critical thinking and lack of confidence in nursing

The Value of Critical Thinking in Nursing

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

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

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

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

How Do Nurses Use Critical Thinking?

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

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

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

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

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

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

Top 5 Ways Nurses Can Improve Critical Thinking Skills

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

Case-Based Approach

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

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

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

Practice Self-Reflection

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

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

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

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

Develop a Questioning Mind

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

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

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

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

Practice Self-Awareness in the Moment

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

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

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

Use a Process

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

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

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

Common Critical Thinking Pitfalls in Nursing

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

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

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

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

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

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

An Essential Skill for All Nurses

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

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

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

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

How does nursing school develop critical thinking skills?

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

Do only nurse managers use critical thinking?

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

Meet Our Contributors

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

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

Jenna Liphart Rhoads, Ph.D., RN

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

Nicholas McGowan, BSN, RN, CCRN

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

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• v.8; Jan-Dec 2022

Nursing Students’ Satisfaction and Self-Confidence Levels After Their Simulation Experience

Kholoud alharbi.

1 Nursing Department, Nursing College, King Saud University, Riyadh, Saudi Arabia

Manal F. Alharbi

2 Maternal & Child Health Department, Nursing College, King Saud University, Riyadh, Saudi Arabia

Nursing students should be well prepared before going to clinical setting as they provide direct care to patient. Simulation gives the learners the opportunity to be active learners who practice, train, and give a reflection on a specific experience.

To obtain an understanding of the human patient simulation experience and nursing students’ perceptions of satisfaction and self-confidence.

Cross-sectional, descriptive design was undertaken. Using purposive sampling, 273 nursing students were enrolled in basic adult nursing courses at levels four and five at female nursing college at King Saud University, Riyadh, Saudi Arabia. A questionnaire was used to measure the demographic characteristics, simulation design characteristics, and simulation educational practice context. Student Satisfaction and Self-confidence in Learning Scale was used to measure students’ satisfaction and self-confidence. Bivariate analyses were utilized where needed and multiple linear regression analysis was performed to find the relationship between variables.

The current study revealed overall, nursing students were satisfied and self-confident after their human patient simulation experience. A relationship was observed between demographic characteristics, simulation design characteristics, and simulation educational practice context with students’ satisfaction and self-confidence.

Simulation is an effective teaching strategy that prepares nursing students for real clinical practice. Findings provided policymakers with information on nursing students’ current levels of satisfaction and self-confidence that can lead to developing future policies.

Introduction/Background

Nursing is an essential profession as it provides holistic care to patients. Nurses should be well prepared for real clinical practice. New graduate nurses are struggling in delivering safe care to their patients because they have underdeveloped critical thinking, low self-confidence, and lack of competency to perform high quality care to the patients ( Unver et al., 2012 ). Nursing students need to be confident when they are taking care of patients. Simulation has been widely used in nursing schools all over the world as an important component of nursing education. Simulation activity is an effective teaching method that enhances the enrollment of nursing students and reduces faculty shortages ( Schoening et al., 2006 ). Rosen (2008) defined simulation as “an imitation of some real thing, state of affairs, or process” (p. 1). Simulation gives the learners the opportunity to be active learners who practice, train, and give a reflection on a specific experience. Students have the opportunity to receive immediate feedback from their instructor for any future improvement in their communication or skills. Also, they are learning from their mistakes via this experience ( Kluwer, 2018 ). In education, simulation is used for teaching theoretical knowledge along with practical skills (Cantrell et al., 2017a).

Review of Literature

Self-confidence is the belief in self and own abilities to accomplish something ( Greenacre et al., 2014 ). Self-confidence is needed by nursing students to be able to deliver safe care to their patients that is free from errors and mistakes. Many studies stated the importance of simulation experiences in nursing education. Satisfaction is the individual's judgment of his/her pleasurable level associated with fulfillment ( Folorunso & Paul, 2015 ). Simulation has a positive impact on the self-confidence of students ( Martins et al., 2018 ). Shin et al. (2015) conducted a study to measure critical thinking skills among nursing students. The tool used was Yoon's Critical Thinking Disposition tool. The study revealed that the critical thinking scores in School A increased by 2.45 points than other schools because it had received three simulation sessions unlike other schools which received one and two simulation sessions. Cantrell et al. (2017b) stated that simulation is a good educational strategy as it guarantees patient safety. Alammary (2017) revealed high self-confidence scores (3.70/5) among students after their simulation experiences. Fawaz and Hamdan-Mansour (2016) reported that the clinical judgment skills of nursing students have been enhanced after simulation experience.

A study by Burns et al. (2010) on 114 nursing students revealed that the self-confidence of the students has increased after their simulation experience. In addition, Au et al. (2016) reported that nursing students felt more confident after simulation. In Ahmed et al. (2018) study, the self-confidence scores in the simulation group (30.8) were higher than the scores of the control group (24.7). Gamble (2017) mentioned that 28 students felt confident because simulation enhanced their problem-solving skills. Jarvill et al. (2018) revealed in their study that nursing students have an improvement in medication administration skills in the simulation group (59.5%) than in the control group (9.3%).

Lubbers and Rossman (2016) found that students’ self-confidence increased because they have an improvement in the following skills: communication and documentation. Tawalbeh (2020) mentioned that the scores of self-confidence of 76 nursing students have increased from 5.36 to 23.00 after simulation experiences. A qualitative study performed by Kaddoura et al. (2016) stated that nursing students feel self-confident after simulation because they practiced skills in an environment that is similar to clinical practice. Nye et al. (2019) stated that 77% of students were satisfied with simulation and they asked to replace the clinical placement with simulation. Silvia (2013) added that 64% of nursing students were satisfied with the simulation experience because they found that their skills were improved.

In another study by McCaughey and Traynor (2010) , 95% of students were satisfied with the simulation because they had the chance to practice in a safe environment. In Kaliyaperumal et al. (2021) study, it was revealed high satisfaction scores of nursing students with simulation ( mean  = 4.60). Demirtas et al. (2021) reported high satisfaction scores of nursing students with simulation: 23.98 out of 25. In Zapko et al. (2018) study, nursing students reported that they were satisfied with the simulation experience because it helped them achieve their learning outcomes. Ha (2018) found that 74.4% of students were satisfied with simulation because it prepared them for future clinical practice. Martins and Pinho (2020) stated that students were satisfied with the simulation because they found an improvement in their collaboration and communication skills. Nye et al. (2019) found that 98% of students reported that simulation should be integrated into the nursing educational program. A systematic review was conducted by Alalhareth and Howarth (2020) which supports that simulation is an effective technique in nursing education because it improves the satisfaction of students. Measuring the students’ outcomes is still challenging. More research studies are needed to understand the students’ satisfaction and self-confidence following their human patient simulation experience.

The main purpose of the current study was to obtain an understanding of the human patient simulation experience and nursing students’ perceptions of satisfaction and self-confidence. The study's objectives were as follows: First, to measure the nursing students’ satisfaction and self-confidence levels following the human patient simulation experience. Second, to examine the relationship between nursing students’ self-confidence and satisfaction levels. Third, to examine the relationship between nursing students’ demographic characteristics and their satisfaction and self-confidence levels. Fourth, to examine the relationship between simulation design characteristics and nursing students’ satisfaction and self-confidence levels. Fifth, to examine the relationship between simulation educational practice context and nursing students’ satisfaction and self-confidence levels.

Conceptual Framework

This study was guided by the National League for Nursing (NLN)/Jeffries Simulation Framework. In 2005, it was published by Jeffries to assess the simulation experience among students. In 2010, the NLN established a project to support Jeffries Simulation Framework that was reviewed by many experts ( Groom et al., 2014 ). This framework is effective in guiding nurse educators in the application of simulation. It was selected because it provides a framework to understand the design, characteristics, application, and evaluation of simulation activities used in nursing education ( Foronda et al., 2018 ). This framework is composed of five constructs: teacher, student, simulation design characteristics, educational practices context, and outcomes ( Ravert & McAfooes, 2014 ). NLN/Jeffries Simulation Framework was adapted in the current study (see Figure 1 ). The interaction between simulation educational practices context, simulation design characteristics, and the students’ demographic characteristics lead to the simulation outcome (satisfaction and self-confidence).

Adaptation of National League for Nursing (NLN)/Jeffries simulation framework.

Study Design

A cross-sectional, descriptive study was undertaken on a sample of nursing students from female nursing college, King Saud University in Riyadh, Saudi Arabia. This design was selected because it offers the advantage of leading to interventions that can be examined in further research studies using quasi-experimental and experimental designs. In descriptive research, the relationship between variables is identified ( Polit & Beck, 2016 ). Moreover, one college was included as the researcher studying at the same university. However, there was no relationship between researcher and sample included in the current study.

Research Question

The following research questions were addressed in this study. First, what is the nursing students’ satisfaction level following their human patient simulation experience? Second, what is the students’ self-confidence level following their human patient simulation experience? Third, what is the relationship between students’ self-confidence and satisfaction levels? Fourth, what is the relationship between students’ demographic characteristics and satisfaction level? Fifth, what is the relationship between nursing students’ demographic characteristics and self-confidence level? Sixth, what is the relationship between simulation design characteristics and nursing students’ satisfaction level? Seventh, what is the relationship between simulation design characteristics and nursing students’ self-confidence level? Eighth, what is the relationship between simulation educational practice context and nursing students’ satisfaction level? Ninth, what is the relationship between simulation educational practice context and nursing students’ self-confidence level?

This study used purposive sampling from the study population. The sample size was calculated using Raosoft Inc (margin of error = 5%, confidence level = 95%, and the response distribution = 50%) ( Raosoft, n.d. ). The required sample size was 260. 20% were added because missing data is common in research; hence, the sample size after adding the 20% was 276. In the current study, 273 nursing students were enrolled in the basic adult nursing courses at levels four and five at the female nursing college at King Saud University in Riyadh, Saudi Arabia was included (see Figure 2 ). The current study had a response rate of 98.94%.

Sample flow.

Inclusion/Exclusion Criteria

To be eligible for the study, nursing students needed to be enrolled in the basic adult nursing courses, which were taught in English. They needed to be studying at either level four or five. Both levels are at an intermediate level. The students were needed to be over 19 years of age. Also, they had the choice to participate or not. The exclusion criteria were the age of students 19 years and below. Also, for those who were not studying at either level four or five. Another exclusion criterion was students who did not volunteer to participate in the study.

A questionnaire was developed by the researcher to measure the first three parts of the study. Students’ demographic characteristics (age, grade point average [GPA], and level), simulation design characteristics (environment, objectives, fidelity, and debriefing), simulation educational practice context (previous educational simulation experience, course type, collaboration, student/teacher interaction, and feedback).

The Student Satisfaction and Self-confidence in Learning Scale (SCLS), was established by the NLN in 2006. In this study, it was utilized to measure the students’ satisfaction and self-confidence levels after their simulation experience. This scale consists of 13 questions, five items on satisfaction and eight items on self-confidence. It is a 5-point Likert scale, ranging from 1 =  strongly disagree to 5 =  strongly agree . The Cronbach's alpha is 0.94 for satisfaction and 0.87 for self-confidence ( Unver et al., 2017 ). In the current study, the reliability coefficient for the SCLS as the following: the Cronbach's alpha was 0.90 for satisfaction and 0.91 for self-confidence. Moreover, the content validity was established by nine experts in simulation who reviewed the tool ( NLN, 2015 ). In the current study, the Cronbach's alpha for satisfaction is 0.90 and for self-confidence is 0.91. There was no cut-off score for the SCLS, hence, the mean was utilized to represent the students’ satisfaction and self-confidence levels.

Data Collection Procedure

A pilot study on 30 nursing students was conducted in November 2021 to evaluate the study's feasibility, tools’ applicability, and duration of the study. Participants who were involved in the pilot study were excluded from the sample of the main study to ensure the validity of the findings. The main data collection of the current study was conducted from December 2021 to February 2022. Students had five simulation sessions during their study in the basic adult nursing courses at levels four and five. The duration of each simulation session was between 20 and 30 min, and the duration of debriefing was from 30 to 50 min. The type of simulation was a human patient simulation. This type consists of human mannequins called SimMan 3G that have realistic physiologic responses, such as breathing, lung and heart sounds, and pulse. The simulation was a requirement in the adult courses. Students were asked to complete the questionnaire and the SCLS after completing all their simulation sessions.

Ethical Consideration

The study was approved by the Institutional Review Board at King Saud University (No: KSU-HE-21-300). Students were informed about the significance and aim of the study before participation. Informed consent was obtained from all the participants. They completely knew that their participation was voluntary and they had the right to withdraw from the study at any time. Confidentiality and privacy were maintained. All the information and personal data were saved on a computer that was locked with a password. Participants were provided with the phone number of the researcher if they had any questions or concerns.

Statistical Analysis

In total, 273 surveys were included in the analysis. The data were analyzed using the SPSS software version 26.0 (IBM Corp.). Before performing the analysis, data were checked for completeness and assumptions of the statistical tests. Descriptive statistics were used to describe the study variables. Bivariate analyses including independent t -test were used to compare the mean values of satisfaction and self-confidence scores in relation to all the categorical variables in the study. The relationship between the GPA and satisfaction scores; and the GPA and self-confidence scores were measured by Pearson's correlation and simple linear regression. Also, the relationship between satisfaction and self-confidence scores was identified by Pearson's correlation and simple linear regression. The dependent variables were examined using multiple linear regression analysis to see how well they were explained by the independent variables.

Sample Characteristics

Out of the total 273 study participants, 95.6% were in the age group of 20–22 years, 52.4% of them from level 4, and their mean GPA is 3.79 ( Table 1 ).

Table 1.

Participants’ Demographic Characteristics .

Four questions have been asked about the simulation design characteristics. The participants’ responses were observed on a binary scale (Yes/No). For the first question, “Was the environment organized and supportive?”, 92.7% of them responded positively (Yes), 94.1% of them responded as Yes, for the question, “Have you been provided with clear objectives at the beginning of the simulation session?”, whereas 79.9% and 86.1% of them had responded positively (yes) for the remaining two questions, “Were case studies and scenarios provided in the simulation laboratory reflective of a real-life situation?” and for the question, “ Does debriefing help you to understand the mistakes that you made during your practice?”

For the simulation educational practices context, five questions have been asked and their responses are given in Table 3 . For the question, “ do you have previous educational experience with human patient simulation?, 67% of them had responded as Yes, 82.4%, 85,3%, and 78.8% of them had responded positively (Yes) to the three questions, “did you have the opportunity to work with your colleagues in the simulation lab?”, did the instructor interact with you before during, and after the simulation activity”, and for the question, “ did you receive constructive feedback from the instructor?”. Out of the 273 subjects, 143 (52.4%) of them have taken the Adult one course of the human patient simulation.

Table 3.

Relationship Between Self-Confidence Scores and All the Study Variables .

The overall mean of satisfaction scores was 18.70 (SD = 4.83); whereas the minimum score is 5 and the maximum is 25. The findings indicate an overall satisfaction among students toward their simulation experience. Moreover, the overall mean of self-confidence scores was 30.28 (SD = 6.97); whereas the minimum is 25 and the maximum is 40. The findings indicate overall self-confidence among students was built after their simulation experience.

Bivariate Analysis

There was a low positive correlation between GPA and satisfaction scores ( r  = .150, p  = .013) and between GPA and self-confidence scores ( r  = .230, p  = <.0001). It also showed a strong positive correlation between satisfaction and self-confidence scores ( r  = .842, p  = <.0001). In addition, the simple regression analysis showed a linear relationship between satisfaction scores and GPA ( R square  = .022; F (1, 271) = 6.225, P  = .013); self-confidence scores and GPA ( R square  = 0.053; F (1,271) = 15.191, P <.001); and satisfaction and self-confidence scores ( R square  = 0.709; F (1,271.) = 658.991, P <.001).

The independent two-tailed t -test showed high satisfaction scores in participants of 20–22 age group ( M  = 18.82, SD  = 4.79) when compared with participants of 23–25 age group ( M  = 16.00, SD  = 5.12), t (271) = 1.99, p  = .048. Also, the mean satisfaction scores in level four participants ( M  = 19.40, SD  = 4.35) were significantly higher than the scores of level five participants ( M  = 17.93, SD  = 5.22), t (271) = 2.53 p  = .012. In addition, there was no statistically significant difference t (271) = 1.85 p  = .066 in mean of self-confidence scores between the participants of two age groups: 20–22 age group ( M  = 30.45, SD  = 6.84); 23–25 age group ( M  = 26.67, SD  = 8.94). In addition, there was no statistically significant difference t (271) = 1.93 p  = .054 in the mean of self-confidence scores between the participants in level four ( M  = 31.06, SD  = 6.09) and level five ( M = 29.43, SD  = 7.76).

Regarding the relationship between satisfaction scores and simulation design characteristics, the independent t -test showed a highly significant difference in the mean satisfaction scores of positive responses than negative responses for all four items. Moreover, the independent t-test showed a significant difference in the mean of self-confidence scores of the positive responses for three items: objectives, fidelity, and debriefing. The mean difference was as the following: 5.41, 4.72, and 5.00. However, there was no statistically significant difference in the mean self-confidence scores between groups based on the environment variable.

Regarding the relationship between satisfaction scores and simulation educational practice context, the independent t -test showed a highly significant difference in the mean satisfaction scores on positive responses than negative responses for two items: student/teacher interaction and feedback. Satisfaction scores were higher with those participants who didn’t have previous simulation experience and who study an adult one course. However, there was no statistically significant difference in the mean satisfaction scores between groups based on the collaboration variable. Moreover, the independent t -test showed a significant difference in the mean self-confidence scores of the positive responses for two items: student/teacher interaction and feedback. The mean difference was as the following: 3.79 and 3.44. However, there was no statistically significant difference in the mean self-confidence scores between groups based on the previous simulation experience, course, and collaboration variables.

Multivariate Analysis

Table 2 showed the following predictors for satisfaction: objectives, student/teacher interaction, debriefing, course type, constructive feedback, age group, and environment. The multiple regression model was statistically significant ( R square  = 0.213; F (8,264) = 8.917, p <0.0001.). Table 3 showed the following predictors for self-confidence: fidelity, GPA, debriefing, objectives, and student/teacher interaction. The multiple regression model was statistically significant ( R square  = 0.213; F (5, 267) = 14.435, p <.0001).

Table 2.

Relationship Between Satisfaction Scores and All the Study Variables .

The current study found that nursing students had overall satisfaction and self-confidence after their human patient simulation experience. In this study, there was a statistically significant difference in the students’ satisfaction scores according to the age variable. The results were similar to Cura et al. (2020) and Cabañero-Martínez et al. (2021) . However, the current study showed there was no statistically significant difference in the students’ self-confidence scores based on their age. This was confirmed by a study performed by Omer (2016) . In addition, the current study showed a correlation between students’ GPA and satisfaction scores; and students’ GPA and self-confidence scores. These findings were different from those of Ma (2013) study who reported no correlation between those variables. Moreover, the findings of the current study were similar to those of King (2012) who stated there was no relationship between students’ study level and self-confidence scores; but it had different findings of no relationship between students’ study level and satisfaction scores to those of current study who showed there was a relationship between of them.

The findings of the current study were consistent with other research studies: García-Mayora et al. (2021) , Verkuyl and Hughes (2019) , and Kirkpatrick et al. (2017) which showed the overall satisfaction among nursing students after their human patient simulation experience. In addition, the following studies: King (2012) and Burns et al. (2010) confirmed the findings of the current study about students’ gaining self-confidence after the simulation experience. Also, Kaliyaperumal et al. (2021) stated there was a strong positive relationship between self-confidence and satisfaction scores ( r  = 0.821, p <0.05). Reid-Searl et al. (2019) reported environment and debriefing are important elements in simulation to increase the students’ satisfaction and self-confidence. Motola et al. (2013) reported a relationship between students’ satisfaction and providing them with objectives before the simulation session. Aljohani et al. (2019) reported that fidelity and objectives increased the students’ self-confidence scores ( mean  = 3.83).

The current study revealed there was no association between collaboration and students’ satisfaction and self-confidence scores. These findings were different from the results of Li et al. (2018) . Brohard and Moreland (2018) confirmed the finding of the current study on the association between receiving feedback from instructors and students’ satisfaction and self-confidence. Guinea et al. (2019) found that student/teacher interaction during simulation increases the self-confidence of students. Omer's (2016) study supported the current study's findings on the association between course type and students’ satisfaction. The current study showed there was an association between previous simulation experience and satisfaction. This was different from the findings of King's (2012) study. In addition, the findings of the current study were confirmed by Omer's (2016) study who stated that there was no association between course type and self-confidence; and King's (2012) study which revealed that there was no association between previous simulation experience and self-confidence scores.

Strengths and Limitations

One of the strengths of the current study is the finding can inform the use of human patient simulation experiences in nursing education for improving the students’ satisfaction and self-confidence in nursing schools in Saudi Arabia. In addition, examining the application and utilization of the adapted framework within the context of nursing education in Saudi Arabia helped to meet the needs of the students in nursing schools in Saudi Arabia. This study had a response rate of 98.94% to the study's questionnaire which is considered another strength of the study and its results. Another strength is that the current study used a reliable tool developed by NLN that measures the nursing students’ satisfaction and self-confidence levels.

The current study had several limitations. The purposive sampling method was utilized, which might lead to bias and decrease the generalization of the findings. Another limitation is that it is difficult to report the cause-and-effect relationship between variables in a cross-sectional research design. Another limitation is that the current study was conducted in one setting which may make the study's findings difficult to generalize. In addition, there might be other factors such as differences in instructors with their experiences in adult one and adult two courses that might affect the satisfaction and self-confidence of nursing students. Therefore, future research is recommended with other study designs on other settings with control of other factors.

Implications for Practice

The findings of the current study have important implications for nursing education since they provide useful insights into students’ perceptions of satisfaction and self-confidence following their human patient simulation experience. Faculty members at nursing colleges should be aware of instructional approaches that can be used to meet clinical course objectives, such as simulation. These findings can be used to improve the usage of simulation experience in nursing education to create a more successful education system. As a result, nursing students’ satisfaction and self-confidence would be improved, all of which have an impact on the quality of patient care. Moreover, the current study's findings provided the policymakers with information on nursing students’ current levels of satisfaction and self-confidence. The outcomes of the study could be used to design policies and actions in Saudi Arabia to improve the human patient simulation experience in laboratory settings.

Simulation is an effective teaching strategy that should be incorporated into nursing education programs to prepare students for future clinical practice. The current study revealed overall satisfaction and self-confidence among students after their human patient simulation experience. The study's findings will lead to the development of policies and interventions to improve the human patient simulation experience in laboratory settings in Saudi Arabia. A recommendation is that replication by further research studies with other research designs should be done including other settings and more than one geographical region.

Acknowledgment

The authors thank the Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia for their support.

Author Contributions: The authors ensure that all authors listed have contributed to this study based on the criteria of the journal Editors. All have approved the manuscript and agreed to be submitted to the journal.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Statement: The study was approved by the Institutional Review Board at King Saud University (No: KSU-HE-21-300).

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Informed Consent: Informed consent was obtained from all the participants.

ORCID iD: Kholoud Alharbi https://orcid.org/0000-0002-6636-0223

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

Affiliations.

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

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

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

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Enhancing Critical Thinking in Clinical Practice

Implications for critical and acute care nurses.

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

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

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

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

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

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

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

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

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

WHAT IS CRITICAL THINKING?

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

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

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

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

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

INTEGRATING RESEARCH, EVIDENCE-BASED PRACTICE, AND CRITICAL THINKING

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

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

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

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

THE NURSING PROCESS AND CRITICAL THINKING

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

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

HOW DO WE LEARN CRITICAL THINKING IN NURSING?

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

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

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

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

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

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

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

STRATEGIES TO ENHANCE CRITICAL THINKING ABILITY

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

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

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

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

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

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

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

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

USING THE INTERACTIVE CASE STUDY APPROACH TO ENHANCE CRITICAL THINKING

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

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

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

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

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

THE INFLUENCE OF THE WORKPLACE ENVIRONMENT

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

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

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

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

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

Acute care; Critical thinking; Decision making

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