with a blended online version of clinical supervision , and I think it will be effective (Jane) .

Personal and professional development

Growth and development were evident from peer group clinical supervisors’ experiences and this growth and development occurred at a personal, professional, and patient/client level. This development also produced an awakening and valuing of one’s passion for self and their profession.

I suppose clinical supervision is about development I can see a lot of development for me and my supervisees , you know personally and professionally , it’s the support really , clinical supervision can reinvigorate it’s very exciting and a great opportunity for nursing to support each other and in care provision (Claire) .

A key to the peer group clinical supervisor’s development was the aspect of transferable skills and the confidence they gained in fulfilling their role.

All of these skills that you learn are transferable and I am a better manager because of clinical supervision (Maria) .

The confidence and skills gained translated into the clinical supervisor’s own practice as a clinical practitioner and clinical supervisor but they were also realistic in predicting the impact on others.

I have empowered my staff , I empower them to use their voice and I give my supervisees a voice and hope they take that with them (Corina) .

Fundamental to the development process was the impact on care itself and while this cannot always be measured or identified, the clinical supervisors could see that care and support of the individual practitioner (supervisee) translated into better care for the patient/client.

Care is only as good as the person delivering it and what they know , how they function and what energy and passion they have , and clinical supervision gives the person support to begin to understand their practice and how and why they do things in a certain way and when they do that they can begin to question and even change their way of doing something (Brid) .

Future opportunities

Based on the clinical supervisor’s experiences there was a clear need identified regarding valuing and embedded peer group clinical supervision within nursing/midwifery practice.

There has to be an emphasis placed on supervision it needs to be part of the fabric of a service and valued by all in that service , we should be asking why is it not available if it’s not there but there is some work first on promoting it and people knowing what it actually is and address the misconceptions (Claire) .

While such valuing and buy-in are important, it is not to say that all staff need to have peer group clinical supervision so as to allow for personal choice. In addition, to value peer group clinical supervision it needs to be evident across all staffing grades and one could question where the best starting point is.

While we should not mandate that all staff do clinical supervision it should become embedded within practice more and I suppose really to become part of our custom and practice and be across all levels of staff (Brid) .

When peer group clinical supervision is embedded within practice then it should be custom and practice, where it is included in all staff orientations and is nationally driven.

I suppose we need to be driving it forward at the coal face at induction , at orientation and any development for the future will have to be driven by the NMPDUs or nationally (Ailbhe) .

A formalised process needs to address the release of peer group clinical supervisors but also the necessity to consider the number of peer group clinical supervisors at a particular grade.

The issue is release and the timeframe as they have a group but they also have their external supervision so you have to really work out how much time you’re talking about (Maria) .

Vital within the process of peer group clinical supervision is receiving peer group clinical supervision and peer support and this needs to underpin good peer group clinical supervision practice.

Receiving peer group supervision helps me , there are times where I would doubt myself , it’s good to have the other group that I can go to and put it out there to my own group and say , look at this , this is what we did , or this is what came up and this is how (Bernie) .

For future roll out to staff nurse/midwife grade resourcing needs to be considered as peer group clinical supervisors who were managers could see the impact of having several peer group clinical supervisors in their practice area may have on care delivery.

Facilitating groups is an issue and needs to be looked at in terms of the bigger picture because while I might be able to do a second group the question is how I would be supported and released to do so (Maria) .

While there was ambiguity regarding peer group clinical supervision there was an awareness of other disciplines availing of peer group clinical supervision, raising questions about the equality of supports available for all disciplines.

I always heard other disciplines like social workers would always have been very good saying I can’t meet you I have supervision that day and I used to think my God what’s this fabulous hour that these disciplines are getting and as a nursing staff it just wasn’t there and available (Bernie) .

To address this equity issue and the aspect of low numbers of certain grades an interdisciplinary approach within nursing and midwifery could be used or a broader interdisciplinary approach across all healthcare professionals. An interdisciplinary or across-services approach was seen as potentially fruitful.

I think the value of interprofessional or interdisciplinary learning is key it addresses problem-solving from different perspectives that mix within the group is important for cross-fertilisation and embedding the learning and developing the experience for each participant within the group (Jane) .

As we move beyond COVID-19 and into the future there is a need to actively promote peer group clinical supervision and this would clarify what peer group clinical supervision actually is, its uptake and stimulate interest.

I’d say it’s like promoting vaccinations if you could do a roadshow with people , I think that would be very beneficial , and to launch it , like you have a launch an official launch behind it (Mary Rose) .

The advantages of peer group clinical supervision highlighted in this study pertain to self-enhancement (confidence, leadership, personal development, resilience), organisational and service-related aspects (positive work environment, staff retention, safety), and professional patient care (critical thinking and evaluation, patient safety, adherence to quality standards, elevated care standards). These findings align with broader literature that acknowledges various areas, including self-confidence and facilitation [ 23 ], leadership [ 24 ], personal development [ 25 ], resilience [ 26 ], positive/supportive working environment [ 27 ], staff retention [ 28 ], sense of safety [ 29 ], critical thinking and evaluation [ 30 ], patient safety [ 31 ], quality standards [ 32 ] and increased standards of care [ 33 ].

In this study, peer group clinical supervision appeared to contribute to the alleviation of stress and anxiety. Participants recognised the significance of these sessions, where they could openly discuss and reflect on professional situations both emotionally and rationally. Central to these discussions was the creation of a safe, trustworthy, and collegial environment, aligning with evidence in the literature [ 34 ]. Clinical supervision provided a platform to share resources (information, knowledge, and skills) and address issues while offering mutual support [ 35 ]. The emergence of COVID-19 has stressed the significance of peer group clinical supervision and support for the nursing/midwifery workforce [ 36 ], highlighting the need to help nurses/midwifes preserve their well-being and participate in collaborative problem-solving. COVID-19 impacted and disrupted clinical supervision frequency, duration and access [ 37 ]. What was evident during COVID-19 was the stress and need for support for staff and given the restorative or supportive functions of clinical supervision it is a mechanism of support. However, clinical supervisors need support themselves to be able to better meet the supervisee’s needs [ 38 ].

The value of peer group clinical supervision in nurturing a conducive working environment cannot be overstated, as it indorses the understanding and adherence to workplace policies by empowering supervisees to understand the importance and rationale behind these policies [ 39 ]. This becomes vital in a continuously changing healthcare landscape, where guidelines and policies may be subject to change, especially in response to situations such as COVID-19. In an era characterised by international workforce mobility and a shortage of healthcare professionals, a supportive and positive working environment through the provision of peer group clinical supervision can positively influence staff retention [ 40 ], enhance job satisfaction [ 41 ], and mitigate burnout [ 42 ]. A critical aspect of the peer group clinical supervision process concerns providing staff the opportunity to reflect, step back, problem-solve and generate solutions. This, in turn, ensures critical thinking and evaluation within clinical supervision, focusing on understanding the issues and context, and problem-solving to draw constructive lessons for the future [ 30 ]. Research has determined a link between clinical supervision and improvements in the quality and standards of care [ 31 ]. Therefore, peer group clinical supervision plays a critical role in enhancing patient safety by nurturing improved communication among staff, facilitating reflection, promoting greater self-awareness, promoting the exchange of ideas, problem-solving, and facilitating collective learning from shared experiences.

Starting a group arose as a foundational aspect emphasised in this study. The creation of the environment through establishing ground rules, building relationships, fostering trust, displaying respect, and upholding confidentiality was evident. Vital to this process is the recruitment of clinical supervisees and deciding the suitable group size, with a specific emphasis on addressing individuals’ inclination to engage, their knowledge and understanding of peer group clinical supervision, and dissipating any lack of awareness or misconceptions regarding peer group supervision. Furthermore, the educational training of peer group clinical supervisors and the support from external clinical supervisors played a vital role in the rollout and formation of peer group clinical supervision. The evidence stresses the significance of an open and safe environment, wherein supervisees feel secure and trust their supervisor. In such an environment, they can effectively reflect on practice and related issues [ 41 ]. This study emphasises that the effectiveness of peer group supervision is more influenced by the process than the content. Clinical supervisors utilised the process to structure their sessions, fostering energy and interest to support their peers and cultivate new insights. For peer group clinical supervision to be effective, regularity is essential. Meetings should be scheduled in advance, allocate protected time, and take place in a private space [ 35 ]. While it is widely acknowledged that clinical supervisors need to be experts in their professional field to be credible, this study highlights that the crucial aspects of supervision lie in the quality of the relationship with the supervisor. The clinical supervisor should be supportive, caring, open, collaborative, sensitive, flexible, helpful, non-judgmental, and focused on tacit knowledge, experiential learning, and providing real-time feedback.

Critical to the success of peer group clinical supervision is the endorsement and support from management, considering the organisational culture and attitudes towards the practice of clinical supervision as an essential factor [ 43 ]. This support and buy-in are necessary at both the management and individual levels [ 28 ]. The primary obstacles to effective supervision often revolve around a lack of time and heavy workloads [ 44 ]. Clinical supervisors frequently struggle to find time amidst busy environments, impacting the flexibility and quality of the sessions [ 45 ]. Time constraints also limit the opportunity for reflection within clinical supervision sessions, leaving supervisees feeling compelled to resolve issues on their own without adequate support [ 45 ]. Nevertheless, time-related challenges are not unexpected, prompting a crucial question about the value placed on clinical supervision and its integration into the culture and fabric of the organisation or profession to make it a customary practice. Learning from experiences like those during the COVID-19 pandemic has introduced alternative ways of working, and the use of technology (such as Zoom, Microsoft Teams, Skype) may serve as a means to address time, resource, and travel issues associated with clinical supervision.

Despite clinical supervision having a long international history, persistent misconceptions require attention. Some of these include not considering clinical supervision a priority [ 46 ], perceiving it as a luxury [ 41 ], deeming it self-indulgent [ 47 ], or viewing it as mere casual conversation during work hours [ 48 ]. A significant challenge lies in the lack of a shared understanding regarding the role and purpose of clinical supervision, with past perceptions associating it with surveillance and being monitored [ 48 ]. These negative connotations often result in a lack of engagement [ 41 ]. Without encouragement and recognition of the importance of clinical supervision from management or the organisation, it is unlikely to become embedded in the organisational culture, impeding its normalisation [ 39 ].

In this study, some peer group clinical supervisors expressed feelings of being impostors and believed they lacked the knowledge, skills, and training to effectively fulfil their roles. While a deficiency in skills and competence are possible obstacles to providing effective clinical supervision [ 49 ], the peer group clinical supervisors in this study did not report such issues. Instead, their concerns were more about questioning their ability to function in the role of a peer group clinical supervisor, especially after a brief training program. The literature acknowledges a lack of training where clinical supervisors may feel unprepared and ill-equipped for their role [ 41 ]. To address these challenges, clinical supervisors need to be well-versed in professional guidelines and ethical standards, have clear roles, and understand the scope of practice and responsibilities associated with being a clinical supervisor [ 41 ].

The support provided by external clinical supervisors and the peer group clinical supervision sessions played a pivotal role in helping peer group clinical supervisors ease into their roles, gain experiential learning, and enhance their facilitation skills within a supportive structure. Educating clinical supervisors is an investment, but it should not be a one-time occurrence. Ongoing external clinical supervision for clinical supervisors [ 50 ] and continuous professional development [ 51 ] are crucial, as they contribute to the likelihood of clinical supervisors remaining in their roles. However, it is important to interpret the results of this study with caution due to the small sample size in the survey. Generalising the study results should be approached with care, particularly as the study was limited to two regions in Ireland. However, the addition of qualitative data in this mixed-methods study may have helped offset this limitation.

This study highlights the numerous advantages of peer group clinical supervision at individual, service, organisational, and patient/client levels. Success hinges on addressing the initial lack of awareness and misconceptions about peer group clinical supervision by creating the right environment and establishing ground rules. To unlock the full potential of peer group clinical supervision, it is imperative to secure management and organisational support for staff release. More crucially, there is a need for valuing and integrating peer group clinical supervision into nursing and midwifery education and practice. Making peer group clinical supervision accessible to all grades of nurses and midwives across various healthcare services is essential, necessitating strategic planning to tackle capacity and sustainability challenges.

Data availability

Data are available from the corresponding author upon request owing to privacy or ethical restrictions.

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Acknowledgements

The research team would like to thank all participants for their collaboration, the HSE steering group members and Carmel Hoey, NMPDU Director, HSE West Mid West, Dr Patrick Glackin, NMPD Area Director, HSE West, Annette Cuddy, Director, Centre of Nurse and Midwifery Education Mayo/Roscommon; Ms Ruth Hoban, Assistant Director of Nursing and Midwifery (Prescribing), HSE West; Ms Annette Connolly, NMPD Officer, NMPDU HSE West Mid West.

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Owen Doody, Kathleen Markey, Claire O. Donnell & Louise Murphy

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OD: Conceptualization, Methodology, Formal analysis, Investigation, Writing - Original Draft, Writing - Review & Editing, Project administration, Funding acquisition. COD: Methodology, Formal analysis, Investigation, Writing - Original Draft, Writing - Review & Editing, Funding acquisition. KM: Methodology, Formal analysis, Investigation, Writing - Original Draft, Writing - Review & Editing, Funding acquisition. JT: Methodology, Formal analysis, Writing - Original Draft, Writing - Review & Editing. LM: Methodology, Formal analysis, Investigation, Writing - Original Draft, Writing - Review & Editing, Funding acquisition.

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Doody, O., Markey, K., Turner, J. et al. Clinical supervisor’s experiences of peer group clinical supervision during COVID-19: a mixed methods study. BMC Nurs 23 , 612 (2024). https://doi.org/10.1186/s12912-024-02283-3

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LingYing Wang 1 ,
WenLing Chang 2 ,
http://orcid.org/0000-0002-1507-7890 HaiTao Tang 3 ,
WenBo He 4 ,
http://orcid.org/0000-0002-6682-8279 Yan Wu 3 , 5
1 Critical Care Medicine Department, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University , Chengdu , China
2 School of Population Health & Environmental Sciences , King’s College London , London SE1 1UL , UK
3 Department of Postgraduate Students, West China School of Medicine/West China Hospital, Sichuan University , Chengdu , China
4 Institute of Hospital Management, West China Hospital, Sichuan University , Chengdu , Sichuan , China
5 College of Marxism, Sichuan University , Chengdu , China
Correspondence to Yan Wu; wuyan{at}wchscu.cn

Objectives This study aimed to investigate the associations between critical thinking (CT) disposition and personal characteristics and tutors’ guidance among medical graduate students, which may provide a theoretical basis for cultivating CT.

Design A cross-sectional study was conducted.

Setting This study was conducted in Sichuan and Chongqing from November to December 2021.

Participants A total of 1488 graduate students from clinical medical schools were included in this study.

Data analysis The distribution of the study participants’ underlying characteristics and CT was described and tested. The Spearman rank correlation coefficient was used to evaluate the correlation between each factor and the CT score. The independent risk factors for CT were assessed using a logistic regression model.

Results The average total CT score was 81.79±11.42 points, and the proportion of CT (score ≥72 points) was 78.9% (1174/1488). Female sex (OR 1.405, 95% CI 1.042 to 1.895), curiosity (OR 1.847, 95% CI 1.459 to 2.338), completion of scientific research design with reference (OR 1.779, 95% CI 1.460 to 2.167), asking ‘why’ (OR 1.942, 95% CI 1.508 to 2.501) and team members’ logical thinking ability (OR 1.373, 95% CI 1.122 to 1.681) were positively associated with CT while exhaustion and burn-out (OR 0.721, 95% CI 0.526 to 0.989), inattention (OR 0.572, 95% CI 0.431 to 0.759), Following others’ opinions in decision-making (OR 0.425, 95% CI 0.337 to 0.534) and no allow of doubt to tutors (OR 0.674, 95% CI 0.561 to 0.809) had negative associations with the formation of CT disposition in the fully adjusted model.

Conclusions Factors associated with motivation and internal drive are more important in the educational practice of cultivating CT. Educators should change the reward mechanism from result-oriented to motivation-maintaining to cultivate students’ CT awareness.

risk factors
public health

Data availability statement

Data are available on reasonable request.

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https://doi.org/10.1136/bmjopen-2023-082461

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STRENGTHS AND LIMITATIONS OF THIS STUDY

Our study focused on postgraduate medical students, and the sample size was relatively large.

Previous research on critical thinking has focused primarily on Europe, the USA and Japan. Hence, researching critical thinking in Chinese populations is a valuable addition to this area.

Given the traditional limitations of cross-sectional studies, the findings of this study cannot be used as direct evidence of a causal relationship between potential influences and outcomes. Nevertheless, they can provide clues to reveal causal relationships.

Introduction

Critical thinking (CT) is reasoned, reflective thinking that decides what to believe or do. The emphasis is on reasonableness, reflection and decision-making. 1 CT is even more important in the medical field, where a lack of CT can lead to delayed or missed diagnoses, incorrect cognition and mismanagement. The centrality of CT is reflected in the competency framework of health professions and is a core skill of healthcare professionals. 2–6 Six crucial skills have been proposed to operationalise the definition of CT: interpretation, analysis, evaluation, inference, explanation and self-regulation. Specifically, interpretation involves comprehending the significance of information and conveying it effectively to others. Analysis requires piecing together fragmented data to decipher their intended purpose. Inference entails identifying and leveraging relevant information to formulate logical conclusions or hypotheses. Evaluation necessitates assessing the trustworthiness of a statement or information. Explanation aims to clarify shared information to ensure its comprehensibility to others. Finally, self-regulation pertains to regulating one’s thoughts, behaviours and emotions. 7–9

The role of CT in assisting medical students in navigating complex health scenarios and resolving clinical issues through sound decision-making is paramount. Extensive research has established positive correlations between CT and clinical proficiency, 10 11 academic excellence 12 and research capabilities. 13 Consequently, the Institute for International Medical Education has emphasised ‘CT and research’ as one of the seven crucial competencies that medical graduates must possess, as outlined in the Global Minimum Essential Requirements. 14 Similarly, the Ministry of Education in the People’s Republic of China has underscored the importance of ‘scientific attitude, innovation and CT’ as essential requirements for Chinese medical graduates. 15

Research on CT in medical students has been carried out to varying degrees in Western countries and many Asian countries. 16 17 Some scholars have pointed out that Western methods, including CT and clinical reasoning, are used in thinking skills education worldwide. However, there are significant differences between Chinese and Western culture, especially educational culture while cultural differences affect ways of thinking 17 18 ; therefore, previous research may not be able to reflect the actual situation of Chinese students and teaching methods may not apply to them. Most Western students tend to possess assimilating learning styles, enabling them to excel in student-centred learning environments. Conversely, Eastern students often exhibit accommodating learning styles that align more with teacher-centred instruction. 19 The discipline-based curriculum in China may not adequately foster the development of CT dispositions among Chinese medical students. This curriculum typically comprises isolated phases (theory, clerkship and internship), limited faculty–student interaction and a knowledge-focused evaluation system. 20

Previous research has suggested that a range of personal characteristics, including gender, major, blended learning methods, increased self-study hours, heightened self-efficacy in learning and performance, exposure to supportive environments and active participation in research activities, contribute to varying degrees of CT dispositions and skills. 21–24 A study conducted in Vietnam revealed that age, gender, ethnicity, educational level, health status, nursing experience, tenure at the current hospital, familiarity with ‘CT’ and job position all influence CT ability. 25 Furthermore, teacher support is paramount to learners’ mental and psychological development. This support encompasses educators’ empathy, compassion, commitment, reliability and warmth towards their students. 26 According to Tardy’s social support paradigm, 27 teacher support is defined as providing informational, instrumental, emotional or appraisal assistance to students, irrespective of their learning setting. Supportive teachers prioritise fostering personal relationships with their students and offering aid, assistance and guidance to those in need. 28 Practical teacher assistance can make students feel comfortable and inspired, motivating them to invest more effort in their studies, engage more actively in educational pursuits and achieve superior educational outcomes. 29

Current CT research on mainland Chinese medical students focuses on the impact of undergraduates’ experiences and classroom instruction. However, for postgraduates, their tutors play a more critical role in education and cultivation. According to Wosinski’s study, 30 tutors should be trained to effectively guide the teamwork of undergraduate nursing students during the problem-based learning (PBL) process to achieve their goals. There is no analysis of the influencing factors of CT focused on medical postgraduates.

Therefore, assessing the tutor’s effect on postgraduates’ CT disposition. This study investigated the associations between CT disposition and personal characteristics and tutors’ guidance among medical graduate students, which may provide a theoretical basis for cultivating CT.

Study design and participants

Study design.

This was a cross-sectional observational study. The project team sent 1525 electronic questionnaire links to WeChat groups of full-time medical graduate students in higher medical institutions in Sichuan and Chongqing between November and December 2021. After removing incomplete and duplicate questionnaires, a total of 1488 valid questionnaires were returned for an effective rate of 97.57%.

Sampling procedure

We employed a random sampling method to select medical graduate students carefully and used PASS V.15.0 software to calculate the sample size for different analyses and outcome scenarios. In the estimation of the sample size with the proportion of CT disposition as the primary outcome, we considered p=0.5, adopted the two-sided Z value under the significance level of a=0.05, and the sample size was the largest when the sampling error was 3%, which was 1067. Moreover, estimating of sample size with the correlation coefficient as the primary outcome, we considered r=0.1 according to the results from the prestudy, and the test power was 0.9; thus, we obtained n=1048. The sample size should be at least 1334 considering a 20% non-response rate.

The inclusion criteria were as follows: (1) full-time medical graduate students (clinical medicine, medicine technology, integrative Chinese and Western medicine, medical laboratory, nursing and so on) in higher medical institutions in Sichuan and Chongqing and (2) after reading the introduction to the research, participants voluntarily agreed to participate and electronically signed the study’s informed consent form. The exclusion criterion was a refusal to participate in the study.

Procedure and data collection

The electronic questionnaire we used consisted of a condensed version of the Critical Thinking Measurement Scale, which was used to evaluate participants’ scores on CT disposition and a Potential Influencing Factors Questionnaire, which investigated participants’ underlying information, personal factors and education-related factors. To increase the response rate, we told the students how long it might take to fill out this questionnaire when we sent the questionnaire link to WeChat groups. Moreover, our participants all had master’s degrees or above whose understanding ability and compliance were better. We also sent reminders to all invited participants three times, and the survey lasted approximately 1 month.

Critical Thinking Measurement Scale

We used the Chinese version of the short-form critical thinking disposition inventory (SF-CTDI-CV), which is based on the CTDI-CV reported by Huang. 31 The CTDI-CV includes seven subscales, namely Truth Seeking, Open-mindedness, Analyticity, Systematicity, Critical Thinking Self-confidence, Inquisitiveness and Cognitive Maturity, which have good reliability and validity (0.90 for the overall Cronbach’s alpha and 0.89 for the overall Content Validity Index). 32 Huang removed ineffective questions based on the CTDI-CV and obtained a simplified scale with 18 items of three factors, which increased the proportion of total explained variation and had better reliability and validity than the original version. Huang selected items according to important indicators in factor analysis, including factor loading and communality. Specifically, Huang removed items whose factor loading was less than 0.4 or whose commonality was less than 0.3. Each item of the SF-CTDI-CV has six options (Likert scale) from 1 to 6 (1 means complete agreement and 6 means disagree entirely); the higher the score is, the stronger the CT tendency. 31 The Kaiser-Meyer-Olkin (KMO) value for SF-CTDI-CV is 0.90 while the p value of Bartlett’s test is less than 0.05, indicating that this short-form inventory has ideal structural validity. A total score of 72 or more indicates a CT disposition, and all participants were divided into two groups according to whether they possessed essential characteristics of thinking.

Potential Influencing Factors Questionnaire

The Potential Influencing Factors Questionnaire was based on previous research and interviews. The interviewees including senior education practitioners and invited medical postgraduate students, focused on their experiences and feelings regarding medical education in China. We compiled an interview outline and invited a total of 22 professionals, including 9 doctoral candidates, 5 doctoral supervisors, 2 counsellors and 6 young backbone teachers, to participate in the interviews. The interview schedule is flexible, but to ensure efficiency, we controlled the interview duration for each participant to within 40 min. After the interviews, we used professional NVivo V.11.0 software to analyse the collected interview data thoroughly.

The Potential Influencing Factors Questionnaire consists of 10 questions in the essential information section, 35 questions in the influencing factors section and 3 flexible questions, for 48 valid entries. The essential information section includes gender, age, secondary education background, higher education major, level of education, type of degree, full-time work experience, type of household registration, the highest level of parental education and whether the respondent was from an only child family. The influencing factors section can be grouped into two main areas: ‘personal factors’ and ‘educational factors’, with personal factors including the individual characteristics section. The educational factors include the practice and training, tutor and team, and educational environment section. This study defines every potential factor as an ordinal variable, with greater rank, depth and frequency of the corresponding factors. For reliability, Cronbach’s alpha=0.795 indicates that the questionnaire’s reliability is good enough for investigation. The content validity of the questionnaire was tested to determine whether the content met the objectives and requirements of the study. Most of the items of the influencing factors questionnaire were selected from previous literature, and the content validity was good. The KMO values and p values for the Bartlett’s test of sphericity for every aspect indicate that the structural validity of the questionnaire is good (see more details in online supplemental table S1 ).

Supplemental material

In the questionnaire design process, we first formed a preliminary framework concerning previous qualitative and quantitative research. Then we conducted interviews with educators, doctoral supervisors and representatives of medical postgraduate students according to the initial framework to understand their work experience in the practice of medical postgraduate education in China. Then, the questionnaire was supplemented according to the frequently mentioned items in the interviews. Finally, a questionnaire focusing on whether personal and educational pathways influence the formation of CT disposition was developed, as well as the key points of CT cultivation.

Data collection and organisation

The project team designed the electronic questionnaire based on the Influencing Factors Questionnaire and Critical Thinking Measurement Scale. Excel 2019 collated the raw data exported from the electronic questionnaire platform. Using the electronic questionnaire platform, answer completion settings rule out the possibility of logical anomalies. Samples with missing answers on the Critical Thinking Inventory were eliminated. Participants who were missing other information were asked to fill in as much as possible through the telephone number they had left. Those who were unable to do so were eliminated. Each factor in the influencing factors section was assigned a value in steps of 1 from lowest to highest (eg, the four categorical variables were assigned values of 1, 2, 3, and 4; 1 for never and 4 for always).

Students and public involvement

Former students were involved in the preparatory phase of this study. They reviewed the informed consent form and provided feedback.

Statistical analysis

The data were analysed by using SPSS V.24.0 software. The distribution of the study participants’ underlying characteristics and CT were described and tested. Continuous variables are described as the mean±SD, and t-tests or one-way analysis of variance (ANOVA) were used for hypothesis tests. Categorical variables are expressed as composition ratios and χ 2 tests are used for hypothesis tests. Correlation analysis: The Spearman rank correlation coefficient was used to evaluate the correlation between each factor and the CT score. Difference analysis: Trend ANOVA was used to test whether there was a trend change in CT scores at different levels of each potential influencing factor. A t-test was used to compare the differences in the levels of influencing factors between different CT trait groups. Factors with differences between groups were included in a multivariate unconditional logistic regression model. We fitted several multivariate logistic regression models to evaluate potential confounding variables. By comparing the χ 2 value, the −2-likelihood ratio, the Akaike information criterion, and the practical meanings of this study’s interesting factors, the final model in which X variables could explain most of the Y variables (CT scores) was chosen. The above tests were performed at 0.05, and a p<0.05 was considered statistically significant.

Essential characteristics

A total of 1488 medical graduate students were included in this study, with an average age of 26.63±3.72 years. Most of the participants had a science background in high school (96.84%), a higher education major in clinical medicine (78.43%) and had never participated in full-time work (71.91%). Most of the participants were female (65.93%), lived in urban areas (61.69%), had parents with junior school education or below (39.18%), were not the only child in the family (51.48%), scientific graduate students (51.61%) and had a master’s degree (55.51%). Among all the research subjects, the average total CT score was 81.79±11.42 points, and the proportion of CT (score ≥72 points) was 78.9% (1174/1488). The essential characteristics of the included subjects are shown in table 1 .

View inline

Participants’ essential characteristics and the distribution of critical thinking dispositions

Distribution of CT disposition

Table 1 demonstrates the distribution of CT disposition among the study participants. For the essential CT scores, participants with urban residence, higher parental education, only-child families, a science background before admission, science-based graduates, longer full-time employment and higher education levels had significantly greater CT scores (p<0.05). According to the CT questionnaire used in this project, subjects with a score more excellent than 72 points were considered to have an apparent CT disposition. The results showed that among our participants, women (80.80% vs 75.10%), science students (79.50% vs 61.70%) and PhD students (81.60% vs 76.80%) had a more significant proportion of CT disposition (p<0.05).

CT scores are linearly correlated with impact factor scores

Table 2 shows the correlation between each factor and the CT scores. The Spearman correlation coefficients suggested that most terms related to personal factors were correlated with CT scores (p<0.001). Sense of achievement (r=0.324), curiosity (r=0.480) and following others’ opinions in decision-making (r=−0.292) were strongly correlated with CT scores. Regarding educational factors, all factors in the practice and training section, all factors in the tutor and team section, and most factors in the educational environment impacted CT scores (p<0.001). Factors in the tutor and team section were more strongly related to CT scores, such as teaching students according to their aptitude (r=0.247) and tutors asking heuristic questions (r=0.242). Only no allow of doubt to tutors hurt the CT scores (r=−0.179, p<0.001).

The correlation between the potential influencing factors and the score of critical thinking

Factors influencing CT disposition

Univariate analysis.

The influencing factors associated with CT disposition are presented in table 3 . Univariate analysis revealed that in terms of personal factors, a sense of achievement, curiosity and interpersonal skills were all possible facilitators of CT disposition (p<0.05), and the group with CT disposition had higher average scores. In contrast, fatigue and burn-out, inattention and following others’ opinions in decision-making were possible hindering factors. Regarding educational factors, most factors in the ‘practice and training’ section, all factors in the ‘tutor and team’ section, and some factors in the ‘educational environment’ section were impact factors on CT disposition. In the practice and traning section, academic performance (p<0.001), number of intensively reading (p<0.001), paper writing (p=0.001), participation in academic conferences (p=0.009), completion of scientific research design with reference (p<0.001), time for extracurricular reading (p=0.006), summarisation and reflection (p<0.001), asking ‘why’ (p<0.001) and knowledge of critical thinking (p<0.001) were all positively related to CT disposition. For the tutor and team section, participants with CT disposition had higher scores for the following factors (p<0.01): tutors sharing thinking methods, communicating learning and life with tutors, tutors asking heuristic questions, encouragement of using ‘possible’ and ‘potential’, advocation of logical thinking training and lifelong learning, teaching students according to their aptitude and team members’ logical thinking skills. No allow to doubt tutors hurt CT disposition (p<0.001). The use of multifunctional classrooms (p<0.001) and having active classes (TBL class, flipped class, p=0.006) in the educational environment section were also correlated with CT disposition.

Impact factors

Multivariate logistics regression analyses

Multivariate logistics regression analysis demonstrated that female (OR 1.405, 95% CI 1.042 to 1.895), curiosity (OR 1.847, 95% CI 1.459 to 2.338), completion of scientific research design with reference (OR 1.779, 95% CI 1.460 to 2.167), asking ‘why’ (OR 1.942, 95% CI 1.508 to 2.501) and team members’ logical thinking ability (OR 1.373, 95% CI 1.122 to 1.681) were the promoting factors for the development of CT disposition after adjusting for other confounding factors. However, exhaustion and burn-out (OR 0.721, 95% CI 0.526 to 0.989), inattention (OR 0.572, 95% CI 0.431 to 0.759) and following others’ opinions in decision-making (OR 0.425, 95% CI 0.337 to 0.534) and no allow of doubt to tutors (OR 0.674, 95% CI 0.561 to 0.809) may be hindering factors for the formation of CT disposition in the fully adjusted model ( table 4 , adjusted R 2 =0.323).

Multifactor regression model

This cross-sectional study explored the factors influencing the CT disposition of Chinese medical graduate students in terms of both personal and educational factors. A total of 78.9% of the participants in this study had positive CT dispositions (score ≥72, 1174/1488), and women were 40.5% more likely than men to have CT dispositions (OR 1.405, 95% CI 1.042 to 1.895). Multivariate logistics regression analysis revealed that among personal factors, curiosity was the promoting factor while exhaustion and burn-out, inattention and following others’ opinions in decision-making may be the hindering factors. For educational factors, completing the scientific research design with reference, asking ‘why’ and the high logical thinking ability of team members were associated with CT disposition. However, no allow of doubt to tutors may hinder the disposition of CT.

According to our demographic information, our study revealed a greater prevalence of CT disposition among women, aligning with Zhai’s findings. 22 Several factors may contribute to this observed gender disparity. A systematic review established that men tend to engage more with objects while women prefer interpersonal interactions. 33 Women are more inclined to engage in dialogue and foster their understanding through collaborative learning, often exhibiting a more receptive mindset. Second, a study using fractional anisotropy measures derived from diffusion tensor imaging in 425 participants, including 118 males, revealed that divergent thinking in females correlates positively with fractional anisotropy in the corpus callosum and the right superior longitudinal fasciculus. 34 Conversely, it correlates with fractional anisotropy in the right tapetum in males. Zhang et al ’s 34 research sheds light on the sex-specific structural connectivity within and between hemispheres that underpins divergent thinking. These gender differences in creativity may reflect the inherent diversity between males and females in society. However, Faramarzi and Khafri 35 reported contrasting results. They concluded that although the results differed between the sexes, the likely cause was females’ higher education level rather than a difference due to gender. Several studies concur that self-esteem is a principal determinant of CT. 22 35 Barkhordary et al , 36 in their study of 170 third-year and fourth-year nursing students in Yazd, identified a significant link between CT and self-esteem. Pilevarzadeh et al further demonstrated that students with higher self-esteem exhibit more robust CT skills. 37 Self-esteem is defined as ‘an individual’s overall subjective emotional assessment of their worth’. 38 Bleidorn et al 39 conducted a groundbreaking large-scale, cross-cultural study with an internet sample of 985 937 participants, examining gender and age differences in self-esteem across 48 nations. They discovered significant gender differences, with males consistently reporting higher self-esteem levels than females, which may influence their responses to negative feedback to some degree.

In the section on personal factors, the results of this study on personal internal and external environmental factors such as curiosity, burn-out and inattention are consistent with previous studies. 40–45 The relationship between these internal and external environmental factors and cognitive capacity has been described in cognitive load theory, 46 particularly the role of ‘working memory’, the capacity to process information. Specifically, researchers 47 reported on a consensus on CT teaching, assessment and faculty development compiled by a high-level team recommended by 32 medical schools across the USA. Learners’ personal attributes, characteristics, perspectives and behaviours are critical components of their motivation to prepare for and engage in deeper learning and laborious clinical reasoning. Distractions and interruptions, on the other hand, can reduce attention to important issues, affecting learners’ ability to engage in clinical reasoning and their CT skills. 48 Making decisions based on the opinions of others in this study may reflect the participants’ interdependent view of self, which was identified by Futami et al 49 as a negative factor for CT dispositions.

Regarding the educational factors, learning methods and research group membership characteristics were more strongly associated with CT disposition than learning frequency and learning form. Completing the scientific research design with reference and asking ‘why’ are learning methods that promote the formation of CT for medical graduate students. Research 50 suggests that CT requires a persistent effort to test any belief or supposed form of knowledge according to the evidence supporting it and the further conclusions it tends to help. Completing scientific research design with reference is the specific manifestation of evidence-based reasoning in the scientific research field, which may be why it affects the formation process of CT. Furthermore, similar to our research, much research has explored the crucial role that questioning or problem-based thinking plays in CT. 47 51–53 Our research also suggested that the teaching style of the group supervisor and the logical thinking ability of other group members also impacted CT dispositions. Although no previous research has explored the role-specific behaviours of subject mentors and peers in CT disposition from a quantitative perspective, Futami et al 49 reported higher CT scores for subjects who had connections with research experts, suggesting a positive influence of research mentors on CT. Self-esteem positively affects CT, and overbearing instructors may undermine students’ self-esteem and, thus, their CT disposition. Moreover, several authors 47 53 54 have argued that professors’ encouragement of students to express uncertainty, to question and assess the quality of knowledge learnt, and to improve team members’ logical thinking skills are all positively associated with CT, consistent with our findings.

The CT scores in our study were lower than those in several Western countries among medical students, 55 56 possibly because of differences in educational culture and methods. In China, medical education comprises three stages: primary medical education, clinical education and internships. Primary medical education introduces students to the medical world. The delivery of traditional courses used to be prescribed and even dull simply because teachers were accustomed to a conventional teaching style and were afraid of making changes to course delivery. 57 The strategies to develop reflective and CT in nursing students in eight countries indicated that reflexive CT was found in most curricula, although with diverse denominations. The principal learning strategies used were PBL, group dynamics, reflective reading, clinical practice and simulation laboratories. The evaluation methods are the knowledge test, case analysis and practical exam. 58

The importance of early clinical exposure is universally acknowledged, particularly in developing countries where its value is profoundly esteemed. For instance, the South African Health Professions Council has spearheaded educational reforms for medical professionals, enabling first-year medical students to participate in healthcare visits. These visits aim to enrich the comprehension of future professional environments and foster a more profound passion for medicine. 59 Notably, most students perceived these visits as invaluable learning experiences, leaving them better prepared for medical practice. Similarly, Chinese medical colleges offer comparable programmes spanning 1–2 weeks. A Peking University study using questionnaires and reports revealed that all students benefited from these activities, gaining perceptual knowledge of clinical work. Remarkably, 61.5% of students reported that their early clinical exposure had significantly assisted them. 60

Interestingly, there was a more significant proportion of PhD students with a CT disposition in our study. This may be because doctoral research is more in-depth and complex, requiring students to engage in more detailed, rigorous and innovative thinking based on their existing knowledge. During the research process, doctoral students must constantly question, analyse, evaluate and reconstruct knowledge, which undoubtedly exercises and enhances their CT abilities. 61 However, this does not imply that master’s students possess lower CT skills than doctoral students. The master’s programme also emphasises cultivating CT, although possibly differing in depth and breadth. Both stages have unique development paths and manifestations in terms of CT. Regardless of the stage, graduate students should focus on developing their CT skills to address challenges in academic research and life.

Our research revealed that factors influencing CT motivation appear to be more closely linked to CT tendencies in personal and educational components. Miele and Wigfield 50 suggested that the factors affecting students’ critical analytical thinking motivation can be divided into two aspects: quantity and quality, the quantitative relationship between motivation and CT, that is, whether students have sufficient motivation to make high-level spiritual efforts. This is reflected in our study regarding curiosity, burn-out, distraction, an interdependent self-view and influence by research team members. The qualitative relationship is the willingness of students to engage in CT, which corresponds to the desire to ask ‘why’ and to refer to existing evidence to complete a research design in this study. This suggests that internal motivation may play an essential role in CT and that educators should focus more on maintaining students’ motivation and building awareness than on the frequency of rigid external research training and curriculum formats. Students are actively promoted and encouraged to apply CT in practice. At the same time, the existing overly outcome-oriented reward mechanism is changed, and assessment criteria are enriched, for example, by including ‘whether you ask interesting questions’ as one of the criteria for classroom assessment to motivate people to become more proactive learners. Recently, medical education has garnered considerable attention and traditionally assumes that medical students are inherently motivated by their dedication to specialised training and a highly focused profession. However, motivation plays a crucial role in determining the quality of learning and ultimate success. Its absence may provide a plausible explanation for why teachers occasionally encounter medical students who appear discouraged, have lost interest or abandon their studies, feeling a sense of powerlessness or resignation. 62

To foster CT among medical students, educational reform should encompass several key aspects: (1) Encouraging active learning and exploration: Teachers must urge students to engage actively in the learning process, providing resources and guidance to kindle their intellectual curiosity. This will empower students to seek out challenges, pose inquiries and address them through a critical lens. 63 (2) Implementing heuristic learning and case studies: Educators should incorporate case studies, enabling students to hone their CT, discriminatory skills and decision-making abilities by analysing authentic or hypothetical scenarios. 64 65 (3) Stressing the mastery of professional knowledge: It is imperative to ensure that students grasp the fundamental theories and principles of the medical field, along with proficiency in practical medical skills. 66 (4) Nurturing teamwork skills: Group discussions, collaborative projects and similar activities should be used to cultivate teamwork among medical students. This teaches them to listen attentively, manage team dynamics, and allocate resources effectively, enhancing their CT and problem-solving capabilities. 67 (5) Providing clinical practical experience: Early exposure to clinical practice is crucial in developing students’ analytical and problem-solving skills through firsthand observation and participation in real-life case management. 68 (6) Shifting teachers’ roles: Educators must evolve into mentors and role models for CT, leading by example and inspiring students through their practices and teachings. 69 Collectively, these recommendations for educational reform will empower medical students to address intricate issues they may encounter in their future medical careers, ultimately increasing the quality and safety of healthcare services.

It is worth noting that our questionnaire incorporated many potential entries with high reliability. It mostly also showed differences between the two groups with or without CT disposition in univariate analysis but were not ultimately presented in the regression models. These factors are meaningful for the development of CT but taking into account the simplicity and informativeness of the model, other entries in the model may have represented them. Our model explained more of the variance in CT than regression models from previous studies. 49 70 71

Strengths and limitations

This study has particular strengths. First, the questionnaire for this study was scientific and practice based. The findings of previous studies on personal and educational factors were extensively referenced, and in-depth interviews were also conducted. Second, our study focused on postgraduate medical students and the sample size was relatively large. Postgraduate medical students are the key group for CT development, and the findings obtained among postgraduate medical students are more relevant and better reflect the thinking characteristics of postgraduate medical students. Research from China has considerably enriched the worldwide sample of CT influencing factors. It has been suggested that cultural context strongly influences CT, 72 but previous research on CT has mostly focused on Europe, the USA and Japan. Therefore, researching CT in Chinese populations is a valuable addition to this area. In addition, this study is the first to quantitatively explore the impact of tutor and team on CT disposition. For Chinese postgraduates, tutors and their scientific research teams are the people who have the most contact during their studies. In our previous interviews, educators, tutors and postgraduates all recognised the vital role of tutors in postgraduate education, especially in the cultivation of thinking. Based on interviews and literature extraction, we summarise the specific influence of tutors and teams and present them as numerical indicators to refine the influence of tutors on educational factors to make them more comprehensive and exact.

There are several limitations to our study. First, given the traditional constraints of cross-sectional studies, the findings of this study cannot be used as direct evidence of a causal relationship between potential influences and outcomes. Still, they can provide clues to reveal causal relationships. Second, some influencing factors, such as participation in project submissions, participation in CT courses, attempts at innovation and entrepreneurship, and exchange abroad may need to be revised when measured due to limited educational resources. The lack of opportunity for most students to participate in the projects mentioned above, even if they had the will to do so, may help obscure the correlation between CT and these factors. Our regression models did not include other factors of the same type with higher coverage, such as article writing. This suggests that specific formal factors do not significantly influence CT disposition and that bias may not affect the overall results. In addition, we did not use the CTDI-CV scale. Given the busy workload of postgraduate medical students and the fact that online surveys are challenging to monitor and quality control, to avoid as much as possible the impact of too many questions on the quality of the study and to increase the recall rate, we used a condensed version of the Critical Thinking Scale, which has a greater total explained variance than the CTDI-CV scale and has good reliability and validity.

Conclusions

In conclusion, this study provides a comprehensive scientific assessment of the factors influencing the CT disposition of Chinese medical postgraduates in terms of personal and educational factors. Being curious, completing the scientific research design with reference, asking ‘why’, and having high logical thinking ability among team members were positively associated with CT. Exhaustion and burn-out, inattention, following others’ opinions in decision-making and not allowing to doubt tutors were negatively associated with CT scores. These findings suggest that we pay more attention to factors related to motivation and internal drive in our educational practice, shift from an outcome-focused reward mechanism and focus on motivation maintenance to build students’ CT awareness.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

The research team collected data after obtaining their consent and signatures on the study’s informed consent form. The Ethics Committee of West China Hospital (tertiary), Sichuan University, approved the study in 2021 (Ethics No. 980).

Acknowledgments

The authors want to acknowledge the medical students who participated in this study.

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LW and WC contributed equally.

Contributors LW and WC were involved in designing the study, reviewing the literature, designing the protocol, developing the questionnaire, collecting the data, performing the statistical analysis and preparing the manuscript. TH and W-BH were involved in searching and collecting the data. YW was involved in interpreting the data and critically reviewed the manuscript. YW is responsible for the overall content as the guarantor . All the authors have read and approved the final manuscript.

Funding This study was supported by the Sichuan University Postgraduate Education Reform project (GSSCU2021038).

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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PMC10779280

Teaching Strategies for Developing Clinical Reasoning Skills in Nursing Students: A Systematic Review of Randomised Controlled Trials

Associated data.

Data are contained within the article.

Background: Clinical reasoning (CR) is a holistic and recursive cognitive process. It allows nursing students to accurately perceive patients’ situations and choose the best course of action among the available alternatives. This study aimed to identify the randomised controlled trials studies in the literature that concern clinical reasoning in the context of nursing students. Methods: A comprehensive search of PubMed, Scopus, Embase, and the Cochrane Controlled Register of Trials (CENTRAL) was performed to identify relevant studies published up to October 2023. The following inclusion criteria were examined: (a) clinical reasoning, clinical judgment, and critical thinking in nursing students as a primary study aim; (b) articles published for the last eleven years; (c) research conducted between January 2012 and September 2023; (d) articles published only in English and Spanish; and (e) Randomised Clinical Trials. The Critical Appraisal Skills Programme tool was utilised to appraise all included studies. Results: Fifteen papers were analysed. Based on the teaching strategies used in the articles, two groups have been identified: simulation methods and learning programs. The studies focus on comparing different teaching methodologies. Conclusions: This systematic review has detected different approaches to help nursing students improve their reasoning and decision-making skills. The use of mobile apps, digital simulations, and learning games has a positive impact on the clinical reasoning abilities of nursing students and their motivation. Incorporating new technologies into problem-solving-based learning and decision-making can also enhance nursing students’ reasoning skills. Nursing schools should evaluate their current methods and consider integrating or modifying new technologies and methodologies that can help enhance students’ learning and improve their clinical reasoning and cognitive skills.

1. Introduction

Clinical reasoning (CR) is a holistic cognitive process. It allows nursing students to accurately perceive patients’ situations and choose the best course of action among the available alternatives. This process is consistent, dynamic, and flexible, and it helps nursing students gain awareness and put their learning into perspective [ 1 ]. CR is an essential competence for nurses’ professional practice. It is considered crucial that its development begin during basic training [ 2 ]. Analysing clinical data, determining priorities, developing plans, and interpreting results are primary skills in clinical reasoning during clinical nursing practise [ 3 ]. To develop these skills, nursing students must participate in caring for patients and working in teams during clinical experiences. Among clinical reasoning skills, we can identify communication skills as necessary for connecting with patients, conducting health interviews, engaging in shared decision-making, eliciting patients’ concerns and expectations, discussing clinical cases with colleagues and supervisors, and explaining one’s reasoning to others [ 4 ].

Educating students in nursing practise to ensure high-quality learning and safe clinical practise is a constant challenge [ 5 ]. Facilitating the development of reasoning is challenging for educators due to its complexity and multifaceted nature [ 6 ], but it is necessary because clinical reasoning must be embedded throughout the nursing curriculum [ 7 ]. Such being the case, the development of clinical reasoning is encouraged, aiming to promote better performance in indispensable skills, decision-making, quality, and safety when assisting patients [ 8 ].

Nursing education is targeted at recognising clinical signs and symptoms, accurately assessing the patient, appropriately intervening, and evaluating the effectiveness of interventions. All these clinical processes require clinical reasoning, and it takes time to develop [ 9 ]. This is a significant goal of nursing education [ 10 ] in contemporary teaching and learning approaches [ 6 ].

Strategies to mitigate errors, promote knowledge acquisition, and develop clinical reasoning should be adopted in the training of health professionals. According to the literature, different methods and teaching strategies can be applied during nursing training, as well as traditional teaching through lectures. However, the literature explains that this type of methodology cannot enhance students’ clinical reasoning alone. Therefore, nursing educators are tasked with looking for other methodologies that improve students’ clinical reasoning [ 11 ], such as clinical simulation. Clinical simulation offers a secure and controlled setting to encounter and contemplate clinical scenarios, establish relationships, gather information, and exercise autonomy in decision-making and problem-solving [ 12 ]. Different teaching strategies have been developed in clinical simulation, like games or case studies. Research indicates a positive correlation between the use of simulation to improve learning outcomes and how it positively influences the development of students’ clinical reasoning skills [ 13 ].

The students of the 21st century utilise information and communication technologies. With their technological skills, organisations can enhance their productivity and achieve their goals more efficiently. Serious games are simulations that use technology to provide nursing students with a safe and realistic environment to practise clinical reasoning and decision-making skills [ 14 ] and can foster the development of clinical reasoning through an engaging and motivating experience [ 15 ].

New graduate nurses must possess the reasoning skills required to handle complex patient situations. Aware that there are different teaching methodologies, with this systematic review we intend to discover which RCTs published focus on CR in nursing students, which interventions have been developed, and their effectiveness, both at the level of knowledge and in increasing clinical reasoning skills. By identifying the different techniques used during the interventions with nursing students in recent years and their effectiveness, it will help universities decide which type of methodology to implement to improve the reasoning skills of nursing students and, therefore, obtain better healthcare results.

This study aims to identify and analyse randomised controlled trials concerning clinical reasoning in nursing students. The following questions guide this literature review:

Which randomised controlled trials have been conducted in the last eleven years regarding nursing students’ clinical reasoning? What are the purposes of the identified RCTs? Which teaching methodologies or strategies were used in the RCTs studies? What were the outcomes of the teaching strategies used in the RCTs?

2. Materials and Methods

This review follows the PRISMA 2020 model statement for systematic reviews. That comprises three documents: the 27-item checklist, the PRISMA 2020 abstract checklist, and the revised flow diagram [ 16 ].

2.1. Search Strategy

A systematic literature review was conducted on PubMed, Scopus, Embase, and the Cochrane Controlled Register of Trials (CENTRAL) up to 15th October 2023.

The PICOS methodology guided the bibliographic search [ 17 ]: “P” being the population (nursing students), “I” the intervention (clinical reasoning), “C” comparison (traditional teaching), “O” outcome (dimension, context, and attributes of clinical reasoning in the students’ competences and the results of the teaching method on nursing students), and “S” study type (RCTs).

The search strategy used in each database was the following: (“nursing students” OR “nursing students” OR “pupil nurses” OR “undergraduate nursing”) AND (“clinical reasoning” OR “critical thinking” OR “clinical judgment”). The filters applied were full text, randomised controlled trial, English, Spanish, and from 1 January 2012 to 15 October 2023. The search strategy was performed using the same process for each database. APP performed the search, and AZ supervised the process.

During the search, the terms clinical reasoning, critical thinking, and clinical judgement were used interchangeably since clinical judgement is part of clinical reasoning and is defined by the decision to act. It is influenced by an individual’s previous experiences and clinical reasoning skills [ 18 ]. Critical thinking and clinical judgement involve reflective and logical thinking skills and play a vital role in the decision-making and problem-solving processes [ 19 ].

The first search was conducted between March and September 2022, and an additional search was conducted during October 2023, adding the new articles published between September 2022 and September 2023, following the same strategy. The search strategy was developed using words from article titles, abstracts, and index terms. Parallel to this process, the PRISMA protocol was used to systematise the collection of all the information presented in each selected article. This systematic review protocol was registered in the international register PROSPERO: CRD42022372240.

2.2. Eligibility Criteria and Study Selection

The following inclusion criteria were examined: (a) clinical reasoning, clinical judgment, and critical thinking in nursing students as a primary aim; (b) articles published in the last eleven years; (c) research conducted between January 2012 and September 2023; (d) articles published only in English and Spanish; and (e) RCTs. On the other hand, the exclusion criteria were studies conducted with students from other disciplines other than nursing, not random studies or review articles.

2.3. Data Collection and Extraction

After this study selection, the following information was extracted from each article: bibliographic information, study aims, teaching methodology, sample size and characteristics, time of intervention, and conclusions.

2.4. Risk of Bias

The two reviewers, APP and AZ, worked independently to minimise bias and mistakes. The titles and abstracts of all papers were screened for inclusion. All potential articles underwent a two-stage screening process based on the inclusion criteria. All citations were screened based on title, abstract, and text. Reviewers discussed the results to resolve minor discrepancies. All uncertain citations were included for full-text review. The full text of each included citation was obtained. Each study was read thoroughly and assessed for inclusion following the inclusion and exclusion criteria explained in the methodology. The CASP tool was utilised to appraise all included studies. The CASP Randomized Controlled Trial Standard Checklist is an 11-question checklist [ 20 ], and the components assessed included the appropriateness of the objective and aims, methodology, study design, sampling method, data collection, reflexivity of the researchers, ethical considerations, data analysis, rigour of findings, and significance of this research. These items of the studies were then rated (“Yes” = with three points; “Cannot tell” = with two points; “No” = with one point). The possible rates for every article were between 0 and 39 points.

2.5. Ethical Considerations

Since this study was a comprehensive, systematic review of the existing published literature, there was no need for us to seek ethical approval.

3.1. Search Results

The initial search identified 158 articles using the above-mentioned strategy (SCOPUS ® n = 72, PUBMED ® n = 56, CENTRAL ® n = 23, and EMBASE ® n= 7), and the results are presented in Figure 1 . After retrieving the articles and excluding 111, 47 were selected for a full reading. Finally, 17 articles were selected. To comply with the methodology, the independent reviewers analysed all the selected articles one more time after the additional search, and they agreed to eliminate two of them because this study sample included nursing students as well as professional nurses. Therefore, to have a clear outcome focused on nursing students, two articles were removed, and the very final sample size was fifteen articles, following the established selection criteria ( Figure 1 ). The reasons for excluding studies from the systematic review were: nurses as targets; other design types of studies different from RCTs; focusing on other health professionals such as medical students; review studies; and being published in full text in other languages other than Spanish or English.

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Flowchart of screening of clinical reasoning RCTs that underwent review.

3.2. Risk of Bias in CASP Results

All studies included in the review were screened with the CASP tool. Each study was scored out of a maximum of 39 points, showing the high quality of the randomised control trial methodology. The studies included had an average score of 33.1, ranging from 30 to 36 points. In addition, this quantitative rate of the items based on CASP, there were 13 studies that missed an item in relation to assessing/analysing outcome/s ‘blinded or not’ or not, and 11 studies that missed the item whether the benefits of the experimental intervention outweigh the harms and costs.

3.3. Data Extraction

Once the articles had undergone a full reading and the inclusion criteria were applied, data extraction was performed with a data extraction table ( Appendix A ). Their contents were summarised into six different cells: (1) CASP total points result, (2) purpose of this study, (3) teaching strategy, (4) time of intervention, (5) sample size, and (6) author and year of publication. After the review by the article’s readers, fifteen RCTs were selected. Of the fifteen, the continent with the highest number of studies was Asia, with 53.33% of the studies (n = 8) (Korea n = 4, Taiwan n = 2, and China n = 2), followed by Europe with 26.66% (n = 4) (Turkey n = 2, Paris n = 1, and Norway n = 1), and lastly South America with 20% (n = 3), all of them from Brazil.

3.4. Teaching Strategies

Different teaching strategies have been identified in the reviewed studies: simulation methods (seven articles) and learning programmes (eight articles). There are also two studies that focus on comparing different teaching methodologies.

3.4.1. Clinical Simulation

The simulation methods focused on in the studies were virtual simulation (based on mobile applications), simulation games, and high-fidelity clinical simulation. Of the total number of nursing students in the studies referring to clinical simulations, 43.85% were in their second year, while 57.1% were senior-year students. The most used method in the clinical simulation group was virtual simulation, and 57.14% of studies included only one-day teaching interventions.

Virtual simulations were used to increase knowledge about medication administration and nasotracheal suctioning in different scenarios [ 21 ], to evaluate the effect of interactive nursing skills, knowledge, and self-efficacy [ 11 ], and to detect patient deterioration in two different cases [ 22 ]. Simulation game methodology was used to improve nursing students’ cognitive and attention skills, strengthen judgment, time management, and decision-making [ 14 ].

Clinical simulation was used to develop nursing students’ clinical reasoning in evaluating wounds and their treatments [ 12 ], to evaluate and compare the perception of stressors, with the goal of determining whether simulations promote students’ self-evaluation and critical-thinking skills [ 23 ], and also to evaluate the impact of multiple simulations on students’ self-reported clinical decision-making skills and self-confidence [ 24 ].

3.4.2. Learning Programs

Different types of learning programmes have been identified in this systematic review: team-based learning, reflective training programs, person-centred educational programmes, ethical reasoning programmes, case-based learning, mapping, training problem-solving skills, and self-instructional guides. Of the total number of nursing students in the studies referring to learning programs, 57.1% were junior-year students, while 43.85% were in their senior year.

Team-based learning is a learner-centred educational strategy that promotes active learning to improve students’ problem-solving, knowledge, and practise performance. It can be implemented in small or large groups divided into teams with an instructor and reading material based on case scenarios [ 25 ]. Reflective training is based on a new mentoring practise to explore, think about, and solve problems actively during an internship. During the reflective training program, the mentors lead students to uncover clinical nursing problems through conversations with them and discussing feedback for their professional portfolios [ 26 ]. The person-centred educational programme focuses on how nursing students perceive individualised care, using design thinking to improve their perception. The use of design thinking gave the students opportunities to apply their theoretical knowledge of the person-centred program to plan innovative solutions that may effectively resolve real-life situations [ 27 ]. Another educational programme identified is the ethical reasoning program, and the aim of this is to improve nursing students’ handling of ethical decision-making situations [ 28 ], engaging the students in complex ethical clinical situations based on real cases.

Case-based learning was used to explore and demonstrate the feasibility of implementing unfolding cases in lectures to develop students’ critical-thinking abilities [ 29 ]. The web-based concept mapping of nursing students was also investigated to determine its impact on critical-thinking skills [ 30 ]. Training problem-solving skills were used to find out how it affected the rate of self-handicapping among nursing students [ 31 ]. And the last article evaluated the effect of the self-instructional guide to improve clinical reasoning skills on diagnostic accuracy in undergraduate nursing students [ 32 ].

4. Discussion

Although 158 studies were initially identified, only 15 articles were finally included in this review. The excluded articles were mainly from other disciplines other than nursing and used a less rigorous study design than RCT.

The three longest interventions were developed in Asia [ 26 , 28 , 29 ]. The longest was 300 h in duration, through one year [ 30 ]. These interventions were based on learning programs, case-based learning, person-centred care (PCC), and reflective training programs. However, it is important to take into account that Asian nursing curriculum programmes are different from European or United States curriculum because their internship is carried out only during the last academic degree year, while in Europe, following the European directive 2005/36/CE, 2013/55/UE nursing education requirements of 4600 h (2300 h of clinical practice) is carried out along the 3–4 years of the academic degree [ 33 ]. On the other hand, the intervention with the biggest sample was 419 nursing students [ 30 ], 210 in the experimental group, and 209 in the control group, and the one with the lowest sample was 51, with 24 students in the control group and 27 in the intervention group [ 32 ]. Therefore, all the included studies had a good sample size.

This systematic review has detected different methodologies to help nursing students improve their reasoning and decision-making skills. Virtual simulation was the most frequently used teaching method, both as a mobile application and as a serious game. In terms of its effectiveness in a study carried out in Taiwan, the use of a mobile application resulted in significantly higher knowledge scores, better skill performance, and higher satisfaction in students than traditional paper materials [ 21 ]. Virtual simulation [ 11 , 14 , 21 ] has also proven to be an effective tool for enhancing knowledge and confidence in recognising and responding to rapidly deteriorating patients, but studies that combined two educational strategies were more effective [ 29 ], like clinical simulation combined with another teaching strategy such as lectures or videos [ 12 ].

An interactive learner-centred nursing education mobile application with systematic contents effectively allowed students to experience positive practical nursing skills [ 11 ]. However, in a study comparing serious game simulation versus traditional teaching methods, no significant difference was found immediately or in the month following the training [ 22 ], but serious games can improve nursing students’ cognitive skills to detect patient deterioration and to make safe decisions about patient care [ 14 ]. Although the innovative teaching method was well received by the students, who expressed higher levels of satisfaction and motivation [ 22 ]. We can affirm that the development of a mobile application and its application can be effectively used by nursing students at all levels [ 11 ]. However, the performance of all these studies was measured on its short-term outcomes, only 40 min [ 21 ], 2 h [ 22 ], and 1 week [ 11 , 14 ] of intervention, and was performed with a mean sample size of 97 nursing students.

The data obtained in a study developed in Brazil [ 12 ] confirm that clinical simulation is effective for the development of nursing students’ clinical reasoning in wound evaluation and treatment and that clinical simulation in conjunction with other educational methods promotes the acquisition of knowledge by facilitating the transition from what the student knows to rational action. Moreover, the high-fidelity simulation strategy increases the perception of stressors related to a lack of competence and interpersonal relationships with patients, multidisciplinary teams, and colleagues compared with the conventional practice class in the skill laboratory. This increase was related to the students’ capacity for self-evaluation and critical reflection, concerning their learning responsibility and the need to acquire the required skills for patient care [ 23 ]. However, in the case of the effect of multiple simulations on students, there are no differences found between the double-versus single-scenario simulations [ 24 ]. The intervention time in these three studies was 30 min [ 23 ], 3.5 h [ 12 ], and 4 days [ 24 ]; then the time used to implement the intervention can determine the results obtained.

The different learning methods have an impact on various learning outcomes and students’ variables. Team-based learning [ 25 ], reflective training [ 26 ], the person-centred education programme [ 27 ], web-based concept mapping [ 30 ], and teaching cognitive-behavioural approaches [ 31 ] have proven to be effective in enhancing problem-solving abilities, knowledge, and reasoning processes and consequently improving the quality of nursing practical education. Team-based learning increased problem-solving ability scores significantly, while those in the control group decreased [ 25 ]. Reflective training, developed in China based on the new mentoring approach, was effective in encouraging nursing students to explore, think about, and solve problems actively during an internship, consequently improving their disposition for critical thinking [ 26 ]. A person-centred education programme using design thinking can effectively improve how nursing students perceive individualised care. Using design thinking allowed the students to apply their theoretical knowledge of the programme to plan innovative solutions that may effectively resolve real health problems [ 27 ]. These programmes were developed in 5 or 6 days [ 27 , 31 ], 1 week or 3 weeks [ 25 , 30 ], and 1 year [ 26 ].

The education programme focused on improving ethical decision-making had statistically significant improvements in nursing students’ self-efficacy in communication confidence, complex ethical decision-making skills, and decreased communication difficulty [ 28 ]. Case-based learning was more effective with lectures than without them in developing students’ critical thinking abilities [ 29 ]. This study was one of the longest developed with 300 h during one school year. This long-term learning intervention could have a positive impact on this study sample. Therefore, the time of the learning intervention could be a limitation in the studied RCTs. The one-time self-instruction guide was ineffective in impacting students’ diagnostic accuracy in solving case studies [ 32 ], and it is possible that only one day of intervention is not enough.

Studies have shown that problem- and team-based learning [ 25 , 31 ] are more beneficial than traditional teaching [ 29 ], as they enhance nursing skills and improve problem-solving abilities, clinical performance, communication competencies, critical thinking, and self-leadership.

Researchers generally agree that clinical reasoning is an important ability and one of the most important competencies for good nursing practise to ensure optimal patient outcomes [ 29 ] and to recognise and address patient deterioration effectively. However, effective communication is crucial in clinical reasoning. It is required to establish a rapport with patients, conduct health evaluations, make collaborative decisions, and discuss clinical cases with colleagues and supervisors. Developing clinical reasoning skills during training is essential to improving nursing professionals’ practice. To enhance clinical reasoning abilities, nursing schools should integrate simulations at every level of education to ultimately improve patient care. Improving nursing students’ preparation will impact the quality of patient care. In addition, new innovative teaching methodologies based on the use of technology could be a motivational driver in nursing clinical reasoning [ 22 ].

5. Limitations

This systematic review did not perform a search on CINAHL. Although most of the journals included in this database are included in MEDLINE, this should be addressed in the future because of the relevance of the database to nursing research. The results of the included studies could have also been influenced by the different times of the interventions and the different contexts. In addition, the reviewers have identified other studies published in languages other than those required by the inclusion criteria. It seems that many articles are published by Asian researchers, but some of them are not in English, so they cannot be analysed.

6. Conclusions

As society progresses, the new generation of nursing students poses a challenge; new technologies are ingrained in their daily lives with access to increasingly advanced technologies like artificial intelligence, and we must adapt training to capture their interest and increase their learning skills. The utilisation of mobile apps, digital simulations, and learning games has a positive impact on the clinical reasoning abilities of nursing students and their motivation. Incorporating new technologies into problem-solving-based learning and decision-making can also enhance nursing students’ reasoning skills. As a result, it is crucial to incorporate these tools into the learning process to maintain students’ interest, motivation, and satisfaction in education. Clinical simulation is particularly important in the training of students in terms of clinical performance. Still, it is necessary to add another teaching method to increase the efficacy of clinical simulations. Therefore, nursing schools should evaluate their current teaching methods and consider integrating or modifying new technologies and methodologies that can help enhance students’ learning, improve their clinical reasoning and cognitive skills, and potentially improve nursing students’ ability to affect patient care positively. By doing so, students will be better equipped to provide high-quality patient care in the future.

Study	Sample Size	Time Intervention	Teaching Strategies	Purpose of the RCTs	CASP
Maurício et al., 2022 [ ]	n = 51	1 day	Self-Instructional Guide	To evaluate the effect of the Self-Instructional Guide for Clinical Reasoning on the diagnostic accuracy of undergraduate nursing students.	36
Calik and Kapucu 2022 [ ]	n = 60	1 week	Simulation game	Evaluated the efficacy of serious games using pre- and post-tests.	36
Zhang et al., 2017 [ ]	n = 157	12 months	Reflective training program	To evaluate the effects of reflective training for nursing students on their critical thinking disposition.	35
Chang et al., 2021 [ ]	n = 110	40 min	Mobile application	To test the hypothesis that nursing students who used a mobile learning app would have significantly higher levels of knowledge about nasotracheal suctioning and medication administration and a better development of skill performance in medication administration.	35
Chang et al., 2021 [ ]	n = 110	40 min	(Virtual simulation)		35
Blanié et al., 2020 [ ]	n= 146	2 h	Gaming and traditional methods	To compare a traditional teaching method with gaming to improve the clinical reasoning skills necessary to help nursing students detect patient deterioration.	35
Bilik et al., 2020 [ ]	n = 419	1 week	Web-based concept mapping education	To investigate the impact of web-based concept mapping education on nursing students’ critical-thinking and concept-mapping skills.	34
Zarshenas et al., 2019 [ ]	n = 90	2 h for 6 days	Problem-solving	To investigate how training problem-solving skills affected the rate of self-handicapping among nursing students.	33
Svellingen et al., 2021 [ ]	n = 146	4 days in 3 years	Clinical simulation	To evaluate the impact of multiple simulations on students’ self-reported clinical decision-making skills and self-confidence.	33
Kim and Suh 2018 [ ]	n = 72	1 week	Mobile application	To determine if a mobile application improved students’ skills and knowledge.	33
Kim and Suh 2018 [ ]	n = 72	1 week	(virtual simulation)		33
Park et al., 2021 [ ]	n = 105	2 h for 5 days	Education program	To develop a feasibility programme for providing foundational knowledge and skills about patient-centred care to fourth-year undergraduate nursing students using the design-thinking approach.	32
Pai et al., 2022 [ ]	n = 101	8 h for 14 weeks	Person-centred education program	To investigate the impact of an ethical decision-making framework on ethical decision-making and communication self-efficacy in nursing students.	32
Silva et al., 2020 [ ]	n = 78	3.5 h for one day	Clinical simulation	To analyse the effect of clinical simulation on the development of clinical reasoning and on nursing students’ acquisition of knowledge of wound evaluation and treatment.	31
Boostel et al., 2018 [ ]	n = 52	30 min	Clinical simulation	To compare and evaluate the perception of stressors by nursing students before and after a high-fidelity conventional laboratory practise class or clinical simulation.	30
Hong and Yu, 2017 [ ]	n = 122	300 h	Cased-based learning	To compare and explore the effectiveness of two styles of case-based learning methods, unfolding nursing cases and unusual nursing cases, implemented in lectures for developing nursing students’ critical-thinking abilities.	30
Kim et al., 2016 [ ]	n = 63	2 h weekly for 3 weeks	Team-based learning	To examine the effects of TBL on learning outcomes and the problem-solving ability (knowledge and clinical performance) of Korean nursing students.	30

Funding Statement

This research received external funding from the European programme Eramus +2021-1-BE02-KA220-HED-000023194.

Author Contributions

Conceptualisation, A.P.-P. and A.Z.; methodology, A.P.-P. and A.Z.; formal analysis, A.P.-P.; writing—original draft preparation, A.P.-P.; writing—review and editing, A.Z.; visualisation, A.Z.; supervision, A.Z. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

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COMMENTS

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Objectives This study aimed to investigate the associations between critical thinking (CT) disposition and personal characteristics and tutors' guidance among medical graduate students, which may provide a theoretical basis for cultivating CT. Design A cross-sectional study was conducted. Setting This study was conducted in Sichuan and Chongqing from November to December 2021. Participants A ...
Teaching Strategies for Developing Clinical Reasoning Skills in Nursing
Clinical simulation was used to develop nursing students' clinical reasoning in evaluating wounds and their treatments , to evaluate and compare the perception of stressors, with the goal of determining whether simulations promote students' self-evaluation and critical-thinking skills , and also to evaluate the impact of multiple ...
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A plan aiming to streamline clinical trial reporting procedures in some circumstances is now out for consultation. Medsafe is seeking public feedback on a series of proposed updates to the regulatory guidelines for people conducting clinical trials for medicines and medical devices.

The Value of Critical Thinking in Nursing

How Do Nurses Use Critical Thinking?

Top 5 Ways Nurses Can Improve Critical Thinking Skills

Case-Based Approach

Practice Self-Reflection

Develop a Questioning Mind

Practice Self-Awareness in the Moment

Use a Process

Common Critical Thinking Pitfalls in Nursing

An Essential Skill for All Nurses

Frequently Asked Questions About Critical Thinking in Nursing

How does nursing school develop critical thinking skills?

Do only nurse managers use critical thinking?

Meet Our Contributors

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

Jenna Liphart Rhoads, Ph.D., RN

Nicholas McGowan, BSN, RN, CCRN

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

What is Critical Thinking in Nursing?

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

ANA Nursing Resources Hub

Critical Thinking in Nursing: Tips to Develop the Skill

What Is Critical Thinking in Nursing?

How Is Critical Thinking Important for Nurses?

Elements of Critical Thinking in Nursing

How to Develop and Apply Critical-Thinking Skills in Nursing

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

What is Critical Thinking?

Definition of Critical Thinking

What is Critical Thinking in Nursing?

What are the Levels of Critical Thinking in Nursing?

1. Basic Critical Thinking:

2. Complex Critical Thinking:

3. Commitment:

Why Critical Thinking is Important in Nursing?

Patient Safety:

Clinical Judgment:

Promotes Problem-Solving:

Drives Creativity:

Fosters Effective Communication:

Aids Learning:

Improves Relationships:

Empowers Independence:

Facilitates Adaptability:

Strengthens Critical Analysis:

How to Apply Critical Thinking in Nursing? (With Examples)

Assess Patient Data:

Diagnose Patient Needs:

Plan and Implement Care:

Evaluate Interventions:

Prioritize Care:

Collaborate with the Healthcare Team:

Ethical Decision-Making:

Patient Education:

Adapt to Changes:

Critical Analysis of Information:

Making Sense of Critical Thinking Skills

Why critical thinking is important in nursing?

How is critical thinking used in the nursing process?

What is an example of the critical thinking attitude of independent thinking in nursing practice?

How to use Costa’s level of questioning for critical thinking in nursing?

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

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Account Management

Why Critical Thinking in Nursing Is Important

Key Nursing Critical Thinking Skills

Example #1: Patient Assessments

Example #2: First Line of Defense

Example #3: Patient Interactions

Example #4: Using Detective Skills

Example #5: Prioritizing

Example #6: Medication & Care Coordination

How Is Critical Thinking Important for Nurses? 