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

how to improve critical thinking 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?

how to improve critical thinking as a nurse

The Value of Critical Thinking in Nursing

Gayle Morris, BSN, MSN

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

Male nurse checking on a patient

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

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

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.

Portrait of Jenna Liphart Rhoads, Ph.D., RN

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.

Portrait of Nicholas McGowan, BSN, RN, CCRN

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.


How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples


Last updated on August 19th, 2023

Nurses play a critical role in making critical decisions that directly impact patient outcomes in the dynamic field of healthcare. Developing strong critical thinking skills is essential for success in this role.

In this article, we present a comprehensive list of 23 nursing-specific strategies aimed at improving critical thinking and improve the quality of patient care.

24 Strategies to improve critical thinking skills in nursing

You may also want to check out: 15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)

1. Reflective Journaling: Delving into Deeper Understanding

Reflective journaling is a potent tool for nurses to explore their experiences, actions, and decisions.

By regularly pondering over situations and analyzing their thought processes, nurses can identify strengths and areas for improvement.

This practice encourages the conscious development of critical thinking by comparing past experiences with current knowledge and exploring alternative solutions.

After a particularly challenging case, a nurse reflects on their decision-making process, exploring what worked well and what could have been done differently.

2. Meeting with Colleagues: Collaborative Learning for Critical Thinking

Regular interactions with colleagues foster a collaborative learning environment. Sharing experiences, discussing diverse viewpoints, and providing constructive feedback enhance critical thinking skills .

Colleagues’ insights can challenge assumptions and broaden perspectives, ultimately leading to more well-rounded clinical judgments.

A nursing team gathers to discuss a recent complex case, sharing their perspectives, insights, and lessons learned to collectively improve patient care strategies.

3. Concept Mapping: Visualizing Complexity

Concept mapping is an excellent technique to synthesize intricate patient information. By creating visual representations of patient problems and interventions, nurses can identify relationships and patterns that might not be apparent otherwise.

This strategy aids in comprehensive care planning and encourages nurses to think holistically about patient care.

Creating a concept map to connect patient symptoms, diagnostics, and interventions reveals patterns that help the nurse formulate a comprehensive care plan.

4. Socratic Questioning: Digging Deeper into Situations

The art of Socratic questioning involves asking probing questions that lead to deeper understanding.

Applying this technique allows nurses to uncover assumptions, examine inconsistencies, and explore multiple viewpoints.

This approach is especially valuable when reviewing patient history, discussing conditions, and planning care strategies.

When assessing a patient’s deteriorating condition, a nurse asks probing questions to uncover potential underlying causes and prioritize appropriate interventions.

5. Inductive and Deductive Reasoning: From Specifics to Generalizations

Developing skills in both inductive and deductive reasoning equips nurses to analyze situations from different angles.

Inductive reasoning involves drawing conclusions from specific observations, while deductive reasoning starts with general premises to arrive at specific conclusions.

Proficient use of these methods enhances nurses’ ability to make accurate clinical judgments.

When encountering a series of patients with similar symptoms, a nurse uses inductive reasoning to identify a common pattern and deduce potential causes.

6. Distinguishing Statements: Fact, Inference, Judgment, and Opinion

Clear thinking demands the ability to differentiate between statements of fact, inference, judgment, and opinion.

Nurses must critically evaluate information sources, ensuring they rely on evidence-based practice.

This skill safeguards against misinformation and supports informed decision-making.

While reviewing a patient’s history, a nurse differentiates factual medical information from inferences and subjective judgments made by different healthcare professionals.

7. Clarifying Assumptions: Promoting Effective Communication

Recognizing assumptions and clarifying their underlying principles is vital for effective communication. Nurses often hold differing assumptions, which can impact patient care.

By acknowledging these assumptions and encouraging open discussions, nursing teams can collaboratively create care plans that align with patients’ best interests.

Before suggesting a treatment plan, a nurse engages in a conversation with a patient to understand their cultural beliefs and preferences, ensuring assumptions are not made.

8. Clinical Simulations: Learning through Virtual Scenarios

Clinical simulations provide nurses with a risk-free environment to practice decision-making and problem-solving skills.

These virtual scenarios mimic real-life patient situations and allow nurses to test different approaches, assess outcomes, and reflect on their choices.

By engaging in simulations, nurses can refine their critical thinking abilities, learn from mistakes, and gain confidence in their clinical judgment.

Engaging in a simulated scenario where a patient’s condition rapidly changes challenges a nurse’s decision-making skills in a controlled environment.

9. Case Studies and Grand Rounds: Analyzing Complex Cases

Engaging in case studies and participating in grand rounds exposes nurses to complex patient cases that require in-depth analysis.

Working through these scenarios encourages nurses to consider various factors, potential interventions, and their rationale.

Discussing these cases with colleagues and experts fosters collaborative critical thinking and widens the spectrum of possible solutions.

Nurses participate in grand rounds, discussing a challenging case involving multiple medical specialties, encouraging a holistic approach to patient care.

10. Continuing Education and Lifelong Learning: Expanding Knowledge

Staying up-to-date with the latest advancements in nursing and healthcare is crucial for effective critical thinking.

Pursuing continuing education opportunities, attending conferences, and engaging in self-directed learning keeps nurses informed about new research, technologies, and best practices.

This continuous learning enriches their knowledge base, enabling them to approach patient care with a well-rounded perspective.

Attending a nursing conference on the latest advancements in wound care equips a nurse with evidence-based techniques to improve patient outcomes.

11. Debates and Discussions: Encouraging Thoughtful Dialogue

Organizing debates or participating in structured discussions on healthcare topics stimulates critical thinking.

Engaging in debates requires researching and presenting evidence-based arguments, promoting the evaluation of different perspectives.

Nurses can exchange insights, challenge assumptions, and refine their ability to defend their viewpoints logically.

Engaging in a debate on the pros and cons of a new treatment method encourages nurses to critically analyze different viewpoints and strengthen their own understanding.

12. Multidisciplinary Collaboration: Gaining Insights from Various Disciplines

Collaborating with professionals from diverse healthcare disciplines enriches nurses’ critical thinking.

Interacting with doctors, pharmacists, therapists, and other experts allows nurses to benefit from different viewpoints and approaches.

This cross-disciplinary collaboration broadens their understanding and encourages innovative problem-solving.

Collaborating with physical therapists, nutritionists, and pharmacists helps a nurse develop a holistic care plan that addresses all aspects of a patient’s recovery.

13. Ethical Dilemma Analysis: Balancing Patient Autonomy and Best Practice

Ethical dilemmas are common in nursing practice. Analyzing these situations requires nurses to weigh the principles of beneficence, non-maleficence, autonomy, and justice.

By critically examining ethical scenarios, nurses develop the capacity to navigate morally complex situations, prioritize patient welfare, and make ethically sound decisions.

When faced with a patient’s refusal of treatment due to religious beliefs, a nurse evaluates the ethical considerations, respects autonomy, and seeks alternatives.

14. Root Cause Analysis: Investigating Adverse Events

When adverse events occur, performing a root cause analysis helps identify the underlying causes and contributing factors.

Nurses engage in a systematic process of analyzing events, exploring the “5 Whys” technique , and developing strategies to prevent similar occurrences in the future.

This approach cultivates a thorough and analytical approach to problem-solving.

After a medication error, a nurse leads a root cause analysis to identify system failures and implement preventive measures to enhance patient safety.

15. Creative Thinking Exercises: Expanding Solution Repertoire

Encouraging creative thinking through brainstorming sessions or scenario-based exercises widens the range of possible solutions nurses consider.

By thinking outside the box and exploring innovative approaches, nurses develop adaptable problem-solving skills that can be applied to complex patient care challenges.

Brainstorming creative approaches to comfort a distressed pediatric patient empowers a nurse to find innovative methods beyond routine interventions.

16. Journal Clubs: Fostering Evidence-Based Discussion

Participating in journal clubs involves healthcare professionals coming together to dissect recent research articles.

This practice ignites critical thinking by allowing nurses to evaluate study methodologies, scrutinize findings, and consider the implications for their practice.

Engaging in evidence-based discussions not only cultivates a culture of critical inquiry but also reinforces continuous learning.

At the monthly journal club meeting, Nurse Mark engages in a discussion on a recent research article focusing on pain management strategies for post-operative patients.

The group analyzes the study design, scrutinizes the findings, and considers the potential implications for their practice.

During the discussion, Mark raises thought-provoking questions about the study’s methodology and suggests potential applications in their hospital’s patient care protocols.

This active participation in journal clubs not only refines Mark’s critical thinking but also instills evidence-based practices into his nursing approach.

17. Critical Reflection Groups: Collaborative Learning and Analysis

Similarly, establishing critical reflection groups, where nurses meet regularly to discuss experiences, cases, and challenges, fosters collective learning.

These sessions encourage the exchange of diverse perspectives, enriching the analysis process and ultimately enhancing patient care strategies.

Through shared insights and discussions, nurses can refine their clinical reasoning and broaden their problem-solving capabilities.

Nurse Emma actively participates in critical reflection groups in order to broaden her clinical knowledge. During a recent meeting, the group tackled a difficult patient case with complicated symptomatology.

Emma suggests alternative diagnostic pathways based on her own experiences. Emma’s critical thinking skills are honed as a result of the group’s dynamic interaction, which also emphasizes the importance of collaborative decision-making in complex scenarios.

18. Mindfulness and Reflection Practices: Enhancing Self-Awareness

Mindfulness techniques, such as meditation and deep breathing, encourage self-awareness and a clear mind.

Engaging in these practices helps nurses become more attuned to their thoughts and emotions, leading to better self-regulation and improved decision-making during high-pressure situations.

Engaging in mindfulness exercises before a demanding shift helps a nurse maintain focus, manage stress, and make clear-headed decisions.

19. Problem-Based Learning: Applying Knowledge in Real Scenarios

Problem-based learning involves presenting nurses with real-world patient cases and encouraging them to collaboratively solve the problems.

This approach bridges the gap between theoretical knowledge and practical application, fostering critical thinking through active problem-solving.

Working through a simulated patient case challenges nurses to apply theoretical knowledge to practical situations, refining their clinical reasoning.

20. Self-Assessment and Feedback: Evaluating Decision-Making Skills

Regularly assessing one’s own decision-making process and seeking feedback from peers and mentors is essential for improvement.

Reflecting on past decisions, considering alternative approaches, and understanding the rationale behind them contribute to the refinement of critical thinking skills.

A nurse evaluates their performance after a patient’s unexpected complication, seeking feedback from peers and mentors to identify areas for improvement.

21. Cultural Competence Training: Navigating Diverse Perspectives

Cultural competence training enhances critical thinking by enabling nurses to understand the diverse cultural beliefs and practices of patients.

This knowledge is vital for providing patient-centered care, as it encourages nurses to think critically about the unique needs of each individual.

A nurse attends cultural competence training to understand the dietary preferences of a diverse patient population, ensuring respectful and patient-centered care.

22. Active Listening and Empathetic Communication: Gathering Insights

Active listening and empathetic communication with patients and their families enable nurses to gather comprehensive information about their conditions, concerns, and preferences.

This data forms the basis for critical analysis and informed decision-making in patient care.

Through attentive listening, a nurse uncovers a patient’s underlying concerns, leading to an informed care plan that addresses both medical needs and emotional well-being.

23. Mentorship and Preceptorship: Learning from Experienced Professionals

Having a mentor or preceptor provides novice nurses with the opportunity to learn from experienced professionals.

Mentors guide critical thinking by sharing their insights, challenging assumptions, and offering guidance in complex situations. This relationship fosters growth and expertise development.

A novice nurse gains valuable insight from a mentor, who guides them through complex cases, offering real-world wisdom and refining critical thinking skills.

24. Self-Assessment and Feedback: Evaluating Decision-Making Skills

Reflecting on past decisions, considering alternative approaches, and understanding the rationale behind them contribute to the refinement of critical thinking skills .

Nurse Sarah regularly takes time to assess her decision-making skills by reviewing past patient cases. After a challenging case involving conflicting symptoms, she reflects on her initial approach, the outcomes, and what she could have done differently.

She seeks feedback from her senior colleague, who provides insights on alternative diagnostic paths. Sarah’s self-assessment and feedback-seeking process enable her to identify areas for improvement and refine her critical thinking in similar situations.

  • Clinical Reasoning In Nursing (Explained W/ Example)
  • 8 Stages Of The Clinical Reasoning Cycle
  • What is Critical Thinking in Nursing? (Explained W/ Examples)

Enhancing critical thinking skills is an ongoing journey that transforms nursing practice.

Reflective journaling, collaborative learning, concept mapping, Socratic questioning , reasoning techniques, distinguishing statements, and clarifying assumptions all play integral roles in nurturing these skills.

By incorporating these strategies into their daily routines, nurses can improve their critical thinking skills.

Additionally, this will help nurses in navigating the complexities of the healthcare field with confidence, expertise, and the ability to make well-informed decisions that improve patient outcomes.

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Developing Critical-Thinking Skills in Student Nurses

April 8, 2020

View all blog posts under Articles | View all blog posts under Master of Science in Nursing

Nurse educators should ensure that students can incorporate critical thinking skills into everyday practice.

Critical thinking skills for nurses include problem-solving and the ability to evaluate situations and make recommendations. Done correctly, critical thinking results in positive patient outcomes, Srinidhi Lakhanigam, an RN-BSN, said in a Minority Nurse article.

“Critical thinking is the result of a combination of innate curiosity; a strong foundation of theoretical knowledge of human anatomy and physiology, disease processes, and normal and abnormal lab values; and an orientation for thinking on your feet,” Lakhanigam said in “Critical Thinking: A Vital Trait for Nurses.” “Combining this with a strong passion for patient care will produce positive patient outcomes. The critical thinking nurse has an open mind and draws heavily upon evidence-based research and past clinical experiences to solve patient problems.”

Since the 1980s, critical thinking has become a widely discussed component of nurse education, and a significant factor for National League for Nursing (NLN) nursing school accreditation. Nursing school curriculum is expected to teach students how to analyze situations and develop solutions based on high-order thinking skills. For nurse educators who are responsible for undergraduate and graduate learners , teaching critical thinking skills is crucial to the future of healthcare.

Characteristics of Critical Thinkers

A landmark 1990 study found critical thinkers demonstrate similar characteristics. The Delphi Report by the American Philosophical Association (APA) identified these cognitive skills common to critical thinkers:


Critical thinkers are able to categorize and decode the significance and meaning of experiences, situations, data, events, and rules, among others.

Critical thinkers can examine varying ideas, statements, questions, descriptions and concepts and analyze the reasoning.

Critical thinkers consider relevant information from evidence to draw conclusions.


Critical thinkers state the results of their reasoning through sound arguments.


Critical thinkers monitor their cognitive abilities to reflect on their motivations and correct their mistakes.

In addition, critical thinkers are well-informed and concerned about a wide variety of topics. They are flexible to alternative ideas and opinions and are honest when facing personal biases. They have a willingness to reconsider their views when change is warranted.

In nursing, critical thinking and clinical reasoning are inextricably linked, columnist Margaret McCartney said in the BMJ . While experienced nurses are able to make sound clinical judgements quickly and accurately, novice nurses find the process more difficult, McCartney said in “Nurses must be allowed to exercise professional judgment.”

“Therefore, education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills,” McCartney said. “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 judgments and decisions are reached in complex healthcare environments.”

Teaching Critical Thinking to Nurses

In 2015, a study in the Journal of College Teaching & Learning found a positive correlation between critical thinking skills and success in nursing school. The study said, “It is the responsibility of nurse educators to ensure that nursing graduates have developed the critical thinking abilities necessary to practice the profession of nursing.”

To help new nurses develop critical-thinking skills, the professional development resources provider Lippincott Solutions recommended nurse educators focus on the following in the classroom:

Promoting interactions

Collaboration and learning in group settings help nursing students achieve a greater understanding of the content.

Asking open-ended questions

Open-ended questions encourage students to think about possible answers and respond without fear of giving a “wrong” answer.

Providing time for students to reflect on questions

Student nurses should be encouraged to deliberate and ponder questions and possible responses and understand that perhaps the immediate answer is not always the best answer.

Teaching for skills to transfer

Educators should provide opportunities for student nurses to see how their skills can apply to various situations and experiences.

In the Minority Nurse article, Lakhanigam also said students who thirst for knowledge and understanding make the best critical thinkers. The author said novice nurses who are open to constructive criticism can learn valuable lessons that will translate into successful practice.

At the same time, however, critical thinking skills alone will not ensure success in the profession , Lakhanigam said in the article. Other factors count as well.

“A combination of open-mindedness, a solid foundational knowledge of disease processes, and continuous learning, coupled with a compassionate heart and great clinical preceptors, can ensure that every new nurse will be a critical thinker positively affecting outcomes at the bedside,” Lakhanigam said.

Another element that ensures success as both an educator and student is earning a nursing degree from a school that focuses on student accomplishments. At Duquesne University’s School of Nursing, students learn best practices in healthcare. The online master’s in nursing program prepares educators to train the next generation of nurses.

About Duquesne University’s online Master of Science in Nursing (MSN) Program

Duquesne University’s MSN curriculum for the Nursing Education and Faculty Role program focuses on preparing registered nurses (RNs) for careers as nurse educators. Students enrolled in the online master’s in nursing program learn the skills needed in the classroom and for clinical training. RNs learn how to empower student nurses to work to their fullest potential.

The MSN program is presented entirely online, so RNs can pursue their career goals and continue personal responsibilities simultaneously.  Duquesne University has been recognized for excellence in education as a U.S. News & World Report Best Online Graduate Nursing Program and best among Roman Catholic universities in the nation.

For more information, contact Duquesne University today.

Critical Thinking: A Vital Trait for Nurses: Minority Nurse

Consensus Descriptions of Core CT Skills And Sub-Skills: Delphi

Margaret McCartney: Nurses must be allowed to exercise professional judgment: BMJ

Predicting Success in Nursing Programs: Journal of College Teaching & Learning

Turning New Nurses Into Critical Thinkers: Wolters Kluwer

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Critical Thinking TACTICS for Nurses: Achieving the IOM Competencies

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© 2010 Jones and Bartlett, Sudbury, MA. ISBN-13: 9780763765842 (second edition)


DOI: https://doi.org/10.1016/S2155-8256(15)30371-9


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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

Critical Thinking in Nursing

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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About the author

Hannah Meinke

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Posted in General Nursing

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  • Critical Thinking

Q&A: What is critical thinking and when would you use critical thinking in the clinical setting?

(Write 2-3 paragraphs)

In literature ‘critical thinking’ is often used, and perhaps confused, with problem-solving and clinical decision-making skills and clinical reasoning. In practice, problem-solving tends to focus on the identification and resolution of a problem, whilst critical thinking goes beyond this to incorporate asking skilled questions and critiquing solutions.

Critical thinking has been defined in many ways, but is essentially the process of deliberate, systematic and logical thinking, while considering bias or assumptions that may affect your thinking or assessment of a situation. In healthcare, the clinical setting whether acute care sector or aged care critical thinking has generally been defined as reasoned, reflective thinking which can evaluate the given evidence and its significance to the patient’s situation. Critical thinking occasionally involves suspension of one’s immediate judgment to adequately evaluate and appraise a situation, including questioning whether the current practice is evidence-based. Skills such as interpretation, analysis, evaluation, inference, explanation, and self-regulation are required to interpret thinking and the situation. A lack of critical thinking may manifest as a failure to anticipate the consequences of one’s actions.

Critical thinking is that mode of thinking – about any subject, content, or problem — in which the thinker improves the quality of his or her thinking by skillfully taking charge of the structures inherent in thinking and imposing intellectual standards upon them.

The Paul-Elder framework has three components:

  • The elements of thought (reasoning)
  • The intellectual standards that should be applied to the elements of reasoning
  • The intellectual traits associated with a cultivated critical thinker that result from the consistent and disciplined application of the intellectual standards to the elements of thought.

Critical thinking can be defined as, “the art of analysing and evaluating thinking with a view to improving it”. The eight Parts or Elements of Thinking involved in critical thinking:

  • All reasoning has a purpose (goals, objectives).
  • All reasoning is an attempt to figure something out, to settle some question, to solve some problem .
  • All reasoning is based on assumptions (line of reasoning, information taken for granted).
  • All reasoning is done from some point of view.
  • All reasoning is based on data, information and evidence .
  • All reasoning is expressed through, and shaped by, concepts and ideas .
  • All reasoning contains inferences or interpretations by which we draw conclusions and give meaning to data.
  • All reasoning leads somewhere or has implications and consequence.

Q&A: To become a nurse requires that you learn to think like a nurse. What makes the thinking of a nurse different from a doctor, a dentist or an engineer?

It is how we view the health care consumer or aged care consumer, and the type of problems nurses deal with in clinical practice when we engage in health care patient centred care. To think like a nurse requires that we learn the content of nursing; the ideas, concepts, ethics and theories of nursing and develop our intellectual capacities and skills so that we become disciplined, self-directed, critical thinkers.

As a nurse you are required to think about the entire patient/s and what you have learnt as a nurse including; ideas, theories, and concepts in nursing. It is important that we develop our skills so that we become highly proficient critical thinkers in nursing.

In nursing, critical thinkers need to be:

Nurses need to use language that will clearly communicate a lot of information that is key to good nursing care, for handover and escalation of care for improving patient safety and reducing adverse outcomes, some organisations use the iSoBAR (identify–situation–observations–background–agreed plan–read back) format. Firstly, the “i”, for “identify yourself and the patient”, placed the patient’s identity, rather than the diagnosis, in primary position and provided a method of introduction. (This is particularly important when teams are widely spread geographically.) The prompt, “S” (“situation”) “o” for “observations”, was included to provide an adequate baseline of factual information on which to devise a plan of care. and “B” (“background”), “A” “agreed plan” and “R” “read back” to reinforce the transfer of information and accountability.

In clinical practice experienced nurses engage in multiple clinical reasoning episodes for each patient in their care. An experienced nurse may enter a patient’s room and immediately observe significant data, draw conclusions about the patient and initiate appropriate care. Because of their knowledge, skill and experience the expert nurse may appear to perform these processes in a way that seems automatic or instinctive. However, clinical reasoning is a learnt skill.

Key critical thinking skills – the clinical reasoning cycle / critical thinking process

To support nursing students in the clinical setting, breakdown the critical thinking process into phases;

  • Decide/identify

This is a dynamic process and nurses often combine one or more of the phases, move back and forth between them before reaching a decision, reaching outcomes and then evaluating outcomes.

For nursing students to learn to manage complex clinical scenarios effectively, it is essential to understand the process and steps of clinical reasoning. Nursing students need to learn rules that determine how cues shape clinical decisions and the connections between cues and outcomes.

Start with the Patient – what is the issue? Holistic approach – describe or list the facts, people.

Collect information – Handover report, medical and nursing, allied health notes. Results, patient history and medications.

  • New information – patient assessment

Process Information – Interpret- data, signs and symptoms, normal and abnormal.

  • Analyse – relevant from non-relevant information, narrow down the information
  • Evaluate – deductions or form opinions and outcomes

Identify Problems – Analyse the facts and interferences to make a definitive diagnosis of the patients’ problem.

Establish Goals – Describe what you want to happen, desired outcomes and timeframe.

Take action – Select a course of action between alternatives available.

Evaluate Outcomes – The effectiveness of the actions and outcomes. Has the situation changed or improved?

Reflect on process and new learning – What have you learnt and what would you do differently next time.

Scenario: Apply the clinical reasoning cycle, see below, to a scenario that occurred with a patient in your clinical practice setting. This could be the doctor’s orders, the patient’s vital signs or a change in the patient’s condition.

(Write 3-5 paragraphs)

Clinical reasoning cycle - Critical Thinking - Thought Leadership

Important skills for critical thinking

Some skills are more important than others when it comes to critical thinking. The skills that are most important are:

  • Interpreting – Understanding and explaining the meaning of information, or a particular event.
  • Analysing – Investigating a course of action, that is based upon data that is objective and subjective.
  • Evaluating – This is how you assess the value of the information that you have. Is the information relevant, reliable and credible?

This skill is also needed to determine if outcomes have been fully reached.

Based upon those three skills, you can use clinical reasoning to determine what the problem is.

These decisions have to be based upon sound reasoning:

  • Explaining – Clearly and concisely explaining your conclusions. The nurse needs to be able to give a sound rationale for their answers.
  • Self-regulating – You have to monitor your own thought processes. This means that you must reflect on the process that lead to the conclusion. Be on alert for bias and improper assumptions.

Critical thinking pitfalls

Errors that occur in critical thinking in nursing can cause incorrect conclusions. This is particularly dangerous in nursing because an incorrect conclusion can lead to incorrect clinical actions.

Illogical Processes

A common illogical thought process is known as “appeal to tradition”. This is what people are doing when they say it’s always been done like this. Creative, new approaches are not tried because of tradition.

All people have biases. Critical thinkers are able to look at their biases and not let them compromise their thinking processes.

Biases can complicate decision making, communication and ultimately effect patient care.

Closed Minded

Being closed-minded in nursing is dangerous because it ignores other team members points of view. Essential input from other experts, as well as patients and their families are also ignored which ultimately impacts on patient care. This means that fewer clinical options are explored, and fewer innovative ideas are used for critical thinking to guide decision making.

So, no matter if you are an intensive care nurse, community health nurse or a nurse practitioner, you should always keep in mind the importance of critical thinking in the nursing clinical setting.

It is essential for nurses to develop this skill: not only to have knowledge but to be able to apply knowledge in anticipation of patients’ needs using evidence-based care guidelines.

American Management Association (2012). ‘AMA 2012 Critical Skills Survey: Executive Summary’. (2012). American Management Association. http://playbook.amanet.org/wp-content/uploads/2013/03/2012-Critical-Skills-Survey-pdf.pdf   Accessed 5 May 2020.

Korn, M. (2014). ‘Bosses Seek ‘Critical Thinking,’ but What Is That?,’ The Wall Street Journal . https://www.wsj.com/articles/bosses-seek-critical-thinking-but-what-is-that-1413923730?tesla=y&mg=reno64-wsj&url=http://online.wsj.com/article/SB12483389912594473586204580228373641221834.html#livefyre-comment Accessed 5 May 2020.

School of Nursing and Midwifery Faculty of Health, University of Newcastle. (2009). Clinical reasoning. Instructors resources. https://www.newcastle.edu.au/__data/assets/pdf_file/0010/86536/Clinical-Reasoning-Instructor-Resources.pdf  Accessed 11 May 2020

The Value of Critical Thinking in Nursing + Examples. Nurse Journal social community for nurses worldwide. 2020.  https://nursejournal.org/community/the-value-of-critical-thinking-in-nursing/ Accessed 8 May 2020.

Paul And Elder (2009) Have Defined Critical Thinking As: The Art of Analysing And Evaluating …

https://www.chegg.com/homework-help/questions-and-answers/paul-elder-2009-defined-critical-thinking-art-analyzing-evaluating-thinking-view-improving-q23582096 Accessed 8 May 2020 .

Cody, W.K. (2002). Critical thinking and nursing science: judgment, or vision? Nursing Science Quarterly, 15(3), 184-189.

Facione, P. (2011). Critical thinking: What it is and why it counts. Insight Assessment , ISBN 13: 978-1-891557-07-1.

McGrath, J. (2005). Critical thinking and evidence- based practice. Journal of Professional Nursing, 21(6), 364-371.

Porteous, J., Stewart-Wynne, G., Connolly, M. and Crommelin, P. (2009). iSoBAR — a concept and handover checklist: the National Clinical Handover Initiative. Med J Aust 2009; 190 (11): S152.

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


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

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

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

© 2020 John Wiley & Sons Ltd.

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How can critical thinking make me a better nurse?

Cliff kilgore posted 14 september 2018 - 10:34.

how to improve critical thinking as a nurse

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Critical thinking ability of new graduate and experienced nurses

Laura j. fero.

Doctoral Candidate, University of Pittsburgh School of Nursing, Pennsylvania, USA

Catherine M. Witsberger

Clinical Nurse Educator, Nursing Education and Research, University of Pittsburgh Medical Center, Pennsylvania, USA

Susan W. Wesmiller

Director, Nursing Education and Research, University of Pittsburgh Medical Center, Pennsylvania, USA

Thomas G. Zullo

Professor Emeritus, Dental Public Health, University of Pittsburgh, Pennsylvania, USA

Leslie A. Hoffman

Professor and Chair, Department of Acute/Tertiary Care, University of Pittsburgh School of Nursing, Pennsylvania, USA

This paper is a report of a study to identify critical thinking learning needs of new and experienced nurses.

Concern for patient safety has grown worldwide as high rates of error and injury continue to be reported. In order to improve patient safety, nurses must be able to recognize changes in patient condition, perform independent nursing interventions, anticipate orders and prioritize.

In 2004–2006, a consecutive sample of 2144 newly hired nurses in a university-affiliated healthcare system completed the Performance Based Development System Assessment consisting of 10 videotaped vignettes depicting change in patient status. Results were reported as meeting or not meeting expectations. For nurses not meeting expectations, learning needs were identified in one of six sub-categories.

Overall, 74.9% met assessment expectations. Learning needs identified for nurses not meeting expectations included initiating independent nursing interventions (97.2%), differentiation of urgency (67%), reporting essential clinical data (65.4%), anticipating relevant medical orders (62.8%), providing relevant rationale to support decisions (62.6%) and problem recognition (57.1%). Controlling for level of preparation, associate ( P = 0.007) and baccalaureate ( P < 0.0001) nurses were more likely to meet expectations as years of experience increased; a similar trend was not seen for diploma nurses ( P = 0.10). Controlling for years of experience, new graduates were less likely to meet expectations compared with nurses with ≥10 years experience ( P = 0.046).

Patient safety may be compromised if a nurse cannot provide clinically competent care. Assessments such as the Performance Based Development System can provide information about learning needs and facilitate individualized orientation targeted to increase performance level.


Concern for patient safety has grown worldwide as high rates of error and injury continue to be reported. A recent Commonwealth Fund international survey of six nations showed that between one-quarter and one-third of patients with health problems experienced medical, medication, or testing errors. A number of countries, including the United States of America, Australia, Canada, Germany, New Zealand and the United Kingdom, have identified a need for improvement in the coordination and delivery of care ( Schoen et al. 2005 ) and a reduction in preventable medical errors ( Kohn & Donaldson 2000 ).

Patient safety can be directly affected by the critical thinking ability of a nurse. Nurses must have the ability to recognize changes in patient condition, perform independent nursing interventions, anticipate orders and prioritize ( Buerhaus et al. 2005 ). These actions require critical thinking ability, advanced problem-solving skills and the ability to communicate clearly ( NACNEP 1996 ). Using root cause analysis, the Joint Commission on the Accreditation of Healthcare Organizational Standards (JCAHO) identified orientation, training, and competence assessment as top factors contributing to patient safety errors over the past 10 years (1995–2005) ( JCAHO 2006 ).

New graduate nurses practise at the novice or advanced beginner level ( Benner 1984 ). They are at the early stage of developing a skill set and applying critical thinking. Nursing shortages and budgetary issues may mean that initial orientation periods for new graduates are shortened ( AORN 2006 ), a potential factor prompting the increase in errors. One means of determining whether new graduates and more experienced nurses can demonstrate the critical thinking ability necessary to ensure patient safety involves asking them to complete a performance-based evaluation.

Patient safety

Patient safety is at the center of today’s healthcare system reform. According to the Institute of Medicine (IOM), more than 98,000 people in the United States of America (USA) die and more than one million patients suffer injuries each year ( Kohn & Donaldson 2000 ). Thirty to 40 percent of every US dollar spent on healthcare is lost to inappropriate use, poor communication, and inefficiency ( Proctor et al. 2005 ). The IOM aims for the 21st century healthcare system include providing safe, effective, patient-centered care that is timely, efficient, and equitable ( IOM 2001 ).

Nursing competence plays a large role in assuring patient safety ( IOM 2004 ). A majority of sentinel events occur in acute care settings, where new graduate nurses traditionally begin their professional careers ( JCAHO 2006 ). According to the Joint Commission International Center for Patient Safety, over 70% of sentinel events reported resulted in a patient’s death and 10% resulted in loss of function ( JCRINC 2007 ). The inability of a nurse to set priorities and work effectively and efficiently may delay patient treatment in a critical situation and result in serious life-threatening consequences ( Redfern et al. 2002 ).

The definition of nursing competence has been extensively debated ( Redfern et al. 2002 ). Competence can be the subject of objective evaluation which includes standardized measurement or subjective observational reporting. In the USA, the only universally accepted method of evaluating competence occurs at entry to practise via the National Council Licensure Examination-Registered Nurse or NCLEX-RN© ( NCSBN 2007 ). This examination does not, however, address ongoing assessment, and there is no agreement on how continued assessment should be accomplished. Current measurement tools do not take into account the evolution of practice with experience or identify areas of weakness in which healthcare organizations should focus orientation or remediation efforts ( NCSBN 2005 ). Therefore, the IOM has encouraged the development of more effective methods to identify and take action when providers are unsafe ( Kohn & Donaldson 2000 ).

Benner (1984) argues that competency assessment should be grounded in actual practice, under pressure, and over time. She further argues that assessment should be related to patient outcome and be context-specific ( Benner 1984 ). The Performance Based Development System (PBDS) assessment is an attempt to evaluate actual performance and remediate deficiencies within the orientation period.

Critical thinking

Critical thinking has been discussed since the time of Socrates and its dimensions have been explored by numerous scholars from Thomas Aquinas to John Dewey ( Facione 1990 ). However, it was not until the late 1980s that the nursing profession began to question how critical thinking relates to clinical practice and to evaluate ways to measure how effectively the educational system achieves critical thinking competence through its curriculum. This movement was started, in part, to address the directive of the US National League of Nursing to measure critical thinking as an outcome criterion for the accreditation of nursing programmes ( AACN 1998 ; Rubenfeld & Scheffer 1999 , Scheffer & Rubenfeld 2000 , Simpson & Courtney 2002 ).

There is no widely accepted definition of critical thinking in the field of nursing, psychology, or education ( Simpson & Courtney 2002 ). Scholars have found the concept very difficult to quantify and therefore to measure, leading to a wide array of interpretations ( Hynes & Bennett 2004 ). In 1988, a Delphi panel was established at the request of the American Philosophical Association to synthesize expert opinion on the concept of critical thinking. The panel identified interpretation, analysis, evaluation, inference, explanation, and self-regulation as necessary components ( Facione 1990 ).

The term critical thinking is often used interchangeably with problem-solving, clinical decision-making, and creative thinking in the nursing literature ( Simpson & Courtney 2002 ). Problem-solving focuses on identification and resolution, whereas critical thinking goes beyond this and incorporates asking questions and critiquing solutions. The notion of clinical decision-making focuses attention on the clinical nature of a problem but falls short of facilitating understanding of the broader spectrum of the issue. Decision-making and critical thinking need to occur concurrently to produce reasoning, clarification, and potential solutions. Creative thinking is a combination of imagination and knowledge ( Simpson & Courtney 2002 ). It helps one to understand solutions that have failed and is certainly part of the subset of skills necessary to be an effective critical thinker.

In order to advance practice, it is necessary to develop and evaluate strategies to help nurses develop essential skills. Most studies show that there is a progression in nursing students’ ability to critically think through their education tenure ( Colucciello 1997 , Thompson & Rebeschi 1999 , Giddens & Gloeckner 2005 ). However, the literature does not identify specific areas of needed attention. In addition, most studies take place in the context of a nursing education programme, rather than following graduation ( Colucciello 1997 , May et al. 1999 , Thompson & Rebeschi 1999 , Beckie et al. 2001 , Chau et al. 2001 , Giddens & Gloeckner 2005 ). To develop in new graduates the responsibilities inherent in clinical practice most effectively, new approaches are needed, and these approaches should be objectively evaluated to determine their effectiveness prior to implementation.

The Performance Based Development System

The PBDS is designed to provide such an assessment ( Performance Management Services, Inc. 2006 ). The Clinical Judgment portion of the PBDS assessment consists of 10 videotaped vignettes which depict common clinical problems that nurses may encounter on a medical-surgical unit (e.g. onset of dyspnea, anxiety, or change in mental status). Respondents are asked to view each vignette and then state, in writing, what they think the problem is, actions they would take in response, and their rationale. The PBDS assessment is designed to identify critical thinking learning needs and assist in the development of an individualized orientation action plan to prepare better nurses for safe clinical practice ( Performance Management Services, Inc. 2006 ). Although the PBDS assessment has been in use since 1985 in over 500 healthcare organizations, reports of its use are limited to descriptive studies ( del Bueno 2001 , 2005 , Performance Management Services, Inc. 2006 ).

Conceptual framework

The purpose of this study was to identify critical thinking learning needs of new and experienced nurses with varying levels of preparation (diploma, associate, baccalaureate degree). The expectation was that nurses having more years of experience and those prepared at the baccalaureate level would have a higher rate of meeting expectations on the PBDS assessment. The theoretical framework guiding this expectation was Patricia Benner’s Novice to Expert Model ( Benner 1984 ). This model was developed through descriptive research using the Dreyfus Model of Skill Acquisition, which identified five levels of competence. These levels are novice, advanced beginner, competent, proficient and expert ( Dreyfus 1980 ). The novice level applies to nurses who have no experience in the environment in which they are expected to perform ( Benner 1984 ). For the purpose of this study, a novice was defined as a new nursing graduate with limited exposure to independently managing a critical situation who operates in a limited and prescribed way. An advanced beginner performs at a marginally acceptable level. At this level, nurses recognize the meaning of a critical situation but may not understand or anticipate the care needed. A competent practitioner begins to see their actions in terms of long-range planning ( Benner 1984 ). A competent nurse is able to determine which aspects of a situation are considered more relevant. This practice level entails planning, considering, analyzing, and contemplating which action to take. After reaching the proficient level, a nurse begins to perceive the meaning of a situation through reflection on previous experience, and often modifies plans based on the response to the event. At the expert level, a nurse has an intuitive grasp of a critical situation and understands deeply what is needed to ensure resolution ( Benner 1984 ).

The novice to expert framework is the basis for a number of clinical ladders in healthcare and is often used to formalize promotional structures and drive work role competencies ( Benner 1984 ). In addition, it has served as a catalyst for staff development programmes with the aim of facilitating nursing excellence. The novice to expert framework has been applied to gain insight into managing clinical problems, practice skills, and communication through innovative teaching methods ( Larew et al. 2006 ).

The aim of the study was to identify critical thinking learning needs of new and experienced nurses.

The specific objectives were to (1) describe the overall rate at which nurses meet expectations on the PBDS assessment; (2) examine the relationship between meeting PBDS expectations and years of nursing experience controlling for preparation level; and (3) examine the relationship between meeting PBDS expectations and nurses’ preparation level (diploma, associate, baccalaureate) controlling for years of nursing experience.

The study was a post hoc retrospective analysis of PBDS assessment data collected prospectively during the initial 2 weeks of employment of 2144 newly hired nurses.


All nurses employed by the same university healthcare system from 1 January 2004 to 30 September 2006 were eligible for inclusion in the study. The healthcare system which provided the de-identified data included 19 acute care, specialty, community and regional hospitals located in southwestern Pennsylvania, USA. All newly hired nurses were assessed using the PBDS in order to customize their orientation at the beginning of their employment tenure.

The sample included nurses prepared at the diploma, associate or baccalaureate level. Diploma programmes offer hospital-based nursing preparation that is typically 2 years in length; courses in the programme are taught by hospital-based educators and may include some college credit. Graduates receive a nursing diploma and are prepared to function at the staff nurse level in hospitals or inpatient facilities. Associate degree programmes are provided by a community college and are typically 2 years in length. Graduates receive an associate degree and are prepared to function at the staff nurse level in hospitals or inpatient facilities. Baccalaureate-prepared nurses attend a 4-year programme offered by a college or university. Graduates receive a baccalaureate degree and are prepared to assume leadership roles in hospitals, inpatient facilities and community settings ( All Star Directories, Inc. 2002–2008 ).

We achieved a power of 90% to detect an effect size (W) of 0.0813 using a chi-square test of independence with 3 d.f. (Specific Aim 2) and 90% power to detect an effect size (W) of 0.0768 using a chi-square test of independence with 2 d.f. (Specific Aim 3) for two-sided hypothesis testing at a statistical significance level of 0.05. Specific Aim 1 was descriptive and not included in sample size estimates.

Data collection

Data were obtained from files of the Nursing Education Department and included demographic data and hard copy summaries of the PBDS assessments. Data regarding the number of individuals who took the PBDS, years of experience, level of preparation and ratings (met, did not meet expectations) were obtained ( Table 1 ). Hard copy records of nurses who did not meet expectations on the assessment were identified. All personal identifiers were removed and de-identified hard copies of the assessment were forwarded to the research team for analysis.

Frequency counts and percentages by degree and years of experience in nursing ( n = 2144) Characteristic Newly hired nurses, n = 2144

Performance Based Development System Assessment were administered and rated based on the process developed by Performance Management Services, Inc. (2006) . Responses were rated by nurses who, by comparing respondents’ answers to model answers, determined if they met or did not meet expectations in the following six subcategories: problem recognition, reports essential clinical data, initiates independent nursing interventions, differentiation of urgency, anticipates relevant medical orders, and provides relevant rationale to support decisions ( Table 2 ). For example, if a nurse was presented with a clinical case in which the patient was recovering from surgery and receiving blood products and experienced an elevated temperature, hives, and chills, it would be expected that they would recognize that the patient was having a blood transfusion reaction, report essential clinical findings to the physician, and prepare to treat the patient based on the orders received.

Subcategory rating matrix for model Performance Based Development System Assessment

The PBDS overall assessment rating (met or did not meet expectations) was developed using a three-step process. Those taking the assessment were first given a preset amount of time to view a series of 10 videotaped vignettes depicting common clinical problems and write their responses. The nurse rater next determined if the nurse met expectations for each vignette using the method illustrated in Table 2 . Using an organizational algorithm reflecting patterns of inconsistency and safety in the answers that was based on the ability to meet expectations in each of the subcategories, the nurse rater then determined an overall assessment rating (met/did not meet expectations) for each nurse. When learning needs were identified, they were included in a summary given to the preceptor, along with an action plan to guide clinical orientation activities. The individual summary and action plan was sent to the unit manager and nurse educator to share with the orientee and preceptor. The nurse raters ( n = 5) all had Master’s degrees and over 10 years of clinical experience, and completed 9–12 months of PBDS rater training. Annual assessments were performed to determine inter-rater reliability and to validate rater competence. One nurse was assigned to rate all subcategories of each assessment. The department rates over 1000 PBDS assessments per year.

Validity and reliability

Reliability and validity of the PBDS assessment have been reported in previous publications ( del Bueno 1990 , 1994 , 2001 , 2005 ). Reliability estimates for the clinical vignettes, obtained using an equivalence approach, averaged 94% for individuals tested in parallel situations ( del Bueno 1990 ).

Ethical considerations

Approval for the study was obtained from a university institutional review board. Study data were de-identified; therefore participant consent was not required.

Data analysis

Descriptive statistics were calculated using SPSS, version 14.0. Descriptive data were available for the entire sample and included years of experience, academic preparation, and the overall assessment rating. Of the 539 nurses who did not meet expectations, 103 (19.1%) did not have complete subcategory scores and therefore were excluded when analyzing these scores. The chi-square test for independence likelihood ratio and Pearson chi-square were used to analyze differences in years of experience and level of preparation. The likelihood ratio was used because of the large sample size. The level of statistical significance was set a priori at 0.05.

Of the sample, 31.4% were diploma graduates, 41.0% associate degree graduates and 27.6% baccalaureate graduates ( Table 1 ). The majority (56.5%) were new graduates, defined as having ≤1 year of experience, while 24.5% had 10 or more years of experience.

Meeting PBDS expectations and areas of deficiency

The majority of newly hired nurses (74.9%) met expectations on the PBDS assessment. Of those who did not meet expectations, 436 (81%) had complete subcategory information. PBDS results indicated that 97.2% did not initiate appropriate nursing interventions, 67.0% did not differentiate urgency, 65.4% did not report essential clinical data, 62.8% did not anticipate relevant medical orders, 62.6% did not understand their decision rationale and 57.1% were deficient in problem recognition. Figure 1 summarizes the percentage of newly hired nurses not meeting expectations by subcategory and level of preparation.

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Percentage of the sample ( n = 436) not meeting expectations by subcategory and level of preparation.

Meeting PBDS expectations and years of experience

New graduates comprised 56.5% ( n = 1211) of the sample. The remaining nurses were categorized into >1 but <5 years of experience ( n = 197), ≥5 but <10 years of experience ( n = 211) and ≥10 years of experience ( n = 525). Years of experience differed statistically significantly in those meeting or failing to meet expectations (χ 2 = 21.631, d.f. = 3, P < 0.0004): those with the least experience had the highest rate of not meeting expectations, while those with the most experience had the lowest rate.

Controlling for level of preparation (diploma, associate, baccalaureate), rates at which nurses met expectations differed statistically significantly in those prepared at associate (χ 2 = 12.085, d.f. = 3, P = 0.007) and baccalaureate levels (χ 2 = 18.498, d.f. = 3, P < 0.0001) based on years of experience. Of these, 29.6% of the new graduates prepared at the baccalaureate level did not meet expectations on the PBDS, whereas only 11.5% with ≥10 years did not meet expectations ( Figure 2 ). At the associate level 31.0% of the new graduates did not meet expectations whereas 18.3% with ≥10 years did not meet expectations. In contrast, there were no statistically significant differences in the rate of meeting expectations for nurses prepared at the diploma level based on years of experience (χ 2 = 6.259, d.f. = 3, P = 0.100).

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Percentage of the sample ( n = 539) not meeting expectations on the Performance Based Development System by years of experience and degree.

Meeting PBDS expectations and level of preparation

There was no statistically significant difference in the rate of meeting or not meeting expectations with regard to level of preparation when the data were analyzed for the total sample (χ 2 = 4.886, d.f. = 2, P = 0.087). However, on controlling for years of experience, new graduates (χ 2 = 6.158, d.f. = 2, P = 0.046) and nurses with ≥10 years of experience (χ 2 = 6.179, d.f. = 2, P = 0.046) differed statistically significantly in pass rates (in those with ≥10 years of experience, the likelihood ratio was statistically significant at P = 0.046, but the Pearson chi-square was not ( P = 0.055). New graduates prepared at the associate level did not meet expectations 31.0% of the time as compared with the baccalaureate (29.6%) and the diploma (23.6%) prepared graduates ( Figure 3 ). In nurses with ≥10 years of experience, those prepared at the diploma level did not meet expectations 22.0% of the time as compared with the associate (18.3%) and baccalaureate (11.5%).

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Percentage of the sample ( n = 539) not meeting expectations on the Performance Based Development System by degree and years of experience.

Study limitations

This study had a number of limitations. The analysis was limited to data collected at the time of the PBDS assessment, i.e. level of preparation and years of nursing experience. Additional information on age, gender, prior healthcare experience in addition to nursing, employment location, and length of employment was not available. These and other potential predictor variables should be considered in future studies. The six subcategories delineating the reasons that newly hired nurses did not meet expectations on the assessment did not have complete data in 19.1% of cases. It is possible that these individuals differed from others with complete subcategory data. Finally, the assessment was based on simulated vignettes, and it is possible that actual clinical decision-making may have differed from the stated actions.

Discussion of results

The results suggest that a substantial minority of these newly hired nurses had identified learning needs with regard to their ability to make appropriate decisions when asked to assess a clinically focused vignette. Overall, approximately 25% of nurses participating in the assessment were not able to recognize the clinical problem, safely prioritize care and implement independent nursing interventions. They appeared to have difficulty reporting relevant clinical data and anticipating medical orders, and were not able to convey clearly a rationale for their decision-making. It is unclear from the assessment process whether this resulted from lack of knowledge, lack of sufficient time to respond, or not completely presenting their rationale in writing. Nevertheless, it emphasizes the importance of continued assessment, mentoring and coaching to improve and validate decision-making skills.

The percentage of new graduates not meeting expectations in the present study did not fall within the range of previously published results ( del Bueno 2005 ). In a study by del Bueno (2005) , from a sample size of 10,988 inexperienced nurses (<1 year of experience) sampled between 1995 and 2004, between 65% and 76% did not meet expectations on the PBDS assessment. Of the 20,413 experienced nurses sampled in the same study, those not meeting expectations ranged between 8% and 69%. Experienced nurses not meeting expectations in the present study ranged from 18.3% to 25.1%. Areas of deficiency on subcategories from their reports were consistent with the present study.

Our findings suggest that, as would be anticipated, nurses with more years of experience were more likely to meet expectations on the PBDS assessment. However, there were differences related to level of preparation. Specifically, those with more experience who were prepared at the baccalaureate or associate level fared better on the assessment than experienced nurses with diploma level preparation. This finding may have resulted from differences in the scope of experience and/or commitment to continuing education fostered by the educational programme. Whether these or other reasons explain the differences are speculative, as our data did not suggest an explanation. This finding is not consistent with previous studies reporting PBDS results. In a study published in 2005, del Bueno reported that after 10 years of analysis there are no consistent findings which indicate differences in clinical judgment ability based on educational preparation or credentialing. Our findings, nevertheless, support a difference in testing outcome based on level of preparation. Further exploration is needed to determine the potential reasons for our results. Possible explanations include the value of and access to advancement via nursing education, the organizational emphasis placed on continuing education, or previous clinical experience.

What is already known about this topic

  • Critical thinking, advanced problem-solving, and expert communication skills are an integral part of nursing practice and should be developed through nursing education programmes.
  • Many nurses with a year or less of experience fail to meet expectations on the Performance Based Development System Assessment.

What this paper adds

  • Approximately 25% of newly hired nurses had deficiencies in critical thinking ability, including problem recognition, reporting essential clinical data, initiating independent nursing interventions, anticipating relevant medical orders, providing relevant rationale to support decisions, and differentiation of urgency.
  • Nurses prepared at the baccalaureate and associate level were more likely to meet expectations on the assessment as years of experience increased; a similar trend was not seen for diploma nurses.
  • New graduates were less likely to meet assessment expectations compared with nurses with 10 years’ experience or more.

Implications for practice and/or policy

  • PBDS can assist in providing information about critical thinking learning needs and facilitate individualized orientation.
  • Further study is needed to identify areas of critical thinking deficiency and begin to test objective, innovative educational strategies that enhance critical thinking in the nursing population.

Our findings support Benner’s conceptualization in her novice to expert framework ( Benner 1984 ). Nurses with more experience were better able to identify appropriate actions when viewing the clinical vignettes, as would be expected. While it is of concern that a substantial minority of newly hired nurses did not meet expectations, it is important to emphasize that 75% were able to state actions that indicated their ability to manage critical situations independently and anticipate the care needed. They were able to prioritize clinical needs, consider potential actions and modify the plan of care based on prior experience. As might be anticipated, new graduates had a higher rate of not meeting expectations and struggled with the ability to make and implement independent nursing interventions in these same clinical scenarios.

Alternative critical thinking assessment methods are coming into vogue, e.g. high fidelity human simulation (HFHS) ( Henrichs et al. 2002 , Nehring et al. 2002 , Parr & Sweeney 2006 ). HFHS may be a better option for assessing critical thinking and decision-making as it provides evaluation activities that are more interactive and offers the added benefit of debriefing to facilitate learning ( Henrichs et al. 2002 , Feingold et al. 2004 , Bearnson & Wiker 2005 , O’Donnell et al. 2005 , Trossman 2005 ). Like the PBDS assessment, the HFHS can be used as a group learning tool without patient risk ( Schwid et al. 2002 ). HFHS provides a more realistic assessment that includes the ability to assess blood pressure, palpable pulses, heart sounds, breath sounds. In addition, it offers the ability to programme responses that mimic physiological actions and patient responses to the timing and selection of interventions ( Euliano 2001 , Lupien & George-Gay 2001 , Kozlowski 2004 ). Accordingly, HFHS may facilitate assessment of critical thinking and decision-making ( Duchscher 2003 ). Studies comparing the various methods of assessment remain few in number and therefore it is not possible to determine objectively which approach is the most valid and cost-effective for assessing the learning needs of new graduates and experienced nurses.

Assessments such as PBDS can provide information about learning needs and facilitate individualized orientation targeted to increase performance level. Evaluation of clinical competence is difficult, as there are few measures that capture how a nurse will perform in an actual clinical emergency when rapid decisions must be made in a complex and emotionally charged environment. Further research is needed to identify further specific areas of deficiency and begin to test objective, innovative educational strategies to enhance the critical thinking ability of both new graduates and experienced nurses. Although a time-intensive endeavor, the outcome has the potential to contribute greatly to the advancement of nursing practice and safe patient care.


The lead author was recipient of the T-32 Technology Grant: Research in Chronic and Critical Illness (T32 NR008857) Pre-Doctoral Fellowship for Doctoral Study at the University of Pittsburg, PA, USA.

Author contributions

Contributor Information

Laura J. Fero, Doctoral Candidate, University of Pittsburgh School of Nursing, Pennsylvania, USA.

Catherine M. Witsberger, Clinical Nurse Educator, Nursing Education and Research, University of Pittsburgh Medical Center, Pennsylvania, USA.

Susan W. Wesmiller, Director, Nursing Education and Research, University of Pittsburgh Medical Center, Pennsylvania, USA.

Thomas G. Zullo, Professor Emeritus, Dental Public Health, University of Pittsburgh, Pennsylvania, USA.

Leslie A. Hoffman, Professor and Chair, Department of Acute/Tertiary Care, University of Pittsburgh School of Nursing, Pennsylvania, USA.

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A Robot-assisted real case-handling approach to improving students’ learning performances in vocational training

  • Published: 14 May 2024

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how to improve critical thinking as a nurse

  • Chun-Chun Chang 1 &
  • Gwo-Jen Hwang   ORCID: orcid.org/0000-0001-5155-276X 2 , 3  

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In vocational education, cultivating students’ ability to deal with real cases is a crucial training objective. The BSFE (i.e., Brainstorming, Screening, Formation, Examination) model is a commonly adopted training procedure. Each stage is designed for guiding students to analyze and find solutions to handle real cases. However, as one teacher is generally responsible for several dozen students, it becomes challenging for the teacher to adequately address each student’s questions and individual needs. Therefore, this study proposed the robot teaching assistant-supported learning (RTAL) mode following the BSFE model to cope with this problem. This investigation assessed its efficacy through an experiment within an Acute Asthma Attack curriculum. The research involved 103 nursing students in their third year from two distinct classes at a vocational university. Fifty-three students from a class constituted the experimental group that implemented the RTAL approach, whereas the other class, comprising 50 students, was the control group utilizing the standard technology-supported learning (CTL) approach. Findings indicated that the experimental group surpassed the control group in various aspects, including learning outcomes, learning attitudes, problem-solving tedencies, critical thinking awareness, acceptance of technology, and satisfaction with the learning experience. The interview findings also revealed that the RTAL mode could cater to individualized learning needs, facilitate interaction, and serve as an auxiliary instructional tool.

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This study is supported in part by the National Science and Technology Council of Taiwan under contract numbers NSTC 112-2410-H-011-012-MY3 and MOST 111-2410-H-011 -007 -MY3. The study is also supported by the “Empower Vocational Education Research Center” of National Taiwan University of Science and Technology (NTUST) from the Featured Areas Research Center Program within the framework of the Higher Education Sprout Project by the Ministry of Education (MOE) in Taiwan.

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The authors contributed to the conceptualization and design of the study. Material preparation, data collection, analysis, project management and methodology were performed by Chun-Chun Chang. Methodology and supervision were performed Gwo-Jen Hwang.

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Chang, CC., Hwang, GJ. A Robot-assisted real case-handling approach to improving students’ learning performances in vocational training. Educ Inf Technol (2024). https://doi.org/10.1007/s10639-024-12778-w

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